A Pap smear is a simple test in which a few cells are taken from the cervix and checked under a microscope for precancerous changes; an HPV test, done on the same kind of sample, looks for the virus that causes these changes [9]. The World Health Organization recommends an HPV test every 5 to 10 years from age 30 [1, 2]; US guidelines recommend an HPV test every 5 years or a Pap smear alone every 3 years, from age 21 or 25 to 65 [3, 4]. If earlier tests were regular and negative, screening can usually stop at around 65 [3, 5].
Key points
- The aim is to find precancer years before it becomes cancer; treating precancer is simple and effective [1].
- The HPV test is more accurate: in four large European studies of more than 170,000 women, the HPV test protected against cervical cancer better than the Pap smear [6].
- How often? An HPV test every 5 years (World Health Organization: every 5 to 10 years); a Pap smear alone every 3 years [2, 3, 4].
- You can take the sample yourself: for an HPV test, a sample a woman takes from her own vagina is almost as reliable as one taken by a clinician [1, 7].
- Had the HPV vaccine? You still need regular screening [3, 9].
What is a Pap smear? How is it different from an HPV test?
The cervix is the lower, narrow part of the womb that opens into the vagina. Cervical cancer starts from changes that HPV causes in its cells, and these changes usually take 15 to 20 years to become cancer [1]. Screening means testing women who have no symptoms, so that these changes are found and treated early [1].
- Pap smear (cervical cytology): cells are looked at under a microscope for changes caused by HPV that may become cancer if left untreated [9].
- HPV test: the sample is checked for high-risk types of HPV [9]. If the virus is not there, the risk of cancer in the following years is very low, which is why the tests can be further apart [6].
- Co-testing: both tests are done together [3].
The sample for both tests is taken in the same way [9]. Read more about the virus itself: What is HPV? Is it dangerous and does it go away?
From what age and how often should you have a Pap smear?
Guidelines differ a little in the details, but the main message is the same: regular testing from your 20s or from age 30, stopping only after several negative results in a row [2, 3, 4]. If you have never been tested, it is not too late: the World Health Organization says that even two tests in a lifetime are beneficial [2].
| Age or group | Recommendation |
|---|---|
| Under 21 | No testing needed; cervical cancer is rare at this age [3] |
| 21 to 29 | Guidelines differ: a Pap smear every 3 years from age 21 [3], or an HPV test every 5 years from age 25 [4]; the World Health Organization recommends starting at 30 [2] |
| 30 to 65 | An HPV test every 5 years, the preferred method [4]; or an HPV test and Pap smear together every 5 years, or a Pap smear alone every 3 years [3]; World Health Organization: an HPV test every 5 to 10 years [2] |
| Over 65 | If earlier tests were regular and negative and you have no history of precancer, testing stops [3, 5]; World Health Organization: after age 50, once two tests in a row are negative [2] |
| Women living with HIV | From age 25, an HPV test every 3 to 5 years [2] |
If you have had an abnormal result or precancer before, or your immune system is weakened, your schedule is different and your doctor will set it [4, 5].
Which is better: a Pap smear or an HPV test?
The HPV test is more accurate. In four large studies in Sweden, the Netherlands, England and Italy of more than 170,000 women, those screened with the HPV test developed cervical cancer less often than those screened with the Pap smear [6]. Among women whose first test was negative, cancers over the next five and a half years in the HPV-test group were about a quarter of those in the Pap-smear group [6]. That is why, with the HPV test, tests can be spaced at least 5 years apart [6].
The World Health Organization considers the HPV test the main screening method [2]. A regular Pap smear every 3 years is also an acceptable method; what matters most is having one of them regularly [2, 3].
Does a Pap smear hurt? How is it done?
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During the test
You lie on your back on an examination table with your knees bent. A doctor, nurse or midwife gently opens the vagina with an instrument called a speculum to see the cervix, and takes a few cells with a soft brush or a tiny spatula. The whole thing takes a few minutes [9].
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Does it hurt?
For most women, the pain is mild. In one study, inserting the speculum caused little pain for most women, and a small amount of lubricating gel made it even less, without spoiling the Pap smear sample [10]. If you are worried or it hurts, tell the doctor.
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After the test
Results usually come back from the laboratory within 1 to 3 weeks [9].
Can I take the HPV test sample myself?
Yes, if your screening programme offers it. With this method a woman uses a small device to take a sample from inside her vagina [5]. The World Health Organization considers a sample a woman takes herself as reliable as one taken by a clinician [1, 2]. In a review of dozens of studies, with a suitable laboratory method, self-samples found precancer almost as well as clinician samples, and sending kits to women's homes brought more women who were rarely tested into screening [7].
A few points [5]:
- This method is for the HPV test, not the Pap smear.
- If the result is negative, the next test is in 3 years, not 5.
- If the result is positive, you will usually need to see a clinician for an examination and further tests.
- For some high-risk women, a clinician-collected sample is still recommended.
Until what age do you need a Pap smear? What if I have had a hysterectomy?
Testing can stop at around 65, provided earlier tests were regular and negative [3, 5]. In the American Cancer Society's latest update, the condition for stopping is a negative HPV test at 60 and at 65, because cervical cancer is not rare in women over 65 [5]. The World Health Organization suggests stopping after age 50, once two tests in a row are negative [2].
If you have never been tested or your tests have not been regular, you still need testing after 65; talk to your doctor [3, 5].
After a hysterectomy: if the womb and cervix were removed for a reason other than cancer or precancer, you do not need testing [3, 9]. If the operation was for cancer or precancer, or the cervix was left in place, ask your doctor [3, 9].
Pap smear results: normal or abnormal?
