How often should an average-risk female with a normal Pap smear have a Pap smear?

Pap Smear Screening Intervals for Average-Risk Women with Normal Results

An average-risk woman with a normal Pap smear should be screened every 3 years if she is between ages 21-29, or every 3 years with Pap alone OR every 5 years with Pap plus HPV co-testing if she is between ages 30-65. 1

Age-Stratified Screening Algorithm

Women Ages 21-29 Years

• Screen every 3 years with Pap test alone after an initial normal result 1, 2
• Do NOT use HPV testing in this age group for routine screening, as HPV prevalence is high (21%) and most infections are transient 1
• Annual screening is explicitly not recommended and provides minimal additional benefit (less than 5% improvement) while significantly increasing false-positives and unnecessary procedures 3

Women Ages 30-65 Years

You have two acceptable options:

Option 1 (Preferred by some guidelines):

• Pap plus HPV co-testing every 5 years 1, 2
• This strategy allows for longer intervals due to the superior sensitivity and negative predictive value of combined testing 1
• The cumulative 5-year risk of CIN2+ after negative co-testing is only 0.34% 1

Option 2 (Equally acceptable):

• Pap test alone every 3 years 1, 2
• The USPSTF considers both strategies equivalent in benefits and harms 1, 2

Critical Point About Screening Frequency

Never screen more frequently than every 3 years in average-risk women, regardless of age or testing method. 1 The average time for high-grade precancerous lesions to progress to invasive cancer is 10 years, providing ample opportunity for detection even with 3-5 year intervals 1

When to Stop Screening

Standard Cessation Criteria at Age 65

Stop screening if the woman has: 1, 4, 2

• 3 consecutive negative Pap tests alone within the past 10 years, OR
• 2 consecutive negative co-tests (Pap + HPV) within the past 10 years
• AND the most recent test was within the past 5 years

Once screening is discontinued after age 65, it should not resume for any reason, even with a new sexual partner 4

Critical Exceptions - Continue Screening Beyond Age 65

Do NOT stop screening in women with: 4, 5

• History of CIN2, CIN3, or adenocarcinoma in situ (continue for 20 years after treatment, even past age 65)
• HIV infection or immunosuppression
• History of cervical cancer
• In utero DES exposure

Special Populations

Post-Hysterectomy

• Stop all screening if the cervix was removed AND there is no history of high-grade precancerous lesions or cervical cancer 1, 2
• Continue screening for 20 years if hysterectomy was performed for cervical cancer or high-grade dysplasia 4

Never-Screened Women Over 65

• Perform at least 2 negative Pap smears 1 year apart before discontinuing screening, regardless of age 3, 4
• This population has 3-4 times higher disease incidence than previously screened women 4

Common Pitfalls to Avoid

Over-screening is harmful and costly: 3

• Annual Pap tests provide less than 5% additional benefit compared to 3-year intervals
• More frequent screening dramatically increases false-positives, unnecessary colposcopies, and potential adverse obstetrical outcomes from cervical procedures
• Despite guidelines, research shows 36% of women still receive annual screening when only 13% receive the recommended triennial screening 6

Under-screening high-risk populations: 3

• Women with previous abnormal results, HIV, immunosuppression, or multiple sexual partners require more frequent screening based on clinical judgment
• Recent immigrants, uninsured women, and those without a usual healthcare source have significantly lower screening rates 7

Misapplication of co-testing: 1

• Co-testing should only be used in women 30 years and older
• When using co-testing, the interval MUST be extended to 5 years to balance the increased detection with population-level harms from false-positives 1