At what age can yearly PAP (Papanicolaou) smears be discontinued?

When to Discontinue Pap Smear Screening

Pap smear screening should be discontinued at age 65 in women who have had 3 consecutive negative Pap tests within the past 10 years, with the most recent test occurring within the past 5 years. 1

Age-Based Discontinuation Guidelines

The major guideline organizations provide consistent recommendations with minor variations:

• USPSTF recommends stopping at age 65 after consistently normal prior screening 2, 1
• American Cancer Society recommends stopping at age 70 after 3 negative tests in the last 10 years 1
• ACOG recommends stopping at age 65-70 after 3 negative tests in the last 10 years 1
• American Geriatrics Society recommends screening every 3 years until age 70 2, 1

The most widely accepted threshold is age 65 with adequate prior screening, as this represents the consensus position of USPSTF and ACOG. 1

Definition of Adequate Prior Screening

Adequate negative prior screening is defined as either: 1

• 3 consecutive negative cytology results within the 10 years before ceasing screening, with the most recent test within the past 5 years, OR
• 2 consecutive negative co-tests (Pap plus HPV) within the 10 years before ceasing screening, with the most recent test within the past 5 years

Evidence Supporting Discontinuation

The rationale for stopping screening at age 65 is compelling:

• Cervical cancer incidence is extremely low in adequately screened older women—only 3 cases per 100,000 in women age 70+ who had at least one normal Pap in the previous 10 years 2, 1
• Continued screening provides minimal benefit: modeling data show that testing previously screened women reduces cervical cancer mortality by only 0.18% at age 65 and 0.06% at age 74 2, 1
• Most cervical cancers in older women occur in those who were never or inadequately screened, not in those with adequate prior screening 1, 3
• The natural history of HPV infection makes it improbable that incident infections after age 65 will progress to invasive cancer within a woman's remaining lifetime 1

When to Continue Screening Beyond Age 65

Do NOT stop screening if any of the following apply: 1

• History of CIN2, CIN3, or adenocarcinoma in situ: Continue screening for at least 20 years after treatment, even if this extends past age 65 1
• Inadequate or undocumented prior screening: Perform screening tests until adequate criteria are met 1
• Immunocompromised status (including HIV infection) 1
• History of cervical dysplasia or cancer 1
• Multiple sexual partners 1
• History of HPV infection 1

Special Population: Women Who Have Never Been Screened

For women of any age who have never had a Pap test, perform at least two negative tests one year apart before considering discontinuation of screening. 2, 1 This is critical because women who have never been screened have an incidence of cervical cancer 3-4 times higher than those with at least one prior normal Pap smear. 1

Post-Hysterectomy Considerations

Discontinue Pap screening immediately in women who have had a hysterectomy with removal of the cervix for benign reasons. 2, 1, 4

Continue screening if the hysterectomy was performed for cervical cancer or its precursors, or if the cervix remains in place. 2, 1

Critical Caveat: Once Stopped, Do Not Resume

Once screening is discontinued after age 65, it should not resume for any reason, even if a woman reports having a new sexual partner. 1 This recommendation is based on the understanding that adequately screened women have extremely low risk that does not meaningfully change with new exposures at advanced age.

Common Pitfall to Avoid

The most significant error is continuing routine screening in adequately screened women beyond age 65. 1 This leads to unnecessary procedures, false-positive results, patient discomfort, and colposcopies with minimal life-years gained. 1 The absolute benefit of extending screening is very small, while the harms from false positives and unnecessary procedures continue. 1

Conversely, failing to screen women who lack documentation of adequate prior screening represents a missed opportunity, as most cervical cancers in older women occur in the under-screened population. 1, 3