What exactly is a Pap smear?
Many patients confuse a Pap smear with a a pelvic exam, which is when a speculum is placed in the vagina and a healthcare provider checks the size and shape of the uterus and ovaries. A Pap smear or cervical cytology is a test that requires a healthcare provider to sample cells on the cervix using a flexible brush after a speculum is placed. So, a woman may have a pelvic exam in the emergency department or physician office without having cervical cancer screening. It is important to review your records or ask your healthcare provider if you are up to date on your Pap smear.
What is the Human Papilloma Virus (HPV)?
HPV is very common. Nearly all sexually active people are exposed to it at some point in their lives. It is spread by having vaginal, anal or oral sex with someone who has the virus. It can be spread even when the infected partner doesn’t have any signs or symptoms. While condoms can decrease the chance of infection, there are areas that are not covered by a condom so complete protection is not guaranteed. Even if a woman has just one sexual partner, her risk of HPV infection is about 10 to 20 percent. Symptoms can develop years after the exposure, so it is often difficult to know when infection occurs.
Certain high-risk types of HPV (16, 18, 45, 31, 33, 52, 58 and 35) account for 95 percent of cervical cancers. Most HPV infections are temporary and the immune system can clear the virus. However, a small percentage of women will have a persistent infection lasting two years or longer and these are more likely to lead to severe changes on the cervix or cancer. Having a suppressed immune system, the HIV virus or smoking cigarettes all increase the risk of having a persistent infection more likely to lead to cervical dysplasia.
When do I need cervical cancer screening?
In the past, cervical cancer screening recommendation was to have a Pap smear yearly. For most patients, the new recommendations are:
- Start screening at 21 years of age (regardless of age of first intercourse). Cervical cancer before this age is very rare.
- 21-29 years of age, cervical cytology (Pap smear) without HPV testing every three years
- 30-65 years of age cervical cytology (Pap smear) PLUS high-risk HPV testing every five years is preferred; another option is to have a Pap more frequently (every three years) without high-risk HPV testing.
Why the Change?
Large-scale studies sow that normal Pap smear results in patients younger than 30 or in older patients who don’t have high-risk HPV have such a low chance of developing cervical cancer that they can go 3-5 years until their next cervical cancer screening. Studies show that yearly Pap smears double or triple the interventions such as biopsies or procedures to remove part of the cervix without preventing cancer of the cervix.
Even with mildly abnormal results, 90% of adolescents and 75% of adult Pap smears will normalize. Screening women less than 30 years of age for high-risk HPV is therefore not helpful because it so often resolves and testing might lead to increased unnecessary interventions.
Don’t forget, screening tests are for patients who are not having any symptoms. If you are having irregular periods, bleeding after intercourse, bleeding after menopause or other concerns, these symptoms need to be evaluated even if the most recent Pap test was normal. Make an appointment if you are having problems.
What if my test is abnormal?
For some women, an examination with a colposcope (an instrument that allows a closer look at the cervix) and a biopsy maybe recommended after an abnormal Pap. Cervical intraepithelial neoplasia (CIN) describes the extent of the abnormality of the cells. CIN 1 is mild, CIN 2 indicates moderate changes and CIN 3 means severe changes that are more likely to lead to cervical cancer.
Special Circumstances
For women who have had a hysterectomy with removal of their cervix and no history of CIN 2 or higher, there is no need for future screening and HPV testing. Such women with a history of CIN 2 or higher should continue to be screened. Women who have had their uterus removed but not the cervix should continue routine cervical cancer screening.
In addition, women who have risk factors for cervical cancer need more frequent cervical cytology screening. Such factors include:
- A suppressed immune system (following organ transplant or on medication for systemic lupus erythematous)
- Being exposed to diethylstilbestrol (DES) in utero
- An HIV infection
- Previously having CIN 2 or CIN 3 or cervical cancer
When can I stop having Pap smears?
After age 65, screening can be discontinued if a woman‘s last three Pap smears were normal (or last two Pap smears show negative high-risk HPV testing in the last 10 years) and she doesn’t have a history of severe changes in her cervix (CIN 2 or 3). Women with a history of CIN 2 or CIN 3 need screening for 20 years regardless of age.
Fighting HPV
In addition to regular screening, women can proactively fight HPV and cervical cancer. The recommendation is clear that boys and girls should receive the HPV vaccine at 11-12 years of age. If men and women under the age of 27 have not yet received the vaccine, they should. The vaccine provides protection against HPV types 16 and 18, which cause 70 percent of cervical cancers. For now, Pap smear screening recommendations are the same for women who have received the vaccine.
Anything that disrupts your immune system from fighting off viruses could allow HPV to cause more problems. For instance, smoking quadruples a woman’s risk for cervical cancer. By maximizing your nutrition, rest and general health, you can do your part in fighting HPV.
Don’t neglect your gynecologist!
Even though you likely won’t need to have Pap smears as often as in the past, yearly exams are still recommended for many reasons. Schedule your appointment today!