What are the guidelines for getting a pap (Papanicolau) smear?

Pap Smear Screening Guidelines

When to Start Screening

All women should begin cervical cancer screening at age 21 years, regardless of sexual activity history or HPV vaccination status. 1, 2 This recommendation represents a shift from older guidelines that tied screening initiation to sexual debut; the change is based on the extremely low incidence of cervical cancer in women under 21 (only 0.1% of all cases occur in this age group). 2

Screening Intervals by Age

Ages 21-29 Years

• Screen every 3 years with Pap test alone 1, 2
• Do not use HPV testing for primary screening in this age group, as HPV infection is common and usually transient in younger women 3
• Annual screening is not recommended and leads to unnecessary procedures without meaningful improvement in cancer prevention 2

Ages 30-65 Years

The preferred approach is co-testing (Pap test plus HPV test) every 5 years 1, 2, 4

An acceptable alternative is:

• Pap test alone every 3 years 1, 2, 4

The 5-year interval with co-testing is safe because HPV testing has increased sensitivity for detecting precancerous lesions, allowing for longer intervals between screens. 2, 4

When to Stop Screening

Women over age 65 may discontinue screening if ALL of the following criteria are met: 2, 4

• Three consecutive negative Pap tests OR two consecutive negative co-tests (HPV + Pap) within the past 10 years 2, 4
• The most recent test was within the past 5 years 2, 4
• No history of CIN2+ (moderate or severe dysplasia) within the past 20 years 4
• No history of cervical cancer 4

Continue screening beyond age 65 in these situations: 4

• Inadequate or unknown prior screening history 4
• History of cervical cancer or high-grade precancerous lesions 4
• HIV infection or other immunocompromising conditions 4
• In utero DES exposure 4

Women in good health may continue screening until age 70 if they have not met discontinuation criteria. 3, 4

Special Populations

Post-Hysterectomy

• Discontinue screening if total hysterectomy (cervix removed) was performed for benign reasons and there is no history of high-grade lesions 2
• Continue screening if cervical cuff remains or if hysterectomy was performed for cervical cancer or precancerous lesions 2

High-Risk Women

Women with HIV, other immunocompromising conditions, or history of high-grade lesions require more frequent screening than outlined above and should follow specialized protocols. 2, 4

Common Pitfalls to Avoid

Over-screening is extremely common and harmful: 5, 6

• 55% of American women report annual Pap smears despite recommendations for 3-year intervals 5
• Even women over age 75 frequently undergo unnecessary annual screening (38% of women aged 75-84) 5
• Annual screening provides less than 5% additional benefit compared to 3-year intervals while substantially increasing false positives and unnecessary procedures 2

Under-screening in appropriate populations: 6, 7

• 9% of women aged 22-30 report never having been screened 6
• Elderly women who were lifelong non-users of screening remain at elevated risk and should be screened if they have inadequate prior screening history 7

Inappropriate HPV testing: 3

• Do not use HPV testing for women under age 30 for primary screening 3
• HPV testing should only be used in women under 30 for triage of ASC-US results 3

Premature discontinuation of screening: 4

• Do not stop screening before age 65 without documented adequate prior negative screening 4
• Ensure proper documentation of screening history before discontinuing 4

Laboratory and Technical Requirements

All cervical screening should use CLIA-certified laboratories that report results using Bethesda 2001 terminology (ASC, ASC-US, ASC-H, LSIL, HSIL). 3, 1 Both conventional and liquid-based cytology are acceptable methods. 3, 1