Should a 22-year-old woman who is sexually inactive get a Pap (Papanicolau) smear?

Pap Smear Recommendations for Sexually Inactive 22-Year-Old Women

A 22-year-old woman who has never been sexually active does not need to undergo Pap smear screening at this time. Current guidelines do not recommend cervical cancer screening for women who have never had vaginal sexual intercourse, regardless of age.

Evidence-Based Rationale

The primary rationale for this recommendation is based on the following key points:

• Cervical cancer is primarily caused by persistent infection with high-risk human papillomavirus (HPV) types, which are sexually transmitted
• Women who have never had vaginal sexual intercourse have an extremely low risk of HPV exposure and subsequent cervical dysplasia
• Screening in this population would lead to unnecessary procedures with potential harms

Current Guideline Recommendations

Multiple guidelines address this specific scenario:

• The American Cancer Society (ACS) explicitly states that "provider discretion and patient choice following counseling should be used to guide the initiation of cervical cytology screening in young women aged 21 and older who have never had vaginal sexual intercourse and for whom the absence of a history of sexual abuse is certain" 1

• The American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force (USPSTF) recommend that cervical screening begin at age 21 years, but this is based on the assumption of sexual activity 1

• The 2015 American College of Physicians guidelines emphasize that screening before age 21 is not recommended regardless of sexual history, but this applies specifically to women under 21 1

Risk Assessment and Decision Algorithm

For a 22-year-old woman who has never had sexual intercourse:

1. Primary consideration: Without vaginal sexual intercourse, the risk of HPV exposure to the cervix is extremely low
2. Age factor: While she is above the age threshold of 21 years when screening typically begins, the absence of sexual activity is the more important factor
3. Exception assessment: Determine if any special circumstances exist:
   • History of sexual abuse (may warrant screening)
   • Immunocompromised status (may warrant screening)

Common Pitfalls to Avoid

1. Automatic age-based screening: Many providers incorrectly initiate Pap testing based solely on age (22 years) without considering sexual history
2. Misunderstanding of guidelines: Research shows that unnecessary Pap testing remains high among young women despite guideline changes 2
3. Confusion between pelvic exam and Pap test: Many women believe they have had a Pap test when they've only had a pelvic examination 1

Special Considerations

• If the patient later becomes sexually active, cervical cancer screening should begin approximately 3 years after the onset of vaginal sexual intercourse 1
• The patient should be educated about the purpose of Pap smears, why screening is not currently indicated, and when to initiate screening in the future
• Document the discussion and decision-making process in the medical record

Conclusion

The evidence clearly supports that this 22-year-old woman who has never been sexually active does not need Pap smear screening at this time. This approach avoids unnecessary testing while maintaining appropriate preventive care.