At what age can women stop undergoing Pap (Papanicolau) screening?

When to Stop Pap Screening

Women should discontinue Pap screening at age 65 if they have had adequate prior screening (3 consecutive negative Pap tests or 2 consecutive negative co-tests within the past 10 years, with the most recent test within the past 5 years) and no history of high-grade cervical dysplasia (CIN2+) in the last 20 years. 1

Standard Cessation Criteria

The major guidelines converge on age 65 as the stopping point, though with slight variations:

• USPSTF recommends discontinuing screening after age 65 in women with consistently normal prior results 1
• ACS and ACOG recommend stopping at age 65-70 after 3 negative tests in the last 10 years 1
• Once screening is discontinued, it should not resume for any reason, even if a woman reports having a new sexual partner 1

The rationale is compelling: in well-screened women over 65, CIN2+ prevalence is extremely low, and modeling data show that continued testing reduces cervical cancer mortality by only 0.18% at age 65 and 0.06% at age 74 1. A Swedish prospective study found only 3 cases per 100,000 among women age 70+ who had at least one normal Pap in the previous 10 years 2, 1.

Critical Exceptions: Continue Screening Beyond Age 65

Women with Prior High-Grade Abnormalities

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, 3 This is non-negotiable due to their substantially elevated risk.

Inadequate Prior Screening

Continue screening if documentation of adequate prior screening cannot be obtained 1. This is crucial because between 28% and 64% of women age 65+ have never had a Pap smear or have not had one within 3 years 1. Women who have never been screened have an incidence of disease 3-4 times higher than those with at least one prior normal Pap 1.

For never-screened women, perform at least two negative tests one year apart, regardless of age 1.

High-Risk Factors Requiring Continued Screening

Continue screening beyond age 65 even with adequate prior screening if the woman has:

• HIV infection or immunosuppression (transplant recipients, chronic steroid use) 1, 3
• History of multiple sexual partners 1
• History of HPV infection 1
• Smoking 1
• Pessary use 1
• High-risk ethnicity (Vietnamese or Hispanic women) 1

Special Circumstance: Hysterectomy

Women who have had a hysterectomy with removal of the cervix for benign reasons should discontinue Pap screening immediately. 1 However, if the hysterectomy was performed because of cervical cancer or its precursors, continue screening per the 20-year rule above 1.

Common Pitfalls to Avoid

Provider-Driven Overscreening

Research shows that 40.8% of women age 70+ had a Pap within the past 3 years, and this overscreening is primarily provider-driven: women who received a provider recommendation were 10.5 times more likely to get a Pap than those who didn't 4. Healthcare providers need education on current guidelines to reduce unnecessary screening in women who will not benefit 4.

Failure to Document Prior Screening

The sharp decline in Pap rates at age 66 (5.9 percentage point drop) suggests guideline adherence 5, but this varies significantly by race, education, and marital status 5. Before discontinuing screening, ensure adequate documentation exists—if it doesn't, perform the necessary screening to meet cessation criteria 1.

Ignoring the 20-Year Rule

The most critical error is stopping screening at age 65 in women with prior CIN2+ without completing the full 20-year surveillance period 1, 3. This population has meaningfully elevated risk that justifies continued screening despite age.

Practical Algorithm

1. Is the woman ≥65 years old? If no, continue routine screening.

2. Has she had adequate prior screening? (3 consecutive negative Paps OR 2 consecutive negative co-tests in the past 10 years, most recent within 5 years) 1

   • If no → Continue screening until criteria met
   • If documentation unavailable → Perform screening to establish adequate history 1

3. Does she have a history of CIN2, CIN3, or adenocarcinoma in situ? 1, 3

   • If yes → Continue screening for 20 years after treatment, even past age 65
   • If no → Proceed to next step

4. Does she have high-risk factors? (HIV/immunosuppression, multiple partners, HPV history, smoking, pessary use, high-risk ethnicity) 1, 3

   • If yes → Consider continuing screening beyond age 65
   • If no → Stop screening 1

5. Has she had a hysterectomy with cervix removal for benign reasons? 1

   • If yes → Stop screening regardless of age
   • If hysterectomy was for cancer/precursors → Follow 20-year rule