At what age can Pap (Papanicolaou) smears be stopped?

When to Stop Pap Smears

Discontinue Pap smear screening at age 65 years if the woman has had adequate prior negative screening, defined as 3 consecutive negative cytology results or 2 consecutive negative HPV co-tests within the past 10 years, with the most recent test within the past 5 years. 1, 2

Standard Cessation Criteria

The USPSTF, American Cancer Society (ACS), and American College of Obstetricians and Gynecologists (ACOG) all converge on age 65 as the appropriate stopping point for average-risk women with adequate prior screening. 1, 2 The American Geriatrics Society extends this slightly to age 70, but the weight of evidence supports age 65 as the standard threshold. 1, 2

Adequate prior screening specifically means: 1, 2

• 3 consecutive negative Pap tests within the past 10 years, OR
• 2 consecutive negative HPV tests within the past 10 years, OR
• 2 consecutive negative co-tests (Pap + HPV) within the past 10 years
• AND the most recent test must have occurred within the past 5 years

The rationale is compelling: modeling data demonstrate that continued screening of previously well-screened women reduces cervical cancer mortality by only 0.18% at age 65 and 0.06% at age 74. 1, 2 In well-screened women older than 65, CIN2+ prevalence is extremely low, and the ratio of colposcopies to life-years gained becomes unfavorable. 2

Critical Exceptions: Continue Screening Beyond Age 65

Do NOT stop screening at age 65 in the following situations: 1, 2

• History of CIN2, CIN3, or adenocarcinoma in situ: Continue routine screening for at least 20 years after treatment, even if this extends screening past age 65. 1, 2

• Inadequate or undocumented prior screening: Women who cannot document adequate negative prior screening should continue screening until cessation criteria are met. 1, 2 This is particularly important as 28-64% of women age 65 and older have never had a Pap smear or have not had one within 3 years. 2

• High-risk factors: 2

  • HIV infection or immunosuppression
  • Multiple sexual partners
  • History of HPV infection
  • In utero DES exposure
  • History of cervical cancer
  • Smoking
  • Pessary use

• Certain high-risk ethnicities: Vietnamese and Hispanic women have higher cervical cancer rates and may warrant continued screening. 2

Post-Hysterectomy Considerations

Stop Pap screening immediately in women who have had a total hysterectomy with removal of the cervix for benign reasons. 1, 2 Confirm through surgical records or direct examination that the cervix was completely removed. 1

Continue screening after hysterectomy if: 1

• The cervix remains (subtotal hysterectomy)
• History of CIN2/3 prior to hysterectomy
• Hysterectomy was performed for cervical cancer or its precursors
• History of in utero DES exposure

Women with a history of CIN2/3 should be screened until three consecutive negative tests within a 10-year period are achieved. 1

Never-Screened Older Women

For women older than 65 who have never been screened or whose screening history cannot be documented, perform screening until adequate negative results are obtained. 1, 2 The American Geriatrics Society recommends at least two negative Pap smears one year apart, regardless of age. 2 This is critical because never-screened women have an incidence of cervical cancer three to four times that of women with at least one prior normal Pap smear. 2

Important Caveats

Once screening is discontinued after age 65, it should NOT resume for any reason, even if a woman reports having a new sexual partner. 1, 2 This recommendation is based on the extended natural history of HPV-related disease—incident HPV infections and newly detected CIN3 after age 65 are unlikely to progress to invasive cancer within the woman's remaining lifetime. 2

The incidence of cervical cancer in older women is almost entirely confined to the unscreened and underscreened populations, not those with adequate prior screening. 1, 2 Research shows that cervical cancer incidence rates corrected for hysterectomy status do not decline until age 85 or older, but this reflects inadequate prior screening rather than failure of the screening cessation guidelines. 3

Potential harms of continued screening beyond age 65 include: 1, 2

• Discomfort during cytology sampling (atrophy, cervical stenosis)
• False-positive results leading to unnecessary colposcopies
• Anxiety and higher healthcare costs
• Extremely small absolute benefit in life-years gained