Is a Pap (Papanicolau) smear indicated in postmenopausal women?

Pap Smear Screening in Postmenopausal Women

Pap smear screening should continue until age 65-70 in postmenopausal women with adequate prior screening, and may be discontinued after this age if they have had 3 consecutive negative tests in the past 10 years with no history of abnormal results. 1, 2

General Recommendations for Postmenopausal Women

• Postmenopausal women should continue cervical cancer screening until age 65 according to USPSTF or age 70 according to the American Cancer Society, as long as they have adequate prior screening 3, 1
• For women aged 30-65 (including postmenopausal women in this age range), the preferred screening approach is either Pap test plus HPV DNA test every 5 years or Pap test alone every 3 years 1, 4
• HPV testing may be more accurate than co-testing in postmenopausal women due to physiologic changes of the hypoestrogenic state that can lead to misinterpretation of atrophic smears 5

Criteria for Discontinuing Screening

• Women may discontinue screening after age 65-70 only if they meet ALL of the following criteria:

  • Have had no abnormal/positive cytology tests within the 10-year period prior to age 65-70 3, 2
  • Have documentation that the 3 most recent Pap tests were technically satisfactory and interpreted as normal 3, 1
  • Have evidence of adequate negative prior screening and no history of CIN2+ within the last 20 years 2

• Once screening is discontinued, it should not resume for any reason, even if a woman reports having a new sexual partner 2

Special Populations Requiring Continued Screening

Screening should continue beyond age 65-70, regardless of menopausal status, in the following situations:

• Women who have not been previously screened 3, 2
• Women for whom information about previous screening is unavailable 3, 1
• Women with a history of cervical cancer or in utero exposure to diethylstilbestrol (DES) 3, 1
• Women who are immunocompromised, including HIV-positive patients 3, 1
• Women with a history of CIN2/3 (screening should continue for at least 20 years) 2
• Women with specific risk factors including multiple sex partners, history of HPV infection, smoking, and pessary use 3, 2
• Certain ethnic populations at higher risk, including Vietnamese and Hispanic women 3, 2

Evidence Supporting These Recommendations

• The prevalence of high-risk HPV is significantly lower in postmenopausal women (11.5%) compared to premenopausal women (41.6%) 5
• In well-screened women older than 65 years, CIN2+ prevalence is low and cervical cancer is rare 2
• 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 2
• Women who have gone through menopause are less likely to have a Pap smear test in subsequent years, highlighting the importance of ensuring adequate screening before discontinuation 6

Common Pitfalls to Avoid

• Discontinuing screening too early (before age 65) when a woman has not had adequate prior screening 1
• Failing to document screening history adequately, which may lead to unnecessary continuation or inappropriate cessation of screening 1
• Assuming that a pelvic examination includes a Pap test - many women erroneously believe that a sample for Pap testing was taken during a pelvic exam when it was not 3
• Stopping screening in women with a history of cervical dysplasia or cancer, immunocompromised status, or other significant risk factors 2
• Overlooking the need for screening in postmenopausal women who have never been adequately screened, as they remain at risk for cervical cancer 7

Practical Algorithm for Screening Decisions in Postmenopausal Women

1. If woman is <65 years old: Continue screening with either Pap test every 3 years or Pap+HPV co-testing every 5 years 1, 4
2. If woman is ≥65-70 years old:
   • If she has had 3 consecutive negative Pap tests within the past 10 years with no history of abnormal results: Stop screening 3, 2
   • If she has inadequate prior screening, history of cervical dysplasia/cancer, immunocompromised status, or other risk factors: Continue screening 1, 2
3. If woman has had a hysterectomy with removal of the cervix for benign reasons: Stop screening 2
4. If woman has never been screened: Perform at least two negative tests one year apart, regardless of age 2