Women in their mid-60s and older often stop having cervical cancer screenings. That’s because most major medical organizations advise women to stop screening once they reach 65 if they’re considered at average risk and have been adequately screened in the past.

Those women often feel relieved to be free of these gynecological exams, during which a health-care provider inserts a speculum into the vagina and uses a tiny brush or swab to collect a sample of cervical cells. They believe that they’re no longer at risk of developing cancer of the cervix. And it is true that many of them will spend the rest of their lives cervical cancer–free…but not as many as you might think.

Out of the 14,100 cases of cervical cancer diagnosed in the US in 2020, 20% occurred in women older than 65. This same age group also accounts for about 37% of cervical cancer deaths.

Screening and Prevention
Cervical cancer used to be one of the deadliest cancers for US women. Thankfully, rates dropped sharply after the introduction of the Pap smear in the 1940s. Now called Pap tests, they allow doctors to examine a patient’s cervical cells under a microscope to detect abnormal cellular changes and ­precancers. Performed regularly, they can catch worrisome changes early. Since cervical cancer symptoms are rare early on, screening is the only way to diagnose it. Catching precancerous changes, also called dysplasia, early means that they can be treated before they progress into full-blown cancer.

If cervical cancer isn’t caught and does progress, symptoms can include abnormal vaginal bleeding (bleeding between periods, unusually heavy or prolonged periods, bleeding after sex and/or postmenopausal bleeding) and unexplained vaginal discharge (watery, bloody or brown). Metastatic cervical cancer symptoms, which are less cervix-specific, include fatigue, lack of appetite and weight loss, painful or difficult urination, pelvic or abdominal discomfort (including pain during intercourse), backache and diarrhea or painful bowel movements.

In 2014, the FDA approved a new screening tool called the Human Papilloma Virus (HPV) DNA test. With HPV DNA testing, a sample of cervical cells is tested for the presence of certain high-risk strains of HPV, an extremely common sexually transmitted virus that is responsible for nearly all cases of cervical cancer. There are more than 100 HPV types overall, including 13 high-risk strains. The most virulent—HPV 16 and 18—cause cancer of the cervix, vagina, vulva, anus, penis and throat. The other strains mostly cause only warts and are not included in the screening.

Most women will contract a high-risk HPV strain at some point in their lives, but it usually is “cleared” by their immune system within a few years. Even then, the virus still may reside in the patient’s cells, but she will not test positive and her risk for cervical cancer declines. But sometimes, due to subtle changes in the patient’s immune system, the HPV result can turn positive again and her risk increases. There currently is no way to remove a preexisting HPV infection, but risk for subsequent infection with a new subtype may be decreased by HPV vaccination, especially when the vaccine is given as a child or teenager. Persistent positive HPV infections elevate cervical cancer risk.

Surprising: Men can carry the virus, but since there is no screening test for men, they often are not aware they have it. Men who have the virus are at risk for anal, penile and oropharyngeal cancers.

Up to 80% of men and women may contract the high-risk HPV virus at some point. HPV persistence in both women and men is more likely in those who smoke or are immunosuppressed.

The virus, which is present on genital skin, usually is asymptomatic. Condoms don’t fully protect against infection. The only way to prevent infection is through early vaccination of both boys and girls.

Over the last two decades, an aggressive screening protocol has evolved featuring the HPV test, Pap testing or a combination of both. Though different organizations endorse slightly different protocols, they generally begin with an initial Pap test at age 21, followed by Pap testing at regular intervals or an initial HPV DNA test at age 25, followed by HPV testing at regular intervals until age 65. Often, a combination of HPV and Pap testing is used, called co-testing. HPV-based testing is more sensitive than Pap alone, so an HPV test should be part of the screen for women over age 25.

To be considered safe enough to stop screening at age 65, a woman’s medical history needs to show that she has…
• Undergone regular screenings between ages 55 and 65 and received at least three negative Pap tests or two negative co-tests.
• Not been diagnosed with a serious cervical cellular abnormality within the past 25 years.

