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

Cervical Cancer Screening Guidelines

Women should begin cervical cancer screening at age 21 regardless of sexual history, with screening every 3 years using cytology (Pap test) alone for ages 21-29, and preferably every 5 years with HPV and cytology co-testing (or every 3 years with cytology alone) for ages 30-65. 1

Age to Begin Screening

• Start screening at age 21 regardless of sexual debut or sexual history
• Screening is not recommended for women under 21 years of age, as cervical cancer is extremely rare in this age group 1, 2
• This represents a significant change from earlier guidelines that recommended starting screening at a younger age or with onset of sexual activity 1

Screening Intervals by Age Group

Ages 21-29:

• Cervical cytology (Pap test) alone every 3 years
• HPV testing is not recommended for this age group 1

Ages 30-65:

• Preferred approach: HPV and cytology co-testing every 5 years
• Acceptable alternative: Cytology alone every 3 years 1, 3
• Annual screening is not recommended by current guidelines 2

When to Discontinue Screening

Women can discontinue cervical cancer screening at age 65 if they meet ALL of the following criteria:

• Have had at least 3 consecutive negative Pap tests or at least 2 consecutive negative HPV and Pap tests within the last 10 years
• Most recent test occurred within the last 5 years
• No history of cervical cancer or high-grade precancerous lesions 1

Women who have had a total hysterectomy (with removal of the cervix) for benign reasons and have no history of high-grade precancerous lesions should discontinue screening 1.

Special Populations Requiring Different Screening Protocols

• Women with HIV infection: Pap test twice in the first year after diagnosis, then annually if results are normal
• Women with immunocompromised status, in utero DES exposure, or previous cervical cancer/high-grade precancerous lesions: Require more intensive screening protocols
• Women who have had a subtotal hysterectomy (cervix remains): Continue age-appropriate screening
• Women with history of cervical cancer, high-grade precancerous lesions, in utero DES exposure, or immunocompromised status: Continue screening beyond age 65 1

Common Pitfalls to Avoid

1. Screening too early: Starting screening before age 21 can lead to unnecessary interventions for transient HPV infections that would likely resolve on their own 1, 2

2. Screening too frequently: Annual screening is no longer recommended for any age group and can lead to overtreatment and increased costs 1, 2

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

4. Failing to screen women aged 22-30: Despite the trend toward following guidelines for not screening women under 21, there has been a concerning increase in the proportion of women aged 22-30 who report never having had a Pap test (from 6.6% to 9.0%) 2

5. Continuing screening unnecessarily: Women who have had a total hysterectomy for benign reasons with no history of high-grade precancerous lesions do not need continued screening 1

The evolution of these guidelines reflects the understanding that cervical cancer is rare in young women and that too-frequent screening can lead to unnecessary procedures and potential harm from overtreatment. Following these evidence-based recommendations optimizes the benefits of screening while minimizing potential harms.