New Guidelines: Pap Tests Should Start at Age 21

Young women should start having Pap tests for cervical cancer screening no sooner than age 21—regardless of when they become sexually active—because earlier testing may lead to unnecessary and possibly harmful treatments for an increasingly rare cancer.


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Young women should have their first Pap test no sooner than age 21, regardless of when they become sexually active, say new guidelines from the American College of Obstetricians and Gynecologists (ACOG). Earlier screening for cervical cancer may lead to unnecessary and possibly harmful treatments for an increasingly rare cancer, according to ACOG, the leading U.S. professional organization for obstetricians and gynecologists.

After age 21, women should have a Pap test every two years, instead of every year. At age 30, if a woman has no history of cervical cancer and has had three normal Pap tests in a row, she can be screened every three years, rather than every two to three years. (Women with certain risk factors, such as those who are HIV positive or who have a suppressed immune system, may need to be screened more often.)

However, annual pelvic exams—which are necessary for performing a Pap test—wont necessarily be going away. ACOG says it may still be appropriate for women to visit their doctor annually for a pelvic exam, even if a Pap test isnt performed. And sexually active adolescents shouldn't wait until age 21 to see a gynecologist for the first time. (Such visits don't necessarily have to include a pelvic exam.)

The guidelines were published this week in the journal Obstetrics & Gynecology.

ACOG had previously recommended that women receive their first Pap test three years after having sex for the first time, or no later than age 21, with annual checkups after that.

Why the change? Rates of cervical cancer, which is caused by the sexually transmitted human papillomavirus (HPV), have declined by 50% since the 1970s. Cervical cancer is now extremely rare, especially among women under the age of 30, the group most affected by the new guidelines. On average, just 14 cases occur nationwide in women between the ages of 15 and 19 each year, according to data from the Centers for Disease Control and Prevention. Among women ages 20 to 24, an average of 123 cases occur.

"The risk of invasive cancer is so exceedingly rare in this age group that to start screening at age 21 will still pick up the overwhelming majority of cases,” says Alan Waxman, MD, a professor of ob-gyn at the University of New Mexico School of Medicine, in Albuquerque, who led the preparation of the document spelling out the recommendations. “The incidence of cervical cancer in 15- to 19-year-olds has been reported at 1 to 2 per million girls. That's a lot of unnecessary pelvic exams and unnecessary potential treatments that can be avoided."

The cervical cancer rate will probably drop even further due to newer vaccines like Gardasil, which are now approved for HPV prevention in girls and women ages 9 to 26. However, ACOG says the vaccines wont affect cervical cancer rates for 15 to 20 years, so they did not play a role in the new cervical cancer screening guidelines. Such vaccines dont protect against all types of HPV that can cause cancer, so Pap tests are still necessary.

About half of all people are infected with HPV at some point in their lifetime, although the infection often goes away on its own. (Only in some cases does the virus damage cervical cells, causing abnormalities that can be picked up on a Pap test.)

Studies that ACOG consulted also show that screening older women every two to three years is nearly as effective as screening annually. And for women whove had healthy Pap tests for years, screening could probably be stopped around ages 65 to 70.

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Ray Hainer
Last Updated: November 20, 2009

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