Pap Smear Screening Guidelines for Elderly Women
For elderly women aged 65 and older with adequate prior screening (3 consecutive negative Pap tests in the past 10 years), discontinue cervical cancer screening. 1, 2
When to Stop Screening
Stop screening at age 65 if the following criteria are met:
- 3 consecutive negative Pap tests within the past 10 years, with the most recent test within the past 5 years 1, 2
- No history of high-grade precancerous lesions (CIN2, CIN3, or adenocarcinoma in situ) 2
- Not immunocompromised or HIV-positive 2
The USPSTF provides high certainty evidence that for women over 65 with adequate prior screening, the benefits of continued screening do not outweigh potential harms. 1 The American Cancer Society and ACOG similarly recommend stopping at age 65-70 after 3 negative tests in 10 years. 2
Critical Exceptions: Continue Screening Beyond Age 65
Do NOT stop screening in the following situations:
Inadequate Prior Screening
- Women who have never been screened should receive at least 2 negative Pap smears 1 year apart, regardless of age 1, 2
- Women with inadequate documentation of prior screening should be screened until criteria are met 2
- Women who have never had cervical screening have a 3-4 times higher incidence of disease compared to those with at least one prior normal Pap smear 2, 3
History of Abnormal Results
- Continue screening for at least 20 years after treatment for CIN2, CIN3, or adenocarcinoma in situ, even if this extends past age 65 2
- This extended surveillance is necessary due to persistent elevated cancer risk 2
High-Risk Factors
Continue screening beyond age 65 if any of the following are present:
- HIV infection or immunosuppression 2, 4
- Multiple sexual partners 2
- History of HPV infection 2
- Smoking 2
- Pessary use 2
- High-risk ethnicity (Vietnamese or Hispanic women) 2
Screening Intervals for Women Under Age 65
For women who have not yet reached the stopping criteria:
Ages 65-70:
- Screen every 3 years with Pap test alone 1, 2
- The American Geriatrics Society recommends continuing screening until at least age 70 1, 2
Beyond age 70:
- Little evidence exists for or against screening women who have been regularly screened in previous years 1
- Individual circumstances should guide decisions, including life expectancy and ability to undergo treatment if cancer is detected 1
Special Considerations
After Hysterectomy
Stop screening if:
- Cervix was removed 2, 4
- Hysterectomy was performed for benign disease 2, 4
- No history of high-grade precancerous lesions or cervical cancer 2, 4
Continue screening if cervical tissue remains or if hysterectomy was performed for cervical cancer or its precursors 1, 2
Evidence Supporting Cessation at Age 65
The rationale for stopping screening is compelling:
- A large prospective study found only 3 cases per 100,000 cervical cancers among women age 70+ who had at least one normal Pap in the previous 10 years 2
- Modeling data show continued testing reduces cervical cancer mortality by only 0.18% at age 65 and 0.06% at age 74 2
- In well-screened women over 65, CIN2+ prevalence is low and cervical cancer is rare 2
- The ratio of colposcopies to years of life gained becomes unfavorable beyond age 65 2
Potential Harms of Continued Screening
- Discomfort during cytology sampling 2
- False-positive screening tests leading to unnecessary procedures 2
- The absolute benefit in life-years gained is very small 2
Common Pitfalls to Avoid
Do not assume all elderly women have been adequately screened: Between 28-64% of women age 65+ have never had a Pap smear or have not had one within 3 years. 2 Always verify screening history before discontinuing.
Do not screen women who meet stopping criteria: Once screening is discontinued based on adequate prior screening, it should not resume for any reason, even if a woman reports a new sexual partner. 2
Do not overlook high-risk populations: Certain ethnic minorities (Vietnamese, Hispanic), uninsured, poor, and rural populations have higher rates of cervical cancer and may require continued screening. 2, 5
Do not screen after hysterectomy with cervical removal for benign disease: This represents unnecessary testing with no benefit. 2, 4
Medicare Coverage
Medicare covers Pap testing and pelvic examination at 3-year intervals for average-risk women, with yearly screening allowed for high-risk women or those with an abnormal Pap smear in the preceding 3 years. 1, 4