At what age should women start getting Pap (Papanicolau) smears and how often should they be done?

Pap Smear Age Recommendations

Women should begin Pap smear screening at age 21 years regardless of sexual activity history, and screening should never be performed before age 21. 1, 2, 3

Screening Initiation

• Start screening at age 21 years for all women, even if they have not yet become sexually active 4, 1, 2
• Women younger than 21 years should never be screened, regardless of when they began having sexual intercourse 4, 1, 5
• The rationale for this age cutoff is compelling: cervical cancer incidence in women under 21 is extremely low (only 0.1% of all cervical cancer cases, with annual incidence of only 1-2 cases per 1,000 females aged 15-19 years) 2
• Screening before age 21 leads to unnecessary anxiety and harmful overtreatment, including conizations that significantly increase the risk of premature births in future pregnancies 4, 2

Age-Specific Screening Intervals

Ages 21-29 Years

• Screen every 3 years with Pap test alone 1, 2, 3
• If using liquid-based cytology, screening may be performed every 2 years 4, 2
• HPV testing should NOT be used in this age group for routine screening or management of abnormal results 1
• After the first normal result, continue screening every 2-3 years 1

Ages 30-65 Years

• Preferred approach: Co-testing with both Pap test and HPV DNA test every 5 years 1, 2, 3
• Alternative approach: Pap test alone every 3 years 4, 1, 2
• The 5-year interval with co-testing is supported by the increased sensitivity of the combined approach 1
• After 3 consecutive normal Pap tests, screening may be performed every 3 years at the physician's discretion 4

Age 65 and Older

• Discontinue screening if the woman has had adequate prior screening with normal results (3 consecutive normal tests in the last 10 years) 1, 2
• Women who have never been screened should have at least two negative smears one year apart before discontinuing screening 1

Special Populations Requiring Modified Screening

High-Risk Women (Any Age)

Women with the following conditions require annual screening regardless of age 4, 1:

• History of cervical cancer or CIN II-III
• HIV infection (should be tested every 6 months during the first year, then annually) 4
• Immunocompromised status (organ transplants, long-term steroid use) 4, 1
• In-utero exposure to diethylstilbestrol 4

Post-Hysterectomy

• Discontinue screening if the cervix was removed and there is no history of high-grade precancerous lesions or cervical cancer 1, 3
• Continue annual vaginal cytology screening if there is a history of CIN II-III lesions or cancer, or if negative history cannot be documented 4

Critical Pitfalls to Avoid

• Over-screening younger women: Screening women under 21 causes more harm than benefit through unnecessary procedures and anxiety 4, 2, 5
• Annual screening in average-risk women: Despite limited evidence of benefit, many women receive annual screening when 3-year intervals are equally effective 1, 6
• Using HPV testing in women under 30: HPV testing is not recommended for routine screening in women aged 21-29 years 4, 1
• Premature discontinuation: Do not stop screening before age 65 unless adequate prior normal screening is documented 1
• Under-screening high-risk populations: Women with HIV, immunosuppression, or previous abnormal results require more frequent screening than standard intervals 4, 1

Evidence Quality Note

The 3-year screening interval is supported by strong evidence showing that performing Pap tests every 1-2 years compared to every 3 years improves screening effectiveness by less than 5% 1. Research demonstrates that screening practices have been moving toward these evidence-based guidelines, with the proportion of women aged 18-21 years never screened increasing from 26.3% in 2000 to 47.5% in 2010 5.