At what age can women stop having Pap (Papanicolau) smear screenings?

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 (Pap plus HPV) within the past 10 years, with the most recent test within the last 5 years. 1

Standard Cessation Criteria

The major guideline organizations align closely on stopping age, though with slight variations:

• USPSTF recommends discontinuation after age 65 with consistently normal prior results 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 in the previous 10 years, cervical cancer incidence was only 3 cases per 100,000 1. Additionally, modeling data show that 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

Critical Exception: Women with Prior Abnormal Results

Women with a history of CIN2, CIN3, or adenocarcinoma in situ must continue routine screening for at least 20 years after treatment, even if this extends screening past age 65. 1, 2

This is a crucial distinction that significantly impacts many women. Research demonstrates that among older low-income women who were appropriately screened due to inadequate prior screening history, 21.9% required biopsies, and 11 of these showed high-grade lesions or cancers 3. This underscores the importance of continued surveillance in women with prior abnormalities.

Algorithm for Deciding When to Stop

Step 1: Verify Age and Screening History

• If age ≥65 AND has 3 consecutive negative Pap tests (or 2 negative co-tests) within past 10 years with most recent within 5 years → STOP screening 1

Step 2: Check for Hysterectomy

• If hysterectomy with cervix removal for benign reasons → STOP screening regardless of age 1
• If hysterectomy was for cervical cancer or precursors → CONTINUE screening 1

Step 3: Assess Prior Abnormalities

• If history of CIN2, CIN3, or adenocarcinoma in situ → CONTINUE screening for 20 years after treatment, even past age 65 1, 2
• If history of lower-grade abnormalities (ASC-US, LSIL, CIN1) → Must demonstrate adequate negative screening AFTER resolution before stopping 2

Step 4: Evaluate Screening Documentation

• If inadequate documentation of prior screening → Perform screening tests until criteria are met 1
• This is particularly important as 59.5% of older low-income women in one study needed continued testing due to inadequate screening histories 3

Step 5: Consider High-Risk Factors

Continue screening beyond age 65 even with adequate prior screening if:

• HIV infection or immunosuppression 1, 2
• Multiple sexual partners 1, 2
• History of HPV infection 1, 2
• Smoking 1, 2
• Pessary use 1, 2
• High-risk ethnicity (Vietnamese or Hispanic women) 1, 2

Common Pitfalls to Avoid

The most critical error is stopping screening at age 65 without verifying adequate prior screening. Research shows that 18.4% of women aged 61-65 years have not been recently screened (no Pap within 5 years) 4, and 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 Pap 1.

Another pitfall is failing to recognize that many older women, especially low-income and minority women, have inadequate screening histories 3. Between 28% and 64% of women age 65 and older have never had a Pap smear or have not had one within 3 years 5. In these women, perform at least two negative tests one year apart before considering cessation 1.

Do not discontinue screening in women with prior abnormalities simply because they reach age 65. The 20-year surveillance period after CIN2+ is absolute and takes precedence over age-based cessation 1, 2.

Rationale for Discontinuation

In well-screened women older than 65 years, CIN2+ prevalence is low and cervical cancer is rare 1. The extended natural history of HPV-related disease means that incident HPV infections and newly detected CIN3 after age 65 are improbable to progress to invasive cancer within the woman's lifetime 1. The ratio of colposcopies to years of life gained becomes unfavorable, as achieving very small gains in life-years comes at the cost of more procedures 1.