A normal (negative) result means no cell changes or high-risk virus were found. Have your next test at the usual interval: 5 years later for an HPV test or co-testing, and 3 years later for a Pap smear alone or a sample you took yourself [3, 4, 5].
An abnormal Pap smear result means changes were found in the cells of the cervix [8]; a positive HPV test means a high-risk type of the virus was found [9]. Most people who get an abnormal result do not have cancer; most have an HPV infection or early changes that only need follow-up [11]. The meaning of each result (such as ASCUS, LSIL or HSIL) and the next step are explained in Abnormal Pap smear or positive HPV test.
I have symptoms: should I wait for my screening appointment?
Pap smears and HPV tests are for women who have no symptoms. If you have any of these symptoms, do not wait for your screening appointment; see a doctor soon [1]:
- Unusual bleeding: between periods, after the menopause or after sex
- More vaginal discharge, or discharge that smells bad
- Persistent pain in the back, legs or pelvis
Most of the time these symptoms are not caused by cancer, but you need to be examined. Read more: What are the symptoms of cervical cancer?
Frequently asked questions
I have had the HPV vaccine; do I still need a Pap smear?
Yes. The vaccine does not protect against all high-risk types of HPV, so women who have been vaccinated also need to be tested on the usual schedule [3, 9]. Read about the vaccine: HPV vaccine
Can I have a Pap smear during my period?
Yes. If you have your period on the day of the test, don't worry; both the Pap smear and the HPV test can be done [8].
Does a Pap smear also find womb (uterine) or ovarian cancer?
The Pap smear and the HPV test are designed to find changes in the cervix [9]. If you have symptoms such as bleeding after the menopause, do not wait for this test; see a doctor [1]. See the symptoms of womb cancer in Symptoms of womb (endometrial) cancer.
My Pap smear is normal but my HPV test is positive: what does it mean?
It means a high-risk virus was found, but the cells have not yet changed in a way that can be seen [9]. This result needs follow-up, and your doctor will decide the next step based on your current and earlier results [11]. The full explanation is in Abnormal Pap smear or positive HPV test.
If my HPV test is negative, why wait 5 years?
Because a negative HPV test means the risk of cancer in the following years is very low. In large European studies, women with a negative HPV test developed cancer far less often over the next five and a half years than women with a negative Pap smear [6]. Based on its reviews, the World Health Organization says an HPV test every 5 to 10 years has more benefit and less harm than testing more often [2]; testing more often than needed may find changes that would have gone away on their own and lead to unnecessary tests and treatment [9].
Comparison of guidelines (for doctors)
For physicians
| World Health Organization (2021) [2] | USPSTF (2018) [3] | American Cancer Society (2020 and 2026 update) [4, 5] | |
|---|---|---|---|
| Age to start | 30 (strong recommendation); women living with HIV, 25 | 21; under 21: against screening (grade D) | 25 |
| Test and interval | HPV DNA as the primary test instead of VIA or cytology (strong recommendation), every 5 to 10 years; HIV: every 3 to 5 years; in programmes not yet using HPV testing, VIA or cytology every 3 years | 21 to 29: cytology every 3 years; 30 to 65: cytology every 3 years, hrHPV alone every 5 years or co-testing every 5 years (grade A) | 25 to 65: primary HPV every 5 years (preferred); co-testing every 5 years or cytology every 3 years acceptable and transitional |
| Self-collected sample | Clinician-collected or self-collected sample (conditional recommendation) | Not addressed in the 2018 recommendation | Acceptable at 25 to 65, only with FDA-approved device and assay combinations; repeat at 3 years after a negative result; clinician sample for some high-risk individuals |
| Stopping | After 50, following two consecutive negative results at the recommended intervals (conditional recommendation) | Over 65 with adequate prior screening: 3 consecutive negative cytology results or 2 consecutive negative co-tests in the 10 years before stopping, the most recent within 5 years (grade D: against continued screening) | 2020: no CIN2+ in the past 25 years and adequate negative screening in the past 10 years; 2026: negative primary HPV tests at 60 and 65 (last test no earlier than 65), or if unavailable 3 consecutive negative cytology results with the last at 65 |
| Hysterectomy | — | Against screening after hysterectomy with removal of the cervix, without a history of CIN2/3 or cancer (grade D) | — |
| Follow-up of a positive result | HPV positive and triage negative: repeat HPV at 24 months; after treatment of CIN2/3 or AIS: HPV test at 12 months | — | According to the 2019 ASCCP risk-based guideline |
Ronco 2014 (follow-up of four trials, Swedescreen, POBASCAM, ARTISTIC and NTCC; 176,464 women aged 20 to 64, median follow-up 6.5 years, 107 invasive cancers): rate ratio of invasive cancer with HPV-based versus cytology-based screening 0.60 (0.40 to 0.89); 0.79 (0.46 to 1.36) in the first 2.5 years and 0.45 (0.25 to 0.81) thereafter; 0.30 (0.15 to 0.60) after a negative entry test, with cumulative incidence of 8.7 versus 36.0 per 100,000 at 5.5 years; adenocarcinoma 0.31 (0.14 to 0.69) [6]. Arbyn 2018 (56 accuracy studies and 25 participation trials): relative sensitivity of self-samples versus clinician samples for CIN2+ 0.99 (0.97 to 1.02) with PCR-based assays and 0.85 (0.80 to 0.89) with signal-amplification assays; specificity 2% or 4% lower; mailing kits to the home increased participation 2.33-fold compared with invitation letters (1.86 to 2.91) [7].
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References
11 referencesShow all references, 5 with a study cardClose the reference list
Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
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- 10Effect of lubricating gel on patient comfort during vaginal speculum examination: a randomized controlled trial
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