Cervical Cancer Screening in a 24-Year-Old Sexually Inactive Patient

Yes, perform a Pap smear—cervical cancer screening should begin at age 21 regardless of sexual activity history. 1, 2

Primary Recommendation

All major guidelines (ACOG, ACS, USPSTF) recommend initiating cervical cancer screening at age 21 years, regardless of whether the patient has ever been sexually active. 1, 2, 3, 4
The screening recommendation is age-based, not based on sexual history, because the goal is to ensure no woman falls through the cracks of preventive care. 1, 2
For women aged 21-29 years, perform cytology (Pap smear) alone every 3 years—do not perform HPV testing in this age group. 1, 3, 4

While the standard guideline is clear, there is room for shared decision-making in this specific scenario:

The American Cancer Society states that for women aged 21 and older who have never had vaginal sexual intercourse and for whom the absence of sexual abuse history is certain, provider discretion and patient choice following counseling should guide the initiation of screening. 2
Cervical cancer incidence is extraordinarily low in women without sexual activity history: 0/100,000/year in ages 15-19 and only 1.7/100,000/year in ages 20-24. 2
HPV transmission occurs primarily through vaginal intercourse, making cervical cancer risk negligible in truly sexually inactive women. 2

If the patient confirms:

Then you may:

Counsel the patient about her extremely low risk of cervical cancer. 2
Offer the option to defer screening until she becomes sexually active or reaches age 25-30, based on patient preference. 2
If the patient prefers screening after counseling, proceed with Pap test alone (not HPV testing). 2
Document the shared decision-making process thoroughly. 2

If there is any uncertainty about sexual history or if the patient prefers screening:

Proceed with standard screening: Pap smear alone, repeat in 3 years if normal. 1, 3, 4

Do not perform HPV testing in women under age 30—it is not recommended for screening in this age group. 1, 3
The conservative approach (screening all women at age 21) exists because approximately 50% of women diagnosed with cervical cancer have never been screened, and another 10% have not been screened within 5 years of diagnosis. 5
Pap screening reduces cervical cancer rates by 60-90% in previously unscreened populations. 5
Even with imperfect test sensitivity (70-80%), repeated screening at recommended intervals makes cervical cancer "an almost entirely preventable disease." 5

This recommendation does NOT apply if the patient is:

HIV-positive or otherwise immunocompromised—these patients require annual screening starting at age 21 or within 1 year of sexual debut, whichever comes first. 6
Has history of cervical cancer, CIN II-III, in-utero DES exposure, or organ transplant—these patients require more frequent screening. 1

For a standard-risk, sexually inactive 24-year-old: Counsel about extremely low risk, offer deferral option, but if proceeding with screening (which is the guideline-concordant default), perform Pap smear alone. 2
If normal result: Repeat in 3 years. 1, 3, 4
Emphasize that annual gynecologic care may still be appropriate for contraception counseling, STI screening, and other preventive services, even if cervical cytology is not performed annually. 1