At what age should women start getting pap (Papanicolau) smears and how often should they be screened?

Cervical Cancer Screening (Pap Smear) Age Requirements and Frequency

Women should begin cervical cancer screening at age 21 regardless of sexual history, with screening every 3 years using cytology (Pap smear) alone until age 30, and then either continue cytology every 3 years or switch to co-testing (cytology plus HPV testing) every 5 years until age 65. 1

Initial Screening Age

• Begin screening at age 21 regardless of when sexual activity began 2, 1
• Previous recommendations to begin screening within 3 years of first sexual intercourse have been replaced by the age-based recommendation 2
• Starting screening before age 21 is not recommended due to:
  • Very low incidence of cervical cancer in women under 21 (only 0.1% of all cervical cases) 2
  • Potential harm from anxiety associated with positive tests 2
  • Increased risk of premature births in women treated with excisional procedures for precursor lesions that would likely regress without treatment 2

Screening Frequency by Age Group

Ages 21-29:

• Screen every 3 years with cytology (Pap smear) alone 2, 1
• HPV testing is not recommended in this age group 1

Ages 30-65:

• Option 1: Continue screening every 3 years with cytology alone 2, 1
• Option 2: Screen every 5 years with co-testing (cytology plus HPV testing) 2, 1
• Women who have had 3 consecutive negative Pap tests may be screened less frequently 2

When to Stop Screening

• Women can discontinue screening at age 65 if they have had:

  • At least 3 consecutive negative Pap tests within the last 10 years, with the most recent test occurring within the last 5 years 2, 1
  • OR at least 2 consecutive negative HPV and Pap co-tests within the last 10 years, with the most recent test occurring within the last 5 years 1

• Women should continue screening beyond age 65 if they have:

  • A history of cervical cancer
  • High-grade precancerous lesions
  • In utero DES exposure
  • Immunocompromised status 1

Special Circumstances

After Hysterectomy:

• Women who have had a total hysterectomy (with removal of the cervix) for benign reasons and no history of high-grade precancerous lesions should discontinue screening 2, 1
• Women who have had a subtotal hysterectomy (cervix remains) should continue age-appropriate screening 1

Women with History of Abnormal Results:

• Women with a history of CIN2/3 should continue screening until they have three consecutive negative Pap tests with no abnormal results within a 10-year period 1
• Women with previous abnormal results are more likely to undergo more frequent screening (80% undergo annual screening) 3

Common Pitfalls to Avoid

1. Overscreening: Despite guidelines recommending less frequent screening, studies show that 55% of American women undergo annual Pap screening 3. This leads to unnecessary procedures, increased healthcare costs, and potential psychological harm.

2. Underscreening: About 11% of women are not being screened regularly 3. Ensure that all eligible women receive appropriate screening.

3. Screening too early: Beginning screening before age 21 is not recommended regardless of sexual activity onset 1.

4. Continuing screening unnecessarily: Screening women who have had a total hysterectomy for benign disease or women over 65 with adequate prior negative screening provides minimal benefit while exposing them to potential harms 1.

5. Stopping screening prematurely: Never discontinue screening before age 65 in average-risk women without verifying adequate prior screening 1.

By following these evidence-based guidelines, clinicians can optimize the benefits of cervical cancer screening while minimizing potential harms to patients.