At what age and frequency should a woman get a pap (Papanicolaou) smear?

Cervical Cancer Screening (Pap Smear) Recommendations

Women should begin cervical cancer screening at age 21, undergo screening every 3 years with Pap tests until age 29, and then either continue Pap tests every 3 years or preferably switch to co-testing (Pap plus HPV test) every 5 years from ages 30-65, after which screening can be discontinued with adequate prior negative results. 1, 2

When to Start Screening

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

Screening Frequency by Age Group

Ages 21-29:

• Screen every 3 years with conventional or liquid-based Pap test only 1, 2
• HPV testing is not recommended for routine screening in this age group 1

Ages 30-65:

• Preferred option: Co-testing with both Pap test and HPV DNA test every 5 years 1, 2
• Acceptable alternative: Pap test alone every 3 years 1, 2
• Approximately one-third of women who are up to date with Pap testing report having had co-testing with their most recent Pap test 4

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, 5
• Women who have had a total hysterectomy (with removal of the cervix) for benign reasons should stop cervical cancer screening 1, 5, 2

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 5, 6
• Women who have never been screened should have at least two negative smears one year apart, regardless of age 2
• High-risk women (HIV positive, immunocompromised, history of cervical dysplasia) may require more frequent screening based on clinical judgment 2

Common Pitfalls to Avoid

• Over-screening: Despite guidelines recommending 3-year intervals, historical data shows that 55% of American women were undergoing annual Pap testing, which increases costs and potential harms without significantly improving cancer detection 7, 2
• Under-screening: About 14 million women aged 21-65 in the US have not been screened within the past 3 years 4
• Continuing screening unnecessarily after hysterectomy: Women who have had their cervix removed for benign reasons do not need continued Pap testing 5, 2
• Screening very elderly women: Despite the low yield, data shows that 38% of women aged 75-84 and 20% of women aged 85+ reported annual Pap smears, which has limited benefit and potential harms 7, 8

Evidence Supporting Current Recommendations

• The 3-year screening interval for Pap tests is supported by strong evidence showing that more frequent screening improves effectiveness by less than 5% 2
• For women aged 30-65, the addition of HPV testing allows for a longer 5-year screening interval due to the increased sensitivity of the combined approach 2
• Once screening is discontinued after age 65, it should not resume for any reason, even if a woman reports having a new sexual partner 5
• The incidence of cervical cancer among women age 70 and older who had at least one normal Pap smear in the previous 10 years is only three cases per 100,000 5

Populations at Risk for Under-screening

• Recent immigrants to the United States 4
• Women without health insurance 4
• Women without a usual source of healthcare 4
• These populations should be targeted for improved access to appropriate cervical cancer screening 4