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

Cervical Cancer Screening Recommendations: When to Start Pap Smears

Pap smear screening should begin at age 21 years, regardless of sexual activity history. 1

Current Age-Based Recommendations

• Screening should begin at age 21 years, regardless of when sexual activity was initiated 1
• For women aged 21-29 years, screening should be performed every 2-3 years 1
• For women aged 30 years and older with normal results, screening can be extended to every 3 years 1
• Women aged 30 years and older may also opt for HPV co-testing with Pap test every 5 years 1
• Screening may be discontinued at age 65-70 years after 3 consecutive normal tests in the last 10 years 1

Evolution of Screening Guidelines

The recommended age to begin cervical cancer screening has evolved over time based on improved understanding of HPV's role in cervical cancer and the natural history of the disease:

• Earlier guidelines (pre-2010) recommended screening approximately 3 years after first vaginal intercourse but no later than age 21 years 1
• Since 2010, major organizations have recommended starting at age 21 years regardless of sexual activity 1
• The American Cancer Society updated their guidelines in 2020 to recommend starting screening at age 25 years, citing the low incidence of cervical cancer in women under 25 and potential harms of treatment 1

Rationale for Current Recommendations

Starting screening at age 21 rather than earlier is based on several important factors:

• Very low incidence of cervical cancer in women younger than 21 years (only 0.1% of all cervical cancer cases) 1
• Annual incidence of only 1-2 cases per 1,000 females aged 15-19 years 1
• Potential harm from anxiety and unnecessary procedures following positive tests 1
• Increased risk of premature births in women previously treated with excisional procedures for precursor lesions that would likely regress without treatment 1

Special Considerations

• Women with hysterectomy (with cervix removed) for benign reasons can discontinue screening 1, 2
• Women at high risk (HIV positive, immunocompromised, history of cervical cancer) may require more frequent screening 2
• Despite guidelines, studies show that many young women under age 21 still receive unnecessary Pap tests (25.1%) and pelvic examinations (30.8%) 3

Common Pitfalls to Avoid

• Over-screening young women under age 21, which can lead to unnecessary procedures and anxiety 4, 3
• Performing Pap tests too frequently (annually) when guidelines recommend longer intervals 2, 4
• Discontinuing screening too early (before age 65) in women without adequate prior normal screening 2, 5
• Continuing screening after hysterectomy when the cervix has been removed for benign reasons 2

Trends in Screening Practices

Recent data shows that screening practices have been moving toward alignment with current guidelines:

• The percentage of women aged 18-21 years reporting never having been screened increased from 26.3% in 2000 to 47.5% in 2010 4
• The proportion of women aged 18-21 years reporting having had a Pap test in the past 12 months decreased from 65.0% to 41.5% 4
• Among women aged 22-30 years, the proportion reporting having had a Pap test within the preceding 12 months decreased from 78.1% to 67.0% 4

By following these evidence-based guidelines, clinicians can optimize the benefits of cervical cancer screening while minimizing potential harms from unnecessary procedures.