What are the screening and treatment recommendations for an asymptomatic 66-year-old female with a history of normal Pap (Papanicolaou) smears who presents after having unprotected sex with a new partner?

Screening and Management Recommendations

This 66-year-old woman should receive STI screening (gonorrhea, chlamydia, syphilis, and HIV) due to her unprotected sexual exposure with a new partner, but cervical cancer screening with Pap smear is generally not indicated at her age unless she has not had adequate prior screening or has specific risk factors. 1

STI Screening After Unprotected Sexual Exposure

Recommended Testing

• Screen for gonorrhea and chlamydia using nucleic acid amplification testing, as women with new sexual partners and unprotected sex are at increased risk for these infections 1
• Screen for syphilis given the exposure risk with a new partner 1
• Screen for HIV as she is at increased risk due to unprotected sexual activity 1
• Consider hepatitis B and C screening if she has additional risk factors or if the partner's status is unknown 1

Important Caveat About STI Screening

While screening for HIV and syphilis has strong evidence for reducing disease burden, screening for gonorrhea and chlamydia in asymptomatic individuals has weaker evidence of benefit and potential harms from antimicrobial overuse 2. However, given her specific exposure history with unprotected sex and a new partner, testing is warranted 1.

Cervical Cancer Screening Considerations

Age-Based Screening Guidelines

• Routine cervical cancer screening typically ends at age 65 for women with adequate prior screening and no history of high-grade lesions 1
• At age 66, she would generally not require Pap smear screening unless she has inadequate prior screening history (defined as not having three consecutive negative cytology results or two consecutive negative HPV tests within the past 10 years before stopping screening) 1

When Cervical Cancer Screening IS Indicated at Age 66

You should obtain a Pap smear with HPV co-testing if any of the following apply:

• She has not had adequate prior screening (fewer than three consecutive normal Pap smears or two negative HPV tests in the past 10 years) 1
• She has a history of cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer—these women require continued surveillance for at least 25 years, even beyond age 65 1
• She is immunocompromised or HIV-positive 1
• She was exposed to diethylstilbestrol (DES) in utero 1

Special Consideration for Women with STI History

While older CDC guidelines from 1993 recommended annual Pap smears for women with STI history 1, current 2021 guidelines prioritize age-based screening cessation at 65 with adequate prior screening 1. The fact that she has a new sexual partner and unprotected sex does not, by itself, restart cervical cancer screening at age 66 if she had adequate prior screening.

Clinical Approach Algorithm

Step 1: Verify her cervical cancer screening history

• Ask specifically when her last Pap smear was performed and the result
• Determine if she has had three consecutive normal Pap smears or two negative HPV co-tests in the past 10 years 1
• Ask about any history of abnormal Pap smears, cervical dysplasia, or treatment 1

Step 2: Perform indicated STI screening

• Gonorrhea and chlamydia NAAT (cervical, urine, or vaginal swab) 1
• Syphilis serology 1
• HIV testing 1

Step 3: Determine need for cervical cancer screening

• If adequate prior screening and no high-risk history: No Pap smear needed 1
• If inadequate prior screening or high-risk history: Obtain Pap smear with HPV co-testing 1

Step 4: Provide counseling

• Discuss safer sex practices and condom use for future encounters 1
• Explain the importance of knowing partner's STI status 1
• If Pap smear is not indicated due to age, explain why screening can safely stop after adequate prior screening 1

Common Pitfalls to Avoid

• Do not assume she has had a Pap smear just because she reports having had pelvic examinations—many women believe they have had Pap smears when they have not 1
• Do not restart routine cervical cancer screening solely based on new sexual activity if she is over 65 with adequate prior screening 1
• Do not perform a screening pelvic examination for general gynecologic conditions, as the USPSTF found insufficient evidence for benefit 1
• Do not delay STI testing—these should be performed regardless of cervical cancer screening decisions 1