There has been a marked drop in early cervical cancer cases. In 2023, cervical cancer accounted for less than 1% of all new cancer diagnoses in the US. Screening plays a large part in that decline, as does the HPV vaccine. ­Ideally administered between ages nine and 14 and before the onset of sexual activity (though it can be given up to age 26), the HPV vaccine is widely credited with decreasing rates of cervical cancer among young women. Although it is FDA-approved and safe for administration up to age 46, there is no additional cancer prevention value in this age group If you’re currently in your 60s or older, vaccinating no longer offers any cancer-prevention benefit.

Older Women May Be At Risk
Just because general screening guidelines stop at age 65 doesn’t mean that cervical cancer can’t still develop. Screening protocols endorsed by the American Cancer Society, US Preventive Services Task Force and American College of Obstetrics and Gynecology all are based on the assumption that a woman has received “adequate screening” and is at average risk. That means women need to have adhered to the screening protocol and have no history of cervical cancer or high-grade dysplasia (moderately or severely abnormal cervical cells), and all normal and adequate tests in the 10 years before stopping. Unfortunately, this is relatively rare for several reasons…

At least one in five US women between ages 30 and 65 has not stayed up to date with her cervical cancer screening, typically because of poor access to health care, hesitation to get screened or tested, or a misunderstanding of their ­ongoing risk. The pandemic also added to this—according to research in Journal of Clinical Oncology, cervical cancer screenings in the US dropped from 45.3% to 39% between 2019 and 2021.Those at particular risk of underscreening include Black and Hispanic women and LGBTQ patients, including transgender patients who have a cervix. In fact, about 15% of women ages 60 to 65 have not been adequately screened for cervical cancer.

Many women have had at least one abnormal Pap or HPV result in their lifetime, effectively kicking them out of the “average risk” category. Any new abnormality starts the clock over again. Example: If you had a high-grade abnormality on a Pap or biopsy at age 50, you would need 25 years of clear screenings after that high-grade result before you’re eligible to end screenings—meaning not until you’re 75 years old.

Many women believe that they’ve been regularly screened and had no abnormal findings, but perhaps they skipped a screening or had an abnormal Pap screening several years ago. Sometimes people have normal Pap tests but abnormal HPV tests, which raise their risk out of the low-risk category, but they may not be aware.

Many women do not have a lifetime record of their screenings.

Result: It isn’t always appropriate to stop screening at 65. Most cases of invasive cervical cancer in patients over age 65 occur in those who stopped having cervical cancer screening without meeting the criteria. Without regular screening, cervical cancer can become more advanced and, by the time it is diagnosed, incurable.

Note: If you have had a hysterectomy and have never had an abnormal Pap, HPV, biopsy or treatment of your cervix (such as cryosurgery or a procedure called a LEEP), you may stop screening at 65.

HPV Infections Don’t 
Discriminate by Age

Many people think sexually transmitted infections affect only younger people who have or have had multiple sexual partners. But nearly every sexually active person will have HPV at some point. Risk rises with the number of sexual partners, but you can contract HPV even if you’ve had only one partner.

If you’ve been in a monogamous relationship for decades and then are ­widowed or divorced, you may begin sexual relationships with new partners—and the chances are high that you’ll be exposed to HPV. Infections are spread by intimate skin-to-skin contact—vaginal intercourse is not necessary. If you are infected with a cancer-causing strain of HPV and your immune system can’t fight it off, you could develop cervical cancer 10 to 20 years later. This is why it’s important to continue screening well into your 60s and perhaps even longer.

What You Can Do Now

Get tested for HPV. If you’re in your 50s or early 60s, ask your health-care provider if you’re currently being screened with HPV DNA testing. Older women are more likely to have had Pap tests than HPV testing, and even though Paps are effective, a negative HPV test is considered more reassuring. Pap tests also are less reliable in menopausal women—estrogen fluctuations can cause cervical cells to change in ways that may look worrisome under a microscope but, in reality, are not cause for concern. Hormone changes do not impact HPV testing.

Discuss testing after age 65. If you are in your early 60s, ask your health-care provider how he/she envisions your future cervical cancer screening. If you’ve ever had an abnormal screening result or dysplasia, especially within the last 25 years, follow the surveillance guidelines issued by the American Society for Colposcopy and Cervical Pathology (ASCCP), which call for more frequent testing in patients with prior abnormal results.

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