What is the recommended Pap smear screening schedule for a 22-year-old female with no history of sexual encounters and no known risk factors for cervical cancer?

Pap Smear Screening for a 22-Year-Old Without Sexual History

For a 22-year-old woman who has never had sexual intercourse, cervical cancer screening can be safely deferred until she becomes sexually active or reaches age 25, based on shared decision-making after counseling about her extremely low risk. 1

Rationale for Deferral

Risk Profile in Non-Sexually Active Women

• Cervical cancer incidence is essentially zero in women without sexual activity history, as HPV transmission occurs primarily through vaginal intercourse 1
• The incidence is 0/100,000 per year in ages 15-19 and only 1.7/100,000 per year in ages 20-24 1
• Among virgins, the incidence of cervical cancer is essentially zero 2
• Only 0.1% of all cervical cancer cases occur in women younger than 21 years 1

Current Guideline Recommendations

• All major societies now align on age 21 as the starting point for cervical cancer screening, regardless of sexual history 3, 1, 4
• However, the American Cancer Society specifically states that for women aged 21 and older who have never had vaginal sexual intercourse and for whom the absence of sexual abuse history is certain, provider discretion and patient choice following counseling should guide the initiation of screening 1
• The American College of Obstetricians and Gynecologists recommends that screening should begin at age 21 years, regardless of sexual activity history, but this represents a population-level recommendation 1

Clinical Approach: Shared Decision-Making

Counseling Points to Discuss

• Explain the extremely low risk of cervical cancer in the absence of sexual activity 1
• Discuss that screening can be safely deferred until she becomes sexually active or reaches age 25-30 1
• Clarify that this recommendation assumes no history of sexual abuse 1

If Patient Prefers to Defer Screening

• Document the shared decision-making process 1
• Advise her to initiate screening when she becomes sexually active or by age 25, whichever comes first 3
• The 2020 American Cancer Society guideline recommends starting at age 25 with primary HPV testing (preferred) or cytology alone every 3 years (acceptable) 3

If Patient Prefers Screening After Counseling

• It is reasonable to proceed with a Pap test alone (not HPV testing) 1
• HPV testing should NOT be used in women aged 21-29 years for routine screening 4
• If screening is performed and normal, repeat in 3 years 1, 4

Important Caveats

Common Pitfall to Avoid

• Do not automatically screen at age 21 without considering sexual history and patient preference 1
• The guideline stating "regardless of sexual history" was designed to prevent missing cases in women who may not accurately report sexual activity, but allows for clinical judgment in clearly non-sexually active women 3, 1

When Standard Age-Based Screening Applies

• If there is any uncertainty about sexual history or possibility of sexual abuse, follow standard guidelines and begin screening at age 21 3, 1
• Screening before age 21 is not recommended regardless of sexual history, as cytologic abnormalities are common but clinically important cervical lesions are rare, leading to unnecessary colposcopy and treatment 3

Transition to Standard Screening

• Once she becomes sexually active, initiate screening within a reasonable timeframe 1
• By age 25, screening should begin regardless of sexual activity status, following the 2020 American Cancer Society recommendations 3