At what age and frequency is a Pap (Papanicolau) smear recommended for women?

Pap Smear Screening Recommendations

Cervical cancer screening should begin at age 21, be performed every 3 years with Pap tests until age 29, then every 5 years with HPV co-testing (preferred) or every 3 years with Pap test alone from ages 30-65, and can be discontinued after age 65 if there have been adequate normal prior results. 1, 2

When to Start Screening

• Cervical cancer screening should begin at age 21 regardless of sexual activity onset 1, 2
• Women under age 21 should not be screened, even if sexually active 2, 3

Screening Frequency by Age Group

• Ages 21-29: Pap test every 3 years 1, 2
• Ages 30-65: Two options:
  • Preferred: Pap test plus HPV DNA test every 5 years 1, 2
  • Acceptable alternative: Pap test alone every 3 years 1, 2

When to Stop Screening

• Women aged >65 years who have had ≥3 consecutive negative Pap tests or ≥2 consecutive negative HPV and Pap tests within the last 10 years, with the most recent test occurring within the last 5 years, should stop cervical cancer screening 1, 4
• Women who have had a total hysterectomy (with removal of the cervix) for benign reasons should stop cervical cancer screening 1, 4
• Once screening is discontinued after age 65, it should not resume for any reason, even if a woman reports having a new sexual partner 4

Special Populations and Considerations

• Women with a history of cervical cancer or high-grade precancerous lesions (CIN2+) should continue screening for at least 20 years after treatment, even if this extends beyond age 65 4, 2
• Women who are immunocompromised, HIV-positive, or have other risk factors may require more frequent screening based on clinical judgment 2
• Women who have never been screened should have at least two negative smears one year apart, regardless of age 2

Evidence Supporting Current Recommendations

• The 3-year screening interval for Pap tests is supported by strong evidence showing that performing Pap tests more frequently improves screening effectiveness by less than 5% 2
• For women aged 30-65, the addition of HPV testing (co-testing) allows for a longer 5-year screening interval due to the increased sensitivity of the combined approach 2
• In well-screened women older than 65 years, CIN2+ prevalence is low and cervical cancer is rare 4
• Modeling studies have concluded that for women who have been screened regularly prior to age 65, the ratio of colposcopies to years of life gained associated with further screening is large because of the small gains in life expectancy 4

Common Pitfalls to Avoid

• Over-screening: Despite recommendations, studies show many women continue to receive annual Pap tests unnecessarily 5, 6
• Under-screening high-risk populations: Women with previous abnormal results, immunocompromised status, or HIV infection require more vigilant screening 2
• Discontinuing screening too early: Women with inadequate prior screening or history of cervical abnormalities should continue screening beyond age 65 4
• Continuing screening after hysterectomy: Unnecessary in women who have had their cervix removed for benign reasons 1, 4
• Confusion between pelvic examination and Pap test: Many women erroneously believe that a pelvic examination includes a Pap test when it may not 1

Current Screening Patterns

• Despite recommendations for less frequent screening, studies show that approximately 55% of women without a history of abnormal results still undergo annual Pap testing 5
• Screening rates have been declining among women aged 18-21 years, moving toward alignment with current guidelines 3
• Among women aged 22-30 years who should be screened every 3 years, a concerning trend shows an increase in the proportion who report never having had a Pap test (from 6.6% to 9.0%) 3