Pap Smear with HPV Testing Recommendations by Age
Pap smear with HPV co-testing is recommended to begin at age 30 and should be performed every 5 years until age 65 in women with normal screening history. 1, 2
Age-Based Screening Recommendations
Ages 21-29
- Begin cervical cancer screening at age 21 regardless of sexual history
- Screening with cytology (Pap test) alone every 3 years
- HPV testing is NOT recommended in this age group
- Rationale: High HPV prevalence but high regression rates make HPV testing less useful 3
Ages 30-65
- Preferred screening: HPV and cytology co-testing every 5 years
- Alternative: Cytology alone every 3 years
- HPV testing alone every 5 years is also acceptable per USPSTF 2
- Rationale: Lower HPV prevalence with age makes co-testing more specific and allows for extended screening intervals 3
After Age 65
- Discontinue screening if:
- At least 3 consecutive negative Pap tests OR
- At least 2 consecutive negative co-tests within the past 10 years
- Most recent test performed within the past 5 years
- No history of CIN2+ within the past 20 years
- Continue screening beyond 65 only for women with:
- History of cervical cancer
- In utero DES exposure
- Immunocompromised status
- Inadequate prior screening 1
Special Populations
After Hysterectomy
- Discontinue screening if cervix was removed for benign reasons
- Continue screening if hysterectomy was performed for cervical precancer or cancer 3, 1
HIV-Positive Women
- Begin screening within 1 year of sexual activity onset but no later than age 21
- Annual screening recommended initially
- After 3 consecutive normal cytology results or normal co-tests, screening interval can be increased to every 3 years
- Lifelong screening is recommended 3
Benefits of Co-testing at Age 30+
- Higher sensitivity for detecting precancerous lesions
- Improved detection of preinvasive glandular lesions
- Extended screening intervals (5 years vs. 3 years)
- Higher negative predictive value (99-100%) 3
Common Pitfalls to Avoid
Overscreening young women: Screening before age 21 or HPV testing before age 30 leads to unnecessary procedures and anxiety with minimal benefit 3, 4
Annual screening habit: Despite guidelines recommending 3-5 year intervals, many providers continue to recommend annual screening 5
Continuing screening after hysterectomy: Women who have had a total hysterectomy with removal of the cervix for benign reasons should discontinue screening 1
Screening beyond age 65: Women with adequate prior negative screening do not benefit from continued screening beyond age 65 3, 1
Failure to extend intervals with co-testing: When using HPV and cytology together, the 5-year interval is safe and reduces unnecessary procedures 3, 2
The evidence clearly supports beginning HPV co-testing at age 30, as HPV testing in younger women has poor specificity due to the high prevalence and transient nature of HPV infections in this population 3. Following these age-appropriate screening guidelines optimizes the balance between early detection of cervical precancer and minimizing harms from overscreening.