At what age should women start having Pap (Papanicolaou) smears?

When to Start Pap Smears for Women

Pap smear screening should begin at age 21 years, regardless of sexual activity history. 1, 2

Current Age-Based Recommendations

• Cervical cancer screening with Pap tests should begin at age 21 years for all women, regardless of when they became sexually active 1, 2
• For women aged 21-29 years, screening should be performed every 3 years with conventional or liquid-based Pap tests 3
• For women aged 30-65 years, screening can be done either:
  • Every 5 years with both HPV test and Pap test (co-testing) - preferred approach 3
  • Every 3 years with Pap test alone - acceptable alternative 3
• Women over 65 years with adequate prior normal screening can discontinue screening 3

Evolution of Screening Guidelines

• Earlier guidelines (pre-2012) recommended screening approximately 3 years after first vaginal intercourse but no later than age 21 years 3
• In 2012, major organizations aligned their recommendations to start screening at age 21 regardless of sexual activity 4
• This change represented a significant shift from previous practice patterns, where many young women were screened annually starting at sexual debut 4
• The trend toward later initiation of screening has been observed in practice, with the percentage of women aged 18-21 years reporting never having been screened increasing from 26.3% in 2000 to 47.5% in 2010 4

Rationale for Current Age Threshold

• The incidence of cervical cancer in women younger than 21 years is extremely low (only 0.1% of all cervical cancer cases) 1
• Annual incidence is only 1-2 cases per 1,000 females aged 15-19 years 1
• Potential harms from screening women under 21 include:
  • Unnecessary anxiety from false positive results 1, 2
  • Overtreatment of transient HPV infections that would likely clear on their own 4, 5
  • Potential adverse effects on future pregnancy outcomes from some treatments for cervical dysplasia 1

Special Considerations

• Women with hysterectomy (with cervix removed) for benign reasons can discontinue screening 3
• Women at high risk (HIV positive, immunocompromised, history of cervical cancer) may require more frequent screening 1, 2
• Women should be educated about the importance of regular screening according to guidelines, as adherence to recommended intervals remains suboptimal 6

Common Pitfalls to Avoid

• Screening women younger than 21 years, which is no longer recommended by any major guideline organization 1, 4
• Screening more frequently than recommended intervals (annual testing is no longer recommended for average-risk women) 3
• Failure to follow up on abnormal results with appropriate management 2
• Discontinuing screening too early (before age 65) in women without adequate prior screening 3

Despite the clear guidelines, some research suggests that younger women (21-<25 years) with certain risk factors (multiple sexual partners, smoking, early childbearing) may still benefit from screening 7, but the current consensus guidelines prioritize avoiding overtreatment in this age group where invasive cancer is rare.