When to Stop Pap Smear Screening
Women should discontinue Pap smear screening at age 65 if they have had 3 consecutive negative Pap tests or 2 consecutive negative co-tests within the past 10 years, with the most recent test occurring within the past 5 years. 1
Standard Cessation Criteria
The major guideline organizations align closely on stopping age, with minor variations:
- USPSTF recommends discontinuation after age 65 in women with consistently normal prior screening 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
The evidence supporting cessation is compelling: among women age 70 and older with at least one normal Pap smear in the previous 10 years, cervical cancer incidence was only 3 cases per 100,000 2, 1. Modeling data shows continued screening reduces cervical cancer mortality by only 0.18% at age 65 and 0.06% at age 74 1. Once screening is discontinued, it should not resume for any reason, even if a woman reports having a new sexual partner. 1
Algorithm for Deciding When to Stop
Step 1: Verify Age and Prior Screening History
- If age ≥65 AND has 3 consecutive negative Pap tests OR 2 consecutive negative co-tests within past 10 years (most recent within 5 years) → STOP screening 1
- If documentation of adequate prior screening cannot be obtained → perform screening tests until criteria are met 1
Step 2: Check for History of High-Grade Abnormalities
- If history of CIN2, CIN3, or adenocarcinoma in situ → CONTINUE screening for 20 years after treatment, even past age 65 1, 3
- If history of lower-grade abnormalities (ASC-US, LSIL, CIN1) → must demonstrate adequate negative screening AFTER resolution before stopping 3
Step 3: Assess Hysterectomy Status
- If hysterectomy with cervix removal for benign reasons → STOP screening immediately, regardless of age 1
- If hysterectomy was performed for cervical cancer or precursors → continue screening per oncology guidelines 1
Step 4: Evaluate High-Risk Factors
Continue screening beyond age 65 if any of the following apply:
- HIV infection or immunosuppression 1, 3
- History of multiple sexual partners 1
- History of HPV infection 1
- Current smoking 1
- Pessary use 1
- High-risk ethnicity (Vietnamese or Hispanic women) 1, 3
Critical Pitfalls to Avoid
The most common error is stopping screening in inadequately screened women. Between 28-64% of women age 65 and older have never had a Pap smear or have not had one within 3 years 2. Women who have never been screened have a 3-4 times higher incidence of cervical cancer compared to those with at least one prior normal test 2, 1. Research shows that 18.4% of women aged 61-65 years are not recently screened, meaning many approach the stopping age without adequate prior screening 4.
For women who have never been screened, perform at least two negative tests one year apart before discontinuation, regardless of age. 1 This is essential because cervical cancer is most commonly diagnosed in unscreened and under-screened women, not in those with adequate prior screening 1.
Rationale for Discontinuation
The extended natural history of HPV-related disease makes continued screening inefficient after age 65 in adequately screened women. Incident HPV infections and newly detected CIN3 after age 65 are improbable to progress to invasive cancer within the woman's remaining lifetime 1. The ratio of colposcopies to years of life gained becomes extremely large because of the minimal gains in life expectancy 1. Potential harms include discomfort during sampling and false-positive results leading to unnecessary colposcopies 1.