At what age should a woman start and stop having Pap (Papanicolau) smears?

Cervical Cancer Screening Guidelines: When to Start and Stop Pap Smears

Women should begin cervical cancer screening at age 21 and can discontinue screening after age 65 if they have had adequate negative prior screening results and are not at high risk for cervical cancer. 1

Starting Age for Cervical Cancer Screening

• Begin screening at age 21 regardless of sexual history or activity
• Screening before age 21 is not recommended as it can lead to unnecessary procedures, anxiety, and increased healthcare costs 1
• This recommendation is consistent across major medical organizations including the American College of Obstetricians and Gynecologists, the USPSTF, and the American College of Physicians 1

Screening Intervals

For women of average risk:

• Ages 21-29: Cytology (Pap test) alone every 3 years
• Ages 30-65: Either HPV and cytology co-testing every 5 years (preferred) OR cytology alone every 3 years 1

When to Stop Screening

Cervical cancer screening can be discontinued at age 65 if the following criteria are met:

• 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+ (moderate or severe cervical dysplasia) within the past 20 years 1

Special Considerations for Continuing Screening Beyond Age 65

Continue screening beyond age 65 ONLY for women with:

• History of cervical cancer
• In utero DES exposure
• Immunocompromised status
• Previous high-grade precancerous lesions within the past 20 years 1

Women Who Have Had a Hysterectomy

• Women who have had a hysterectomy with removal of the cervix for benign reasons should discontinue screening 1
• Women who have had a hysterectomy but still have their cervix should continue age-appropriate screening as outlined above

Common Pitfalls to Avoid

1. Overscreening: Despite guidelines recommending longer intervals, research shows that 55% of American women undergo annual Pap screening 2. This leads to unnecessary procedures, patient anxiety, increased healthcare costs, and potential harms from false positive results.

2. Underscreening in older women: Some providers incorrectly assume that older women don't need screening. While the American Geriatrics Society has recommended Pap tests every three years until age 70 1, many older women report not being screened regularly.

3. Continuing screening unnecessarily after hysterectomy: Women who have had a total hysterectomy (with cervix removal) for benign disease do not need continued Pap screening.

4. Stopping screening too early: Women with risk factors should continue screening beyond age 65.

Patient Education

Healthcare providers should clearly communicate:

• The recommended screening schedule based on age and risk factors
• The rationale for starting at age 21 and potentially stopping at age 65
• The risks and benefits of screening at different intervals
• The importance of adherence to recommended intervals rather than annual testing

By following these evidence-based guidelines, healthcare providers can maximize the benefits of cervical cancer screening while minimizing potential harms from both over and underscreening.