When to Stop Vaginal (Pelvic) Examinations for Cervical Cancer Screening
Discontinue cervical cancer screening at age 65 years if the woman has had 3 consecutive negative Pap tests alone OR 2 consecutive negative HPV tests OR 2 consecutive negative cotests (Pap + HPV) within the past 10 years, with the most recent test within the past 5 years, and no history of CIN2+ in the past 25 years. 1
Standard Cessation Criteria
The decision to stop screening is based on meeting ALL of the following criteria:
- Age ≥ 65 years 1
- Adequate prior negative screening documented:
- 3 consecutive negative Pap tests alone within 10 years, OR
- 2 consecutive negative HPV tests within 10 years, OR
- 2 consecutive negative cotests (Pap + HPV) within 10 years 1
- Most recent test within the past 5 years 1
- No history of CIN2, CIN3, or adenocarcinoma in situ within the past 25 years 1
- No history of cervical cancer ever 1
Once screening is discontinued after meeting these criteria, it should not resume for any reason, even if the woman reports having a new sexual partner. 1
Critical Exceptions: Continue Screening Beyond Age 65
Women with Prior High-Grade Lesions or Cancer
Women with a history of CIN2, CIN3, or adenocarcinoma in situ must continue routine screening for at least 20-25 years after treatment, even if this extends screening well past age 65 years. 1 This extended surveillance is necessary because these women remain at elevated risk for persistent or recurrent disease for decades after treatment. 1
Immunocompromised Women
Continue screening regardless of age in women who are: 1
- HIV-positive
- Immunocompromised by organ transplantation
- On chronic corticosteroid treatment or chemotherapy
- Solid organ or stem cell transplant recipients
Women with Other High-Risk Factors
Continue screening beyond age 65 in women with: 1
- History of in utero diethylstilbestrol (DES) exposure
- History of cervical cancer
Inadequate Prior Screening Documentation
If adequate prior screening documentation cannot be obtained, continue screening until cessation criteria are met, regardless of current age. 1 This is particularly important for women with limited healthcare access or those from countries without established screening programs. 1 Between 28% and 64% of women age 65 and older have never had a Pap smear or have not had one within 3 years, highlighting the critical importance of verifying screening history before cessation. 2
For women who have never been screened, perform at least 2 negative tests one year apart before considering cessation, regardless of age. 2
When to Stop Screening Before Age 65
Total Hysterectomy for Benign Disease
Discontinue screening immediately at any age if the woman has had a total hysterectomy with removal of the cervix for benign indications and no history of CIN2+ lesions. 1 Confirm through surgical records or physical examination that the cervix was completely removed. 1
Important caveat: Women who have had a subtotal (supracervical) hysterectomy with the cervix retained should continue screening according to standard guidelines. 1
Hysterectomy for High-Grade Lesions or Cancer
Women who have had a hysterectomy for CIN2, CIN3, or cervical cancer should continue vaginal vault cytology screening for at least 20 years post-surgery. 1
Limited Life Expectancy
Cervical cancer screening may be discontinued at any age in women with severely limited life expectancy or comorbid life-threatening illness. 1
Evidence Supporting Age 65 Cessation
The rationale for stopping screening at age 65 in adequately screened women is compelling:
Cervical cancer develops slowly, and risk factors decrease with age. 1 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—an 84% risk reduction. 3
Cervical cancer in the United States is most commonly diagnosed in unscreened and underscreened women, not in those with adequate prior screening. 1 In well-screened women older than 65 years, CIN2+ prevalence is low and cervical cancer is rare. 1
Based on the extended natural history of HPV-related disease, it is improbable that incident HPV infections and newly detected CIN3 after age 65 will have sufficient time to progress to invasive cancer in the woman's lifetime. 1
Modeling studies demonstrate that for regularly screened women, the ratio of colposcopies to life-years gained becomes very large beyond age 65, indicating screening becomes inefficient. 1, 4 The absolute benefit in terms of life-years gained from extending screening beyond age 65 is very small. 1
Potential Harms of Continued Screening
Continuing screening beyond age 65 in adequately screened women carries potential harms: 1
- Discomfort during cytology sampling
- False-positive screening tests leading to unnecessary colposcopies
- Overtreatment of lesions unlikely to progress within the patient's lifetime
- Anxiety and psychological distress from abnormal results
Common Pitfalls to Avoid
Do not stop screening at age 65 simply because the patient has reached that age. Verify that ALL cessation criteria are met, including documented adequate prior screening. 1
Do not confuse pelvic examination with cervical cancer screening. The question addresses cervical cancer screening specifically (Pap tests and HPV testing), not routine pelvic examinations for other indications. 5, 6, 7 While cervical cancer screening can be discontinued at age 65 with adequate prior screening, some guidelines suggest continuing periodic visual inspection of the vulva in women over age 70 to screen for vulvar disease. 5
Do not restart screening once discontinued, even if the woman reports a new sexual partner. 1 The evidence supporting cessation is based on the long natural history of cervical cancer and the low probability of newly acquired HPV infections progressing to cancer within the remaining lifespan of adequately screened older women.
Carefully document the screening history. If documentation is incomplete or unavailable, err on the side of continuing screening until adequate negative results are obtained. 1