Does an elderly female require regular Pap (Papanicolaou) smears?

Pap Smear Screening in Elderly Women

Elderly women can discontinue Pap smear screening at age 65 if they have had adequate prior negative screening (3 consecutive negative Pap tests within the past 10 years, with the most recent within 5 years), but must continue screening beyond age 65 if they lack adequate prior screening history, have a history of cervical dysplasia (CIN2+), or possess significant risk factors. 1

When to Stop Screening

Standard Cessation Criteria (Age 65-70)

The major guidelines converge on stopping screening between ages 65-70 for adequately screened women:

• USPSTF recommends discontinuation at age 65 after consistently normal prior tests 1
• American Cancer Society recommends stopping at age 70 after 3 negative tests in the last 10 years 1
• American College of Obstetricians and Gynecologists recommends stopping at age 65-70 after 3 negative tests in the last 10 years 1
• American Geriatrics Society recommends continuing every 3 years until age 70 1

The evidence supporting cessation is compelling: women age 70 and older with at least one normal Pap smear in the previous 10 years have an incidence of only 3 cases per 100,000 2. Modeling data shows continued testing reduces cervical cancer mortality by only 0.18% at age 65 and 0.06% at age 74 1.

Definition of Adequate Prior Screening

Adequate negative prior screening requires:

• 3 consecutive negative Pap tests within 10 years before cessation, with the most recent within 5 years 1
• OR 2 consecutive negative co-tests (Pap plus HPV) within 10 years, with the most recent within 5 years 1

Once screening is discontinued, it should not resume for any reason, even with a new sexual partner 1

Critical Exceptions: When to Continue Screening Beyond Age 65-70

Women Who Must Continue Screening

1. History of High-Grade Cervical Abnormalities

• Women with prior CIN2, CIN3, or adenocarcinoma in situ must continue routine screening for at least 20 years after treatment, even if this extends screening past age 65 1, 3
• This is non-negotiable due to substantially elevated long-term cancer risk 1

2. Inadequate Prior Screening History

• Between 28-64% of women age 65 and older have never had a Pap smear or have not had one within 3 years 2, 1
• Women who have never been screened have 3-4 times the incidence of cervical cancer compared to those with at least one prior normal Pap 2, 1
• For never-screened women: perform at least 2 negative Pap smears 1 year apart, regardless of age 1
• If documentation of recent screening cannot be obtained, perform screening tests until cessation criteria are met 1

3. High-Risk Factors Requiring Continued Screening

Continue screening beyond age 65 even with adequate prior screening if the patient has: 2, 1, 3

• HIV infection or immunosuppression (transplant recipients, chronic steroid use)
• Multiple sexual partners
• History of human papillomavirus (HPV) infection
• Smoking
• Pessary use (anecdotally associated with cervicovaginal cancers)
• High-risk ethnicity: Vietnamese women (incidence >2.5 times other groups) or Hispanic women

Special Populations and Considerations

Hysterectomy Status

• Women who had hysterectomy with cervix removal for benign reasons should discontinue Pap screening 1
• Screening is not required unless the surgery was performed for cervical cancer or its precursors 1

The Reality of Underscreening

Most cervical cancers in women ≥65 occur in those who were never adequately screened 4. In one study, 59% of women ≥65 diagnosed with cervical cancer had inadequate prior screening, and only 25% had met criteria for stopping screening 4. The corrected incidence rate for cervical cancer among older women does not decline until age ≥85 years 5.

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

Common Pitfalls to Avoid

1. Assuming All Elderly Women Have Been Adequately Screened

• Always verify screening history before discontinuing 5
• The proportion not recently screened increases from 12.1% at ages 41-45 to 18.4% at ages 61-65 5

2. Stopping Screening in Women with Prior Abnormalities

• Women with history of CIN2+ require 20 years of continued screening after treatment 1, 3
• Even lower-grade abnormalities (ASC-US, LSIL, CIN1) require adequate negative screening AFTER resolution before cessation 3

3. Ignoring Risk Factors

• Ethnic minorities, particularly Vietnamese and Hispanic women, have substantially higher cervical cancer rates 2, 1
• Immunosuppressed patients require indefinite screening 1, 3

4. Discontinuing Screening in Women Who Would Tolerate Treatment

• Only stop screening if life expectancy is very short or the patient could not tolerate radiation therapy if cancer were detected 2