As of July 2022, the referral schedule for cervical cancer screening has been modified. Previously, all HPV-positive participants with cytological abnormalities were referred. In the new referral schedule, referrals are made on the basis of hrHPV typing. Also, the timing of the control smear test has been extended from six to 12 months.

What has been changed?

The referral policy has been modified. In the past, all HPV-positive participants with ASC-US were referred to the gynaecologist, either immediately or after the control examination at six months. In the new referral schedule, hrHPV genotyping is used. A distinction is made between hrHPV types 16 and 18 (HPV 16/18) with a clearly increased risk and the other hrHPV types (HPV other) with a moderately increased risk.

The referral policy remains the same for participants with HPV 16/18. Cytological abnormalities from ASC-US upwards (small cell abnormalities) are referred immediately. If the result is HPV 16/18 with no cell abnormalities detected, these participants will be invited for a control smear test after 12 months.

Table 1 Advice based on the outcome




Screening round completed

HPV+ with NILM Control smear test in 12 months

HPV other with ASC-US or LSIL

Control smear test in 12 months

HPV 16/18 with ASC-US of LSIL

Referral (direct)

HPV+ with HSIL+

Referral (direct)

Follow-up smear with ASC-US+

Referral (indirect)

Follow-up smear with NILM

Screening round completed

No proper result

New sample in six weeks

Why this change to the referral schedule?

The introduction of primary HPV screening resulted in more health gains, but more participants were referred to the gynaecologist than before. Of these, more than half turned out not to have any precancerous stage of cervical cancer. The Health Council of the Netherlands saw opportunities to reduce the number of clinically irrelevant referrals by adjusting the referral policy. It is expected that the current adjustment to the referral schedule will reduce the number of unnecessary referrals by about a half.