Should a woman who has never been sexually active be screened for cervical cancer with Pap smears based on her age?

Cervical Cancer Screening in Women Who Have Never Been Sexually Active

Women who have never been sexually active should still undergo routine cervical cancer screening starting at age 21 years (or age 25 per newer ACS guidelines), following the same screening intervals as sexually active women, because sexual history does not modify the age-based screening recommendations. 1

Rationale for Screening Regardless of Sexual History

The major U.S. guidelines explicitly state that screening should begin at the recommended age regardless of sexual history. 1 This recommendation is based on several key principles:

• HPV transmission can occur through non-penetrative sexual contact, and the absence of vaginal intercourse does not eliminate all risk of HPV exposure. 1

• Cervical carcinogenesis is a slow, multi-step process that can take decades to progress, and the guidelines are designed to capture all women at the appropriate age when screening becomes beneficial. 1

• Obtaining accurate sexual histories is unreliable in clinical practice, and basing screening decisions on self-reported sexual activity could result in missed cancers. 1

• The harms of screening before age 21 outweigh benefits due to the extremely low cancer burden and high rates of transient HPV infections that regress spontaneously, but this applies to all women under 21, not just those who are sexually inactive. 1

Age-Specific Screening Recommendations

Women Ages 21-29 Years (or 25-29 per ACS 2020)

• Screen with cervical cytology (Pap smear) alone every 3 years, regardless of sexual history. 1, 2

• The American Cancer Society's 2020 guideline recommends starting at age 25 with primary HPV testing every 5 years as preferred, but cytology every 3 years remains acceptable. 2, 3

• HPV testing (alone or co-testing) is not recommended in women under age 30. 1, 2

Women Ages 30-65 Years

• Three equally acceptable options exist for women in this age group, regardless of sexual activity status: 1, 4, 2

  • Primary HPV testing every 5 years (preferred by ACS)
  • Co-testing (cytology plus HPV) every 5 years
  • Cytology alone every 3 years

• Current sexual activity does not modify these recommendations—even women who have never been sexually active should continue routine screening. 4

Common Pitfalls to Avoid

Do not skip or delay screening based on patient report of never being sexually active. 1 The USPSTF found "little evidence to determine whether and how sexual history should affect the age at which to begin screening" and concluded that screening earlier than age 21 regardless of sexual history leads to more harms than benefits, but this does not mean sexually inactive women should avoid screening after age 21. 1

Do not confuse the recommendation against screening before age 21 with a recommendation to avoid screening in sexually inactive women. 1 The guideline explicitly states screening should begin at age 21 "regardless of sexual history." 1

When Screening Can Be Discontinued

Screening may be stopped at age 65 years or older only if all of the following criteria are met: 1, 4

• Adequate prior screening: 3 consecutive negative cytology results OR 2 consecutive negative co-tests within the past 10 years
• Most recent test within 5 years
• No history of high-grade precancerous lesions (CIN 2/3) or cervical cancer in the past 20-25 years
• Not immunocompromised (no HIV, organ transplant, chronic immunosuppression)
• No in utero diethylstilbestrol (DES) exposure

Sexual activity status is not a criterion for discontinuing screening. 4 Women who have never been sexually active but meet the age and adequate screening criteria may discontinue screening at age 65, but those who have not been adequately screened should continue screening even after age 65. 1, 5

Special Considerations

• Women who were previously sexually active but are not currently active should continue routine screening, as HPV can remain latent for many years and cervical carcinogenesis can take decades to progress. 4

• Screening after hysterectomy: Discontinue screening only if the cervix was removed and there is no history of high-grade precancerous lesions or cervical cancer. 1, 2

• HPV vaccination status does not change screening recommendations—vaccinated women follow the same schedule as unvaccinated women because vaccines do not cover all oncogenic HPV types. 2, 3