At what age can I stop ordering Papanicolaou (Pap) smears for cervical cancer screening?

When to Stop Ordering Pap Smears

Discontinue cervical cancer screening at age 65 if the patient has adequate prior negative screening (3 consecutive negative Pap tests OR 2 consecutive negative HPV tests OR 2 consecutive negative cotests within the past 10 years, with the most recent test within the past 5 years) and no history of high-grade precancerous lesions (CIN2+) or cervical cancer. 1, 2, 3

Standard Cessation Criteria at Age 65

You can safely stop screening when ALL of the following are met:

• Age ≥65 years 1
• Adequate prior negative screening documented: Either 3 consecutive negative Pap tests OR 2 consecutive negative HPV tests OR 2 consecutive negative cotests within the past 10 years, with the most recent test occurring within the past 5 years 1, 2, 3
• No history of CIN2, CIN3, adenocarcinoma in situ, or cervical cancer in the past 25 years 1, 4
• No current high-risk conditions (see below) 2, 5

This recommendation comes from consensus among the USPSTF, American Cancer Society, ACOG, and other major guideline organizations. 1, 3

Critical Exceptions: Continue Screening Beyond Age 65

Never stop screening at age 65 in these situations:

History of High-Grade Lesions

• Continue screening for at least 20-25 years after treatment for CIN2, CIN3, or adenocarcinoma in situ, even if this extends screening well past age 65 1, 4, 5
• This extended surveillance is necessary because these patients remain at elevated risk for decades after treatment 4, 5

Inadequate Prior Screening Documentation

• If you cannot document adequate prior negative screening, continue screening until cessation criteria are met 1, 2, 5
• This is particularly important for women with limited healthcare access, minority women, and immigrants from countries without screening programs 2, 5
• Approximately 28-64% of women age 65+ have never had a Pap smear or have not had one within 3 years 2
• Verbal patient report alone is insufficient—you must verify through medical records 5

High-Risk Medical Conditions

Continue screening regardless of age if the patient has: 2, 5

• HIV infection or immunosuppression (transplant recipients, chronic immunosuppressant therapy)
• In utero diethylstilbestrol (DES) exposure
• History of cervical cancer

Never-Screened Women

• For women who have never been screened, perform at least 2 negative tests one year apart, regardless of age 2
• Unscreened women have 3-4 times the incidence of cervical cancer compared to those with at least one prior normal Pap 2
• 42% of women ≥65 years diagnosed with cervical cancer had never been screened 5

When to Stop Screening Before Age 65

Stop screening at any age if the patient has had a total hysterectomy with removal of the cervix for benign reasons (not for high-grade lesions or cancer) 1, 3

• Confirm through surgical records or direct examination that the cervix was removed 1
• This does NOT apply if hysterectomy was performed for CIN2+, adenocarcinoma in situ, or cervical cancer—these patients need continued vaginal cuff cytology for 20-25 years 5

Stop screening at any age if life expectancy is severely limited 1

Common Pitfalls to Avoid

• Don't stop at age 65 without verifying adequate prior screening history through documentation 5—approximately 18.4% of women aged 61-65 are not up to date with screening 6
• Don't discontinue screening in women with prior CIN2+ until 20-25 years have elapsed since treatment, regardless of current age 4, 5
• Don't screen women who had hysterectomy with cervix removal for benign disease—this provides no benefit and represents overutilization 5, 3
• Don't restart screening after cessation, even if the patient reports a new sexual partner 2

Evidence Supporting Age 65 Cessation

The rationale for stopping at age 65 with adequate prior screening is compelling:

• Among adequately screened women, the 20-year absolute risk of cervical cancer is only 8 per 10,000, compared to 49 per 10,000 in unscreened women—an 84% risk reduction 5
• In well-screened women older than 65, CIN2+ prevalence is low and cervical cancer is rare 2
• Given 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 patient's remaining lifespan 2
• Modeling studies show that for regularly screened women, the ratio of colposcopies to life-years gained becomes very large beyond age 65, indicating screening becomes inefficient 2

However, approximately 20% of new cervical cancer cases are diagnosed in women ≥65 years, accounting for 25% of all cervical cancer deaths annually—but these occur predominantly in unscreened or underscreened women, not those with adequate prior screening 5