What are the recommended pap smear screening guidelines for a 55-year-old female with a history of abnormal Pap (Papanicolau) smears?

Pap Screening Recommendations for a 55-Year-Old Woman with History of Abnormal Paps

A 55-year-old woman with a history of abnormal Pap smears should continue cervical cancer screening every 3 years with Pap testing alone or every 5 years with co-testing (Pap plus HPV), and cannot discontinue screening at age 65 unless she has documented adequate negative screening for at least 20 years after her last abnormal result. 1, 2

Screening Frequency at Age 55

For women aged 30-65 years, the recommended screening approach is: 3

• Preferred: Pap test plus HPV DNA test (co-testing) every 5 years 3
• Acceptable: Pap test alone every 3 years 3

This applies to your patient currently at age 55, regardless of her history of abnormal Paps, as long as she does not have a history of high-grade lesions (CIN2 or CIN3). 3

Critical Impact of Abnormal Pap History on Screening Cessation

The history of abnormal Paps fundamentally changes when this patient can stop screening:

Standard cessation criteria (which do NOT apply to this patient): 3, 1

• Women can stop screening at age 65 if they have had ≥3 consecutive negative Pap tests OR ≥2 consecutive negative HPV and Pap co-tests within the last 10 years, with the most recent test in the last 5 years 3, 1

Modified cessation criteria for women with abnormal Pap history: 1, 2

• If the patient had CIN2, CIN3, or adenocarcinoma in situ: Routine screening must continue for at least 20 years after treatment, even if this extends screening past age 65 1, 2
• If the patient had lower-grade abnormalities (ASC-US, LSIL, or CIN1): She must demonstrate adequate negative screening (3 consecutive negative Paps or 2 negative co-tests over 10 years) AFTER resolution of the abnormality before cessation criteria apply 1, 2

Specific Algorithm for This Patient

Step 1: Determine the severity of past abnormalities 1, 2

• Review records to identify whether she had CIN2+, CIN1, or lower-grade abnormalities
• Document when the last abnormality occurred and when it resolved

Step 2: If CIN2 or CIN3 history: 1, 2

• Continue screening for 20 years from the date of treatment/resolution
• This will extend well beyond age 65
• Use either co-testing every 5 years or Pap alone every 3 years 1

Step 3: If CIN1 or lower-grade abnormality history: 1, 2

• Continue current screening intervals (every 3-5 years) through age 65
• Can only stop at age 65 if she achieves 3 consecutive negative Paps or 2 negative co-tests in the 10 years AFTER the abnormality resolved 1, 2
• The 10-year "clock" starts after resolution, not from the date of the abnormality 1

Step 4: If documentation is inadequate: 1, 2

• Assume she needs continued screening through age 65 at minimum
• Perform screening tests until adequate negative screening history is established 1, 2

Common Pitfalls to Avoid

Do not discontinue screening at age 65 prematurely: 1, 2

• The most critical error is stopping screening at age 65 in a woman with prior abnormal Paps who has not had adequate subsequent negative screening 1, 2
• Women with a history of abnormal Paps are at significantly higher risk and require extended surveillance 3, 4

Do not count screening tests that occurred before or during the abnormal period: 1, 2

• Only negative tests obtained AFTER resolution of the abnormality count toward the "adequate screening" requirement 1

Do not under-screen based on age alone: 3, 4

• Women with inadequate prior screening or history of abnormalities have 3-4 times higher incidence of cervical disease compared to adequately screened women 3, 1

Additional Risk Factors to Consider

Beyond the abnormal Pap history, assess for other risk factors that may warrant continued screening beyond standard age cutoffs: 3, 1

• Immunosuppression (HIV, transplant recipients, chronic steroid use) 3, 1
• History of multiple sexual partners 3, 1
• Smoking 3, 1
• Pessary use 3
• High-risk ethnicity (Vietnamese or Hispanic women have higher cervical cancer rates) 3

If any of these risk factors are present, consider continuing screening beyond age 65 even with adequate negative screening history. 3, 1

Quality of Life Considerations

While continued screening involves some discomfort and potential for false-positive results leading to unnecessary procedures, the mortality benefit in women with prior abnormal Paps justifies ongoing surveillance. 1, 5 The absolute risk reduction is meaningful in this population, unlike in women with consistently normal screening histories. 1, 5