What are the guidelines for a Pap (Papanicolau) procedure in females between 21 and 65 years old with a normal immune system and no history of cervical cancer or abnormal Pap results?

Pap Smear Screening Guidelines for Average-Risk Women Ages 21-65

For women aged 21-29 years, perform Pap testing alone every 3 years; for women aged 30-65 years, the preferred approach is co-testing with both Pap and HPV testing every 5 years, with Pap testing alone every 3 years as an acceptable alternative. 1, 2, 3

When to Start Screening

• Begin cervical cancer screening at age 21 years, regardless of sexual activity history or other risk factors. 1, 2, 3
• Do not screen women under age 21, as cervical cancer incidence is extremely low in this population (only 0.1% of all cervical cancer cases). 1
• Previous recommendations to start screening within 3 years of sexual debut are now obsolete. 1

Age-Specific Screening Protocols

Women Aged 21-29 Years

• Screen with Pap test alone every 3 years after the initial normal result. 1, 2, 3
• HPV co-testing is not recommended in this age group because HPV infections are extremely common and usually transient in younger women. 1
• Either conventional or liquid-based Pap tests are acceptable. 1

Women Aged 30-65 Years

• Preferred strategy: Co-testing with both HPV DNA test and Pap cytology every 5 years. 1, 2, 3
• Acceptable alternative: Pap test alone every 3 years. 1, 2, 3
• The 5-year interval with co-testing is safe due to the increased sensitivity and high negative predictive value of dual-negative results. 1, 2
• HPV testing should never be used as a stand-alone screening test. 1

Evidence Supporting These Intervals

• Screening every 3 years versus annually improves effectiveness by less than 5%, making annual screening unnecessary. 1, 2
• The extended intervals reduce false positives and unnecessary procedures while maintaining nearly the same level of cancer prevention. 1
• For women aged 30-65 with negative co-testing, the interval can be safely extended to 5 years due to the combined approach's increased sensitivity. 2

When to Stop Screening

Women over age 65 should discontinue screening if they meet ALL of the following criteria: 1, 2, 3

• Either ≥3 consecutive negative Pap tests within the last 10 years, OR
• ≥2 consecutive negative HPV and Pap co-tests within the last 10 years
• The most recent test must have occurred within the last 5 years

Additional Criteria for Stopping

• Women who have had a total hysterectomy with removal of the cervix for benign reasons and have no history of high-grade precancerous lesions (CIN2 or higher) should discontinue screening. 1, 3

Critical Caveat for Age 65 Exit Criteria

• Women reaching age 65 with an HPV-negative ASC-US result should NOT stop screening. 4
• These women should be retested in 3 years and continue surveillance until they have 2 consecutive negative co-tests or 3 consecutive negative Pap tests. 4
• Although dysplasia risk is low after HPV-negative ASC-US results, cancer risk is disproportionately high in this group. 4

Populations Requiring Different Protocols (Excluded from Standard Guidelines)

Your question specifically asks about women with normal immune systems and no history of cervical cancer or abnormal results. However, be aware that the following populations require modified screening:

• Women with a history of CIN2, CIN3, or adenocarcinoma in situ must continue screening for at least 20-25 years after treatment, even if this extends past age 65. 2, 3
• HIV-positive or immunocompromised women require annual screening indefinitely, regardless of age. 2, 3
• Women with in utero diethylstilbestrol exposure require continued screening beyond standard intervals. 2

Common Pitfalls to Avoid

• Do not perform annual screening in average-risk women. Despite 55% of American women reporting annual Pap smears, this exceeds guideline recommendations and leads to overtreatment. 5
• Do not use HPV testing alone for screening—it must be combined with Pap testing (co-testing) or not used at all in women under 30. 1
• Do not stop screening in women over 65 who lack adequate prior negative screening documentation. An estimated 50% of cervical cancers occur in women who have never been screened or were inadequately screened. 1
• Do not assume HPV-vaccinated women need different screening protocols—they should follow identical recommendations as unvaccinated women. 1
• Pregnant women should follow the same screening intervals as non-pregnant women, though treatment is deferred until after delivery unless invasive cancer is detected. 1

Special Management Considerations

• For women aged 21-24 years with abnormal results, conservative management is recommended due to low cancer risk, high rates of spontaneous regression, and increased risk of preterm delivery with treatment. 4
• For women aged 25-29 years, co-testing may be incorporated into follow-up strategies after abnormal results to minimize complexity, as cancer risk begins to increase in this age group. 4
• For women aged 30-65 years in follow-up after colposcopy, co-testing is preferred over Pap-only pathways to reduce the frequency of subsequent visits. 4