Pap Smear Guidelines Key Points

• Pap screening should begin at age 21. Women should have Pap smears every 2 years.

• Women who have had a hysterectomy for benign disease should not have Pap smear screening.

• Women are not required to have a Pap smear before starting hormonal contraception.

• Women do not need a pap smear over age 65 if they have had normal results in the past.

Although the Pap smear is still the mainstay of cervical cancer screening, recent advances in the understanding of human papillomavirus (HPV) have revolutionized this field. HPV is the most common sexually transmitted infection (STI), with its highest prevalence among the 20-to 24-year-old age group (44.8%) (Dunne et al., 2007). Although HPV is typically spread through sexual activity, 5.2% of women in this study who reported that they had never had sex were infected with HPV. Physicians should keep in mind that some of these women may have been uncomfortable disclosing their sexual activity, even on an anonymous survey, whereas others may have had sexual contact they did not consider intercourse. Risk factors for

Table 25-1 USPSTF Level A and B Recommendations for Adult Women




Alcohol misuse

Screening and behavioral counseling


High blood pressure

Office sphygmomanometry


Breast cancer

Mammogram, with or without clinical breast exam, every 1-2 years for women 40 and older


Pap smear

Screening at least every 3 years, starting within 3 years of sexual activity or at age 21



Women age 24 and younger who have ever been sexually active


Lipid disorders

Women age 45 and older at increased risk for heart disease


Women age 20-45 at increased risk for heart disease


Colorectal cancer

Adults age 50-75, using fecal occult blood testing, sigmoidoscopy, or colonoscopy



Screening in adults as part of clinical practices with systems to ensure accurate diagnosis, effective treatment, and follow-up


Type 2 diabetes

Adults with blood pressure >135/80 mm Hg



Screening adults; behavioral and counseling interventions


Routine screening of women age 65 and older



Screening of women age 60 and older at increased risk


Tobacco use

Screening adults; cessation interventions


US Preventive Services Task Force recommendations, available at nic/uspstfix.htm.

*Strength of recommendation taxonomy (level of evidence).

HPV infection include lifetime number of sexual partners, age at first intercourse, smoking, and lack of condom use (Burchell et al., 2006).

Strength of recommendation taxonomy (SORT) level A recommendations for cervical cancer screening include starting Pap test screening at age 21 and repeating every 2 years. "Low-risk women" are defined as those with three consecutive normal Pap tests, no history of cervical intraepithelial neoplasia type II (CIN-II) or higher, and no immunocompromise. A screening option for women age 30 and older is to perform Pap smear and HPV testing together, with repeat Pap tests every 3 years if both are normal. The recommendations for fewer Pap tests in women under 21 and over 30 are consistent with the epidemiology of HPV. Younger women acquire HPV infections more frequently, but most will clear the infection without intervention. Older women are less likely to develop new HPV infections, and only persistent HPV is a concern for cervical cancer. Women are not required to have a Pap smear before starting hormonal contraception. Physicians can use visits when a Pap test is not needed as an opportunity to educate female patients about STIs and reproductive health, as well as perform the other, evidence-based screening recommendations previously cited (ACOG, 2003).

Abnormal Pap Smear Management

Guidelines for management of abnormal Pap tests have also been updated to reflect understanding of the epidemiology of HPV infection (Wright et al., 2007). These guidelines include recommendations for the management of special populations, such as adolescents, pregnant women, and postmenopausal women, and are available online at the American Society for Colposcopy and Cervical Pathology (ASCCP) at Most women with low-grade squamous intraepithelial lesions (LSIL), atypical squamous cells of undetermined significance (ASCUS) with positive HPV testing, and high-grade SIL (HSIL) should have colpos-copy.

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