Cervical Cancer Screening in Elderly Women: Impact of Aging on Cytology and the Role of HPV Testing

Screening for cervical cancer using the Papanicolaou (Pap) smear has reduced morbidity and mortality associated with cervical cancer. However, anatomical and hormonal changes with age make diagnosis more complex in elderly women. This narrative review used a structured literature search of databases including PubMed, Scopus, Google Scholar, and ScienceDirect from 2010 to 2024. It included studies related to the impact of age on cervical cytology and HPV prevalence, the importance of cervical sampling adequacy, the diagnostic difficulties encountered in postmenopausal women, and the use of adjunctive cervical screening methods such as liquid-based cytology (LBC), high-risk HPV (HR-HPV) DNA testing, and topical estrogen therapy. Clinical practice guidelines from various organizations, including ACS, USPSTF, and WHO, were also reviewed. Studies have shown that menopause-related estrogen deficiency causes atrophy, reduced cellularity, and transformation zone (TZ) recession, resulting in a high number of unsatisfactory smears and false-positive interpretations that may mask HSIL. Although HPV prevalence decreases with age, persistent and re-emerging high-risk HPV types among older women are strongly associated with CIN2+. Both HR-HPV testing and LBC have demonstrated higher sensitivity for detecting cervical lesions in postmenopausal women compared with conventional cytology. Evidence also indicates that short-term topical estrogen therapy facilitates transformation zone visualization and improves sample adequacy. Gaps in screening persist among women aged 65 and older. To optimize cervical cancer prevention in this aging demographic, it is important to develop individualized cervical screening strategies that take into consideration hormone status, high-risk HPV persistence, and improved diagnostic techniques to strengthen the protection of elderly women who remain at risk.