At what age should a woman start getting Pap (Papanicolau) smears and how often should she get them?

Pap Smear Screening: Age and Frequency

Women should begin Pap smear screening at age 21 years (not earlier, regardless of sexual activity) and continue every 3 years until age 29, then transition to either Pap testing alone every 3 years or preferably HPV co-testing every 5 years from ages 30-65. 1

Starting Age: 21 Years

• Do not screen women under age 21, even if sexually active 1, 2
• This represents a critical shift from older guidelines that recommended starting screening within 3 years of sexual debut 3
• The rationale: cervical cancer is extremely rare in women under 21, and HPV infections in this age group are typically transient and clear spontaneously, making screening more harmful than beneficial due to unnecessary procedures 4

Age-Specific Screening Intervals

Ages 21-29 Years

• Pap test alone every 3 years 1, 2
• If using liquid-based cytology, screening every 2 years is acceptable after an initial normal result 1
• Never use HPV testing for routine screening in this age group - HPV prevalence is too high (causing excessive false positives) and most infections resolve without intervention 2
• HPV testing may only be used to triage abnormal Pap results (specifically ASC-US) in women aged 25-29 2

Ages 30-65 Years

• Preferred option: HPV co-testing (Pap + HPV DNA test) every 5 years 1, 2
• Acceptable alternative: Pap test alone every 3 years 1
• The 5-year interval with co-testing is safe because the combined approach has 51% higher detection of high-grade lesions and provides greater reassurance when both tests are negative 2
• Primary HPV testing alone every 5 years is also an acceptable alternative 2

Age 65 and Older

• Discontinue screening if adequate prior screening with normal results 1
• "Adequate prior screening" means three consecutive normal Pap tests or two consecutive negative co-tests within the past 10 years, with the most recent test within 5 years 1
• Exception: Continue screening for at least 20 years in women with history of high-grade lesions, even beyond age 65 2

Special Populations Requiring Modified Approach

Never Screen

• Women under age 21 1
• Women who have had total hysterectomy (cervix removed) for benign reasons with no history of high-grade lesions or cervical cancer 1

More Frequent Screening Required

• HIV-positive or immunocompromised women may need annual screening 1, 5
• History of cervical cancer or high-grade precancerous lesions requires individualized intervals 1
• Women with persistent high-risk HPV types need closer surveillance 1

Critical Pitfalls to Avoid

Over-Screening

• Annual Pap smears are not recommended for average-risk women at any age 3, 1
• Despite guidelines, 55% of American women still undergo annual screening when only 3-year intervals are needed 6
• Over-screening increases costs and harms (unnecessary colposcopies, biopsies, anxiety) without meaningful improvement in cancer detection - performing Pap tests every 1-2 years versus every 3 years improves effectiveness by less than 5% 1

Under-Screening High-Risk Groups

• Women who have never been screened should have at least two negative smears one year apart, regardless of age 1
• Approximately 50% of women diagnosed with cervical cancer had not been screened in the 3 years before diagnosis 3
• Screening rates remain lower in women with less than high school education (77%), foreign-born women (61%), uninsured women (62%), and certain racial/ethnic groups 3

Premature Discontinuation

• Do not stop screening before age 65 unless hysterectomy was performed 1
• The cervical cancer burden remains significant in women over 65, and emerging data suggests current recommendations to stop screening may not be adequately evidence-based 7

Management of Abnormal Results

HPV-Positive with Normal Cytology (Age 30+)

• Repeat HPV DNA testing and Pap smear at 6-12 months 5
• Proceed to colposcopy if either test is abnormal at follow-up 5
• Immediate colposcopy required if HPV types 16 or 18 are detected, or if any cytologic abnormality is present 5

Counseling Point

• HPV positivity does not mean cancer is present - most HPV infections are transient and clear spontaneously, which is why repeat testing rather than immediate intervention is appropriate 5