At what age should women start getting Pap (Papanicolau) smear tests?

Cervical Cancer Screening: When to Start Pap Smear Testing

Women should start cervical cancer screening at age 21 regardless of sexual history, as recommended by the American Cancer Society, American College of Obstetricians and Gynecologists (ACOG), and the US Preventive Services Task Force (USPSTF). 1

Current Recommendations for Starting Cervical Cancer Screening

The most recent guidelines provide clear direction on when to begin screening:

• Start screening at age 21 regardless of sexual activity or other risk factors 1
• Prior to age 21, Pap testing is not recommended, even for sexually active individuals 1, 2
• This recommendation represents a consensus among major medical organizations including:
  • American Cancer Society
  • American College of Obstetricians and Gynecologists
  • US Preventive Services Task Force

Rationale Behind Age 21 Recommendation

There are several evidence-based reasons for starting at age 21:

• Cervical cancer is extremely rare in women under 21 years 1, 2
• HPV infections in young women typically resolve without intervention 1
• Screening too early can lead to unnecessary procedures and potential overtreatment 2
• The harms of screening (anxiety, additional testing, unnecessary treatments) may outweigh benefits in very young women 2

Screening Schedule After Initial Testing

Once screening begins at age 21, the recommended intervals are:

• Ages 21-29: Cytology (Pap test) alone every 3 years 1
• Ages 30-65: Preferred approach is HPV and cytology co-testing every 5 years, or cytology alone every 3 years as an acceptable alternative 1
• Annual screening is NOT recommended for any age group 1

Special Considerations

Some populations may require different screening approaches:

• Women with HIV infection: Pap test twice in the first year after diagnosis, then annually if results are normal 1
• Women with immunocompromised status, in utero DES exposure, or previous cervical cancer/high-grade precancerous lesions: More intensive screening protocols are needed 1

Common Pitfalls to Avoid

1. Starting too early: Despite updated guidelines, a study found that 25.1% of women still received Pap tests before age 21 3. This contradicts current recommendations and may lead to unnecessary interventions.

2. Screening too frequently: Many women continue to receive annual screening despite guidelines recommending longer intervals. About 36% of routinely screened women receive annual cervical smears rather than following the recommended 3-year interval 4.

3. Confusion about sexual activity: Older guidelines recommended starting Pap tests within 3 years of sexual debut or by age 21, whichever came first 5. Current guidelines have simplified this to age 21 regardless of sexual history 1, 2.

4. Stopping screening too early: Screening should continue until age 65 if results remain normal, with specific criteria for discontinuation 1.

Trends in Screening Practices

There has been gradual movement toward alignment with current guidelines:

• Between 2000-2010, the percentage of women aged 18-21 years reporting never having been screened increased from 26.3% to 47.5% 2
• The proportion of women aged 18-21 reporting having had a Pap test in the past 12 months decreased from 65.0% to 41.5% 2

However, there is still room for improvement in educating both providers and patients about current evidence-based recommendations.