At what age should women start getting screened for Human Papillomavirus (HPV) with a Pap (Papanicolaou) test?

HPV Screening with Pap Test: Age Recommendations

Cervical cancer screening with Pap testing should begin at age 21 years, regardless of sexual activity history. 1

Current Screening Guidelines

Initial Screening Age

• Begin screening at age 21 years
• Previous guidelines that recommended screening 3 years after first sexual intercourse have been replaced with this fixed age recommendation 1

Screening Intervals by Age Group

• Ages 21-29 years:

  • Pap test alone every 3 years 1
  • HPV testing is NOT recommended in this age group 1

• Ages 30-65 years:

  • Preferred: Pap test PLUS HPV test (co-testing) every 5 years 1
  • Acceptable alternative: Pap test alone every 3 years 1

When to Stop Screening

• Women >65 years who have had ≥3 consecutive negative Pap tests or ≥2 consecutive negative HPV and Pap tests within the last 10 years (with the most recent test occurring in the last 5 years) should stop cervical cancer screening 1
• Women who have had a total hysterectomy (with removal of the cervix) for benign reasons should discontinue screening 1

Rationale for Current Guidelines

The recommendation to begin screening at age 21 years is based on several important factors:

1. Very low incidence of cervical cancer in young women: Only 0.1% of all cervical cancer cases occur in women younger than 21 years, with an annual incidence of just 1-2 cases per 1,000 females aged 15-19 years 1

2. Harm reduction: Earlier screening can lead to unnecessary interventions for lesions that would likely regress spontaneously 1

3. Pregnancy complications: There is concern about increased risk of premature births in women previously treated with excisional procedures for precursor lesions 1

HPV Testing Considerations

• HPV testing should NOT be used for:

  • Women under age 21 1
  • Primary screening without a Pap test 1
  • STD screening 1
  • Deciding whether to vaccinate for HPV 1

• For women aged ≥30 years with normal Pap tests and negative tests for high-risk HPV, the screening interval can safely be extended to 3-5 years 1

Patient Concerns and Adherence

Despite evidence-based guidelines, patient adherence and preferences may differ:

• Many women still believe annual screening is necessary (74.1% in one study) 2
• While 68.4% of women would extend screening to every 3 years if recommended by their doctor, only 25.2% would accept 5-year intervals 2
• Approximately 60% of women express a strong preference for Pap testing over HPV testing alone 2

Clinical Pitfalls to Avoid

1. Don't start screening too early: Beginning cervical cancer screening before age 21 can lead to unnecessary procedures and anxiety with minimal benefit

2. Don't confuse pelvic exams with Pap tests: Many women erroneously believe they've had a Pap test when only a pelvic examination was performed 1

3. Don't screen too frequently: More frequent screening than recommended provides minimal additional benefit while increasing costs and potential harms

4. Don't continue screening unnecessarily: Women who meet criteria for discontinuation (age >65 with adequate negative prior screening or post-hysterectomy for benign disease) should not continue routine screening

5. Don't use HPV testing alone for primary screening without a Pap test, as this is not currently recommended in guidelines 1