What are the guidelines for Pap (Papanicolau) smears in women over 70?

Guidelines for Pap Smears in Women Over 70

Pap smear screening should be discontinued after age 70 in women who have had at least three consecutive normal Pap tests and no abnormal tests within the past 10 years. 1

Current Recommendations for Older Women

The guidelines for cervical cancer screening in women over 70 years of age are clear but often misunderstood by both patients and providers. Here's what the evidence shows:

When to Stop Screening

• American Geriatrics Society (AGS): Recommends Pap tests every three years until age 70 1
• American Cancer Society (ACS): Previously recommended that women aged 70+ who have had three or more consecutive normal tests and no abnormal tests within the past 10 years may choose to stop screening 1
• U.S. Preventive Services Task Force (USPSTF): Recommends discontinuing regular Pap testing after age 65 in women who have had consistently normal results on previous tests 1

Special Circumstances Requiring Continued Screening

Certain women should continue screening beyond age 70:

1. Women who have never been screened or have inadequate screening history
2. Women with a history of cervical cancer
3. Women with in utero exposure to diethylstilbestrol (DES)
4. Immunocompromised women (including HIV-positive)
5. Women with a history of CIN2/3 (high-grade cervical lesions)

For these high-risk groups, screening should continue as long as they are in reasonably good health and would benefit from early detection and treatment 1.

Rationale Behind Age-Based Discontinuation

The recommendation to stop screening at age 70 (or 65 according to some guidelines) is based on several factors:

• The incidence of cervical cancer in older women is almost entirely confined to the unscreened and underscreened population 1
• Modeling data suggest that continued testing of previously screened women reduces the risk of cervical cancer mortality by only 0.18% at age 65 and by 0.06% at age 74 1
• Potential harms of screening in older women include:
  • Difficulty obtaining satisfactory samples due to atrophy and cervical stenosis
  • Anxiety and discomfort during sampling
  • False-positive results leading to unnecessary procedures
  • Higher healthcare costs with minimal benefit 1

Special Consideration: Post-Hysterectomy

Women who have had a total hysterectomy (with removal of the cervix) for benign gynecologic disease should not continue Pap testing 1. However:

• Women who have had a subtotal (supracervical) hysterectomy should continue screening according to age-appropriate guidelines
• Women with a history of CIN2/3 prior to hysterectomy should continue screening until they have three consecutive normal tests with no abnormal tests within a 10-year period 1

Common Pitfalls in Practice

Despite clear guidelines, overscreening remains common:

• About 40.8% of women over 70 years had a Pap smear within the past 3 years 2
• Nearly 40% of women over 70 reported receiving a recommendation for a Pap smear from their provider in the past year 2
• Many providers continue to recommend annual screening despite evidence showing minimal benefit of such frequency 3

This overscreening suggests that both providers and patients may need better education about current guidelines. Many women resist less frequent screening due to concerns that recommendations are cost-driven rather than evidence-based 4.

Algorithm for Decision-Making in Women Over 70

1. Assess screening history:

   • Has the woman had at least 3 consecutive normal Pap tests?
   • Has she had no abnormal tests in the past 10 years?
   • If YES to both → Discontinue screening
   • If NO to either → Continue screening

2. Assess risk factors:

   • History of cervical cancer, CIN2/3, or DES exposure?
   • Immunocompromised status?
   • If YES to any → Continue screening as long as reasonably healthy
   • If NO → Follow standard discontinuation criteria

3. Assess hysterectomy status:

   • Total hysterectomy for benign disease with cervix removed?
   • If YES → No further screening needed
   • If NO → Continue age-appropriate screening

Remember that the decision to stop screening should prioritize the patient's overall health status and life expectancy, as the benefits of screening diminish while the harms may increase with advancing age.