At what age can a woman with a normal immune system and no history of cervical cancer or high-grade cervical dysplasia stop getting routine Pap (Papanicolaou) smears?

Age to Stop Pap Smears

Women with normal immune systems and no history of cervical cancer or high-grade dysplasia should discontinue Pap smear screening at age 65 years if they have adequate prior negative screening documented within the past 10 years. 1, 2

Defining Adequate Prior Screening

Before stopping screening at age 65, you must verify one of the following within the past 10 years, with the most recent test within the recommended interval: 1, 3

• 3 consecutive negative Pap tests alone, OR
• 2 consecutive negative HPV tests, OR
• 2 consecutive negative cotests (Pap + HPV)

The most recent test must have occurred within 5 years for cytology alone or within the recommended interval for the specific test used. 1

Critical Exceptions: Continue Screening Beyond Age 65

Do not stop screening at age 65 in the following situations:

History of High-Grade Lesions

• Women with prior CIN2, CIN3, or adenocarcinoma in situ must continue screening for at least 20-25 years after treatment, even if this extends screening well past age 65 years. 1, 4

Inadequate Prior Screening Documentation

• If you cannot document adequate negative prior screening through medical records review, continue screening until cessation criteria are met. 1, 4
• Verbal patient report alone is insufficient—you must verify through actual records. 4
• Women with limited healthcare access, minority women (particularly Vietnamese and Hispanic), and immigrants from countries without screening programs are especially likely to lack adequate documentation. 3, 4

High-Risk Medical Conditions

Continue screening regardless of age for: 3, 4

• HIV infection or immunosuppression
• Solid organ or stem cell transplant recipients
• Chronic immunosuppressant therapy
• In utero diethylstilbestrol exposure

Never Previously Screened

• Women who have never been screened should receive at least 2 negative tests one year apart, regardless of current age. 3, 5
• Unscreened women have 3-4 times the incidence of cervical cancer compared to those with at least one prior normal Pap smear. 3, 6

When to Stop Before Age 65

Stop screening at any age if the patient has had a total hysterectomy with removal of the cervix for benign indications (not for high-grade lesions or cancer). 1, 2

You must confirm through surgical pathology reports or direct examination that the cervix was actually removed—do not rely on patient report alone. 1, 4

Evidence Supporting Age 65 Cessation

The rationale for stopping at age 65 with adequate prior screening is compelling: 1, 4

• 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. 4
• Modeling studies show the ratio of colposcopies to life-years gained becomes very large beyond age 65, indicating screening becomes inefficient in previously screened women. 1, 5
• Cervical cancer in the United States is most commonly diagnosed in unscreened and underscreened individuals, not in those with adequate prior screening. 1
• Given the extended natural history of HPV-related disease, incident HPV infections and newly detected CIN3 after age 65 are improbable to progress to invasive cancer within a woman's remaining lifetime. 1

Important Caveats

Approximately 20% of cervical cancers are diagnosed after age 65, accounting for 25% of cervical cancer deaths annually—but these occur predominantly in women who were never adequately screened. 4

Once screening is discontinued at age 65, it should not resume for any reason, even if the woman reports a new sexual partner. 1, 3

Screening may be discontinued at any age if life expectancy is severely limited by other conditions. 1, 5