When should a Pap (Papanicolau) test be repeated if the cytology result is negative and no Human Papillomavirus (HPV) test is performed?

Repeat Pap Testing Intervals for Negative Cytology Without HPV Testing

For women with negative cytology results and no HPV testing, a Pap test should be repeated every 3 years. 1

Age-Based Screening Recommendations

The appropriate interval for repeating Pap tests depends on several factors:

• Women aged 21-29 years:

  • Pap test every 3 years without HPV testing
  • HPV testing is not recommended in this age group

• Women aged 30-65 years:

  • Ideally, co-testing with both Pap and HPV is preferred (every 5 years if both negative)
  • If HPV testing is not available, Pap test alone every 3 years is acceptable 1

• Women over 65 years:

  • Can discontinue screening if they have had adequate negative prior screening
  • Adequate screening defined as three consecutive negative Pap tests or two consecutive negative co-tests within the past 10 years, with the most recent test within the past 5 years 1

Special Considerations

Unsatisfactory Pap Results

• Repeat testing is required regardless of HPV status
• The repeat test must be determined satisfactory before resuming regular screening intervals 1

Negative Pap Without Transformation Zone Component

• No early repeat needed if the Pap is otherwise satisfactory and negative
• Risk for cervical intraepithelial neoplasia (CIN3+) is not increased compared to samples with endocervical cells 1

Women with HIV Infection

• More frequent screening may be appropriate
• Consider 3-year intervals only if CD4 count is >500 cells/μL and HPV testing is negative 1, 2

Post-Hysterectomy

• Routine Pap testing not required if hysterectomy was performed for benign indications
• Continue screening if hysterectomy was due to CIN2+ until three consecutive negative Pap tests 1

Evidence Strength and Clinical Implications

The 3-year interval recommendation for Pap testing without HPV co-testing is based on strong evidence. Research shows that the risk of developing high-grade cervical lesions after a negative Pap test alone is higher than after negative co-testing (Pap plus HPV), but still relatively low 1, 3.

The American Cancer Society and ASCCP guidelines both support the 3-year interval for Pap testing alone, which balances the benefits of screening against potential harms of over-screening 1.

Common Pitfalls to Avoid

1. Annual Pap testing is no longer recommended for average-risk women with normal results, as it leads to unnecessary procedures without improving cancer detection

2. Screening women under 21 regardless of sexual activity onset is not recommended

3. Continuing screening indefinitely after age 65 in women with adequate negative prior screening

4. Performing HPV testing in women under 30 years outside of specific clinical scenarios (such as ASC-US triage)

5. Assuming a negative Pap test alone provides the same reassurance as negative co-testing - the risk is somewhat higher with Pap alone, hence the shorter screening interval of 3 years versus 5 years for co-testing

When HPV testing is available, co-testing is preferred for women aged 30-65 as it allows for longer screening intervals (5 years) when both tests are negative 1, 3.