What is the recommended frequency of Pap smears for a female patient with a uterus, who has never had an abnormal Pap smear, and is immunocompetent with no high risk factors for cervical cancer?

Cervical Cancer Screening Recommendations for Women with a Uterus and No History of Abnormal Pap Smears

For an immunocompetent woman with a uterus and no history of abnormal Pap smears, screening should occur every 3 years with Pap test alone for ages 21-65, or every 5 years with HPV co-testing (Pap plus HPV test) for ages 30-65. 1

Age-Specific Screening Intervals

Ages 21-29 Years

• Screen with Pap test alone every 3 years 1
• HPV testing should NOT be used in this age group for routine screening 1
• Do not screen women under age 21, regardless of sexual activity 1

Ages 30-65 Years

• Preferred approach: HPV co-testing (Pap test plus HPV DNA test) every 5 years 2, 1
• Acceptable alternative: Pap test alone every 3 years 2, 1
• The 5-year interval with co-testing is supported by strong evidence showing similar cancer detection rates and lower rates of CIN3 in subsequent screening rounds compared to cytology alone 2

Age 65 and Beyond

• Discontinue screening if the patient has adequate prior negative screening history, defined as either 3 consecutive negative Pap tests OR 2 consecutive negative co-tests within the past 10 years, with the most recent test within 5 years 2, 1, 3
• Once screening is discontinued after age 65, it should not resume for any reason, even with a new sexual partner 3

Critical Caveats and Common Pitfalls

Never Assume Adequate Screening Without Documentation

• Between 28% and 64% of women age 65 and older have never had a Pap smear or have not had one within 3 years 2, 3
• For never-screened or inadequately screened women presenting after age 65: Screening can reduce mortality by 74% and should be offered with strategies extending to age 70-75 years 2, 4
• Obtain at least 2 negative Pap smears 1 year apart for previously unscreened women, regardless of age 2, 4

Avoid Annual Screening

• Annual Pap testing provides less than 5% improvement in screening effectiveness compared to every 3 years, while significantly increasing costs and potential harms from false-positives 1, 5
• The majority of American women are screened more frequently than recommended, contributing to unnecessary procedures and psychological distress 5, 6

High-Risk Populations Require Different Intervals

• Women with HIV infection, immunosuppression, history of cervical cancer, or history of high-grade precancerous lesions (CIN2+) require more frequent screening that may continue well beyond age 65 1, 4, 3
• For women with prior CIN2+ lesions, continue screening for at least 20-25 years after treatment, even if this extends past age 65 4, 3

Post-Hysterectomy Considerations

• Women who had their cervix removed during hysterectomy for benign reasons should discontinue screening entirely 1, 3
• Women who had hysterectomy for cervical cancer or high-grade lesions require continued vaginal cytology screening 4

Evidence Supporting These Recommendations

The 3-year screening interval for Pap tests is based on the natural history of cervical cancer progression, which typically takes 10-15 years from HPV infection to invasive cancer 2. For women aged 30-65, adding HPV testing allows safe extension to 5-year intervals because the combined approach has higher sensitivity—the cumulative 5-year incidence of cervical cancer is lower with negative co-testing (3.2 per 100,000) compared to cytology alone (7.5 per 100,000) 2.

The recommendation to stop screening at age 65 with adequate prior screening is supported by modeling studies showing that continued screening provides minimal benefit (less than 1 life-year gained) while increasing harms from false-positives and unnecessary procedures 2. 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 4.