At what age should a 19-year-old woman start getting Pap (Papanicolaou) smears?

Cervical Cancer Screening for 19-Year-Old Women

A 19-year-old woman should not begin Pap smear screening until age 21, regardless of sexual history or activity. 1, 2

Current Guidelines on Cervical Cancer Screening

The most recent guidelines from multiple authoritative organizations are consistent in their recommendations for when to begin cervical cancer screening:

• The U.S. Preventive Services Task Force (USPSTF) recommends that cervical screening begin at age 21 years 1
• The American College of Obstetricians and Gynecologists (ACOG) recommends starting screening at age 21 1, 2
• The American Cancer Society (ACS) recommends that women begin cervical cancer screening at age 21, regardless of sexual history 1, 2

Rationale for Starting at Age 21

There are several important reasons why screening is not recommended before age 21:

• Low incidence of cervical cancer in women under 21 1
• Limited utility of screening in younger women 1
• Risk of overtreatment and adverse events from too-frequent screening in young women 3
• HPV infections in adolescents and young women are often transient and clear spontaneously 1

Screening Schedule After Age 21

When the patient reaches age 21, the recommended screening schedule is:

• Ages 21-29: Screening every 3 years with cytology (Pap smear) alone 1, 2
• HPV testing should not be used for screening women in this age group 1
• Ages 30-65: Preferred approach is screening every 5 years with HPV testing and cytology ("co-testing"), or alternatively every 3 years with cytology alone 1, 2

Important Considerations

Common Misconceptions

• Despite current guidelines, research shows that 25.1% of women still receive Pap tests before age 21 4
• Many women and providers may still follow older guidelines that recommended starting Pap tests at age 18 or with onset of sexual activity 1, 5
• There is a common misconception that annual screening is necessary, when in fact guidelines explicitly recommend against annual screening for most women 1, 6

Special Circumstances

• These recommendations apply to average-risk women. Women with special risk factors (immunocompromised status, HIV infection, in utero DES exposure, previous cervical cancer) may require different screening protocols 1
• Even for women with early sexual debut or multiple partners, screening should still begin at age 21 2

Counseling Points for 19-Year-Old Patients

When discussing this recommendation with a 19-year-old patient:

• Explain that cervical cancer is extremely rare in women under 21
• Reassure that HPV infections in young women typically resolve without intervention
• Emphasize that unnecessary screening can lead to unnecessary procedures and potential harm
• Discuss the importance of beginning regular screening at age 21
• Address the importance of HPV vaccination if not already completed

Conclusion

While cervical cancer screening is a critical preventive health measure, current evidence-based guidelines from all major medical organizations clearly recommend against Pap testing before age 21, regardless of sexual history or activity. This recommendation balances the benefits of early detection against the potential harms of overscreening and overtreatment in young women.