What are the recommended Pap smear screening guidelines for a female patient between 21 and 65 years old with no significant medical history or risk factors?

Pap Smear Screening Guidelines

For women aged 21-65 with no significant risk factors, screen with Pap test every 3 years for ages 21-29, and either Pap test alone every 3 years OR co-testing (Pap plus HPV) every 5 years for ages 30-65. 1

Age-Specific Screening Protocols

Women Ages 21-29 Years

• Screen with Pap test alone every 3 years 2, 3, 1
• Do NOT use HPV testing in this age group, as transient HPV infections are extremely common and lead to unnecessary interventions without improving outcomes 4
• Begin screening at age 21 regardless of sexual history or HPV vaccination status 4

Women Ages 30-65 Years

Two equally acceptable options exist:

• Option 1 (Preferred): Co-testing with Pap test plus HPV DNA test every 5 years 2, 3, 1
• Option 2 (Acceptable): Pap test alone every 3 years 2, 3, 1

The 5-year interval with co-testing provides comparable mortality reduction to 3-year cytology alone, making it a reasonable choice for women who prefer less frequent screening 4

When NOT to Screen

Women Under Age 21

• Do not screen women younger than 21 years, regardless of sexual activity 2, 1
• Cervical cancer is extremely rare before age 21, and screening causes substantial harm through overtreatment of transient lesions that would resolve spontaneously 4

Women Over Age 65

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

Women Who Have Had Hysterectomy

• Stop screening immediately if the cervix was removed for benign reasons and there is no history of high-grade precancerous lesions (CIN2/3) or cervical cancer 2, 1

Critical Exceptions Requiring Modified Screening

High-Risk Populations Requiring More Frequent Screening

Women with the following conditions may need more frequent screening beyond standard guidelines:

• History of CIN2, CIN3, or adenocarcinoma in situ: Continue routine screening for at least 20 years after treatment, even if this extends well past age 65 4, 5
• HIV infection or immunocompromised state (organ transplant, chronic corticosteroids, chemotherapy) 2, 4, 5
• In utero diethylstilbestrol (DES) exposure 2, 5
• History of cervical cancer 5

Common Pitfalls to Avoid

Over-Screening

• Do not screen more frequently than recommended intervals 4
• Screening more often than every 3 years with cytology alone provides less than 5% improvement in effectiveness while substantially increasing harms, including unnecessary procedures and treatment of transient lesions 3
• Annual screening is not recommended and leads to overtreatment with potential adverse effects on future pregnancies, including cervical incompetence and preterm labor 2

Under-Screening High-Risk Groups

• Recent immigrants, uninsured women, and women without a usual source of healthcare are at higher risk of being under-screened 6
• Approximately 14 million eligible women aged 21-65 have not been screened within the past 3 years 6

Premature Discontinuation

• Do not discontinue screening at age 65 without verifying adequate prior screening through medical record review 4
• Between 28-64% of women over age 65 have never had a Pap smear or have not had one within 3 years, highlighting the need for careful documentation review 5
• Women who have never been screened should receive at least 2 negative Pap smears 1 year apart before discontinuing screening, regardless of age 3, 5

Co-Testing Considerations

• Women choosing co-testing should understand that positive HPV results are more common than abnormal cytology alone (11% in women aged 30-34, declining to 2.6% in women aged 60-65), which may require prolonged surveillance with additional testing 2
• Approximately one-third of women up to date on Pap testing report having co-testing, suggesting variable implementation of this option 6

Evidence Supporting Current Recommendations

The 3-year screening interval for Pap tests is supported by strong evidence showing that screening every 1-2 years compared to every 3 years improves effectiveness by less than 5%, while substantially increasing costs and harms 3. For women aged 30-65, adding HPV testing allows for a safe 5-year interval due to the increased sensitivity of the combined approach 3. Cervical cancer deaths have decreased dramatically since widespread screening implementation, from 2.8 to 2.3 deaths per 100,000 women between 2000 and 2015 1. Most cervical cancers occur in women who have not been appropriately screened, not in those following recommended intervals 2.