Clinical considerations and recommendations When should screening begin? Screening for cervical cancer should begin at age 21 and should not be performed in women under 21 years of age, regardless of the age of the patient’s first sexual encounter or the presence of other risk factors associated with sexual activity. This recommendation is based on the very low incidence of cervical cancer in women under 21 years of age and the lack of data to prove that cervical cancer screening is effective for these women. Only 0.1% of cervical cancers occur before the age of 20, which means that 1-2 cases of cervical cancer will occur for every 1 million women aged 15-19 years. In addition, studies from the United States and the United Kingdom have shown that screening younger women does not reduce the prevalence of cervical cancer. Young women are often infected with human papillomavirus shortly after vaginal intercourse (30-33, 72, 73), and almost all can rely on the immune system to clear the virus without tumorigenesis within 1-2 years (23, 30, 34 38). Although cancer is very rare in the adolescent population, tumorigenic changes can occur. Of 10 090 Pap test screening results in 12- to 18-year-olds, 422 specimens (5.7%) were reported as LSILs and only 55 specimens (0.7%) as HSILs. Screening for cervical cancer earlier than recommended by guidelines may increase patient anxiety, morbidity, cost, and excessive follow-up. The emotional impact of labeling adolescents with sexually transmitted infections and potentially precancerous lesions cannot be ignored because of the heightened focus on self-image and emergence of sexual curiosity during adolescence. Studies have demonstrated an increased rate of preterm birth following excision of cervical neoplasia, and in a systematic review and meta-analysis, it was suggested that these women who had undergone cervical lesion excision had a significantly higher incidence of preterm birth only when compared to those without abnormal cervical cytology and colposcopy findings. It is clearly advisable to avoid unnecessary hysterectomy or ablation in young women, although the relationship between LEEP treatment and preterm birth has been controversial. Initiation of reproductive health care should not be based on cervical cancer screening. Important strategies to prevent cervical cancer in young women younger than 21 years of age should include HPV vaccination and counseling on safe sexual practices to prevent transmission of the disease.