Is a PAP (Papillary Ascitic Fluid) smear recommended for a 23-year-old woman with no history of penetrative sex?

Cervical Cancer Screening in a 23-Year-Old Woman Without Sexual Activity History

Yes, you can perform a Pap smear in this patient, but it is not routinely recommended and should be guided by provider discretion and patient choice following counseling. 1

Current Guideline Recommendations

The most recent guidelines universally recommend that cervical cancer screening should begin at age 21 years, regardless of sexual activity history. 1, 2, 3 This represents a shift from older recommendations that tied screening initiation to sexual debut.

Key Points About Age-Based Screening:

• ACOG (2009) and current guidelines recommend screening initiation at age 21 years as a fixed age, not based on sexual history 1, 2
• The American Cancer Society (2002) previously recommended screening approximately 3 years after onset of vaginal intercourse but no later than age 21, creating an upper age limit to ensure protection 1
• All major societies now align on age 21 as the starting point 1, 3

Special Consideration for This Patient Population

For women aged 21 and older who have never had vaginal sexual intercourse and for whom the absence of sexual abuse history is certain, the American Cancer Society specifically states that provider discretion and patient choice following counseling should guide the initiation of cervical cytology screening. 1

Rationale for Flexibility:

• Cervical cancer incidence is extremely low in women without sexual activity history, as HPV transmission (which causes >99% of cervical cancers) occurs primarily through vaginal intercourse 1, 4
• The incidence of invasive cervical cancer in ages 15-19 years is 0/100,000/year, and only 1.7/100,000/year in ages 20-24 years 1
• Only 0.1% of all cervical cancer cases occur in women younger than 21 years 1, 3

Clinical Decision Algorithm

If the patient has NEVER had vaginal intercourse AND no history of sexual abuse:

1. Discuss with the patient the extremely low risk of cervical cancer in her situation 1
2. Explain that screening can be deferred until she becomes sexually active or reaches age 25-30 1
3. If patient prefers screening after counseling, it is reasonable to proceed 1
4. If deferring screening, establish a plan to initiate screening when appropriate 2

If there is ANY history of vaginal intercourse (including non-consensual):

1. Proceed with screening using standard guidelines for age 21-29: Pap test every 3 years 1, 2, 3
2. Do NOT use HPV testing in this age group for routine screening 1, 5

Important Caveats and Pitfalls

Common Pitfalls to Avoid:

• Over-screening women under 21 or more frequently than recommended intervals leads to unnecessary anxiety and potential harm from overtreatment of lesions that would spontaneously regress 2, 3
• Assuming all sexual activity equals risk: The risk of HPV transmission to the cervix is low for non-penetrative sexual activities 1
• Failing to ask about sexual history: Many providers don't inquire, which is why age 21 was established as a universal starting point 1
• Not documenting the discussion: If screening is deferred, document the counseling and shared decision-making 2

Special Populations Requiring Different Approach:

• HIV-positive or immunocompromised women should follow different guidelines: Pap test twice in the first year after HIV diagnosis, then annually thereafter, regardless of sexual history 1
• History of sexual abuse (especially post-puberty with vaginal intercourse): These patients may be at increased risk and should be screened once psychologically and physically ready 1

Practical Recommendation

For this specific 23-year-old patient with no penetrative sex history:

• Counsel the patient about her extremely low risk 1
• Offer the option to defer screening until she becomes sexually active 1
• If she prefers screening, proceed with Pap test alone (not HPV testing) 5, 3
• If screening is performed, follow standard intervals: repeat in 3 years if normal 1, 2, 3
• Document the shared decision-making process 2

The key principle is that while screening CAN be done, it is not mandatory in this low-risk scenario, and the decision should involve patient preference after appropriate counseling about risks and benefits.