Can We Talk About Pap Smears?
Several times a week I get asked with a bit of anxiety, “You mean I don’t need a Pap smear EVERY year?”
The annual exam gives a lot of us a sense of security and for DECADES this was the expectation – annual health maintentace exam with Pap test.
But why? The annual exam is more than a Pap smear but that is the thing most of us focus on.
The purpose of a Pap smear is prevention and early detection of cervical cancer.
Please note: All pelvic exams are not Pap smears. I often hear, “they did my pap n the ER”? Nope. They did not. ER physicians do not perform routine screening exams.
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What is a pap exactly?
A speculum is placed in the vagina and the cervix is identified. Exfoliated cells are collected with a brush from the transformation zone of the cervix and transferred to a vial of liquid preservative that is processed in the lab (liquid-based technique) or transferred directly to a slide and fixed (conventional technique).
Large blood, discharge, and some lubricants (including personal lubricants used by patients) may interfere with specimen interpretation. A pap does not routinely test for sexually transmitted infections like gonorrhea or chlamydia; however, it can be run on the specimen if requested.
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The incidence of cervical cancer in the United States has decreased more than 50% in the past 30 years because of widespread screening.
Most cases of cervical cancer occur in women who were either never screened or were screened inadequately.
New technologies for cervical cancer screening continue to evolve, as do recommendations for managing the results. There are age-specific screening recommendations for women at different ages given different risk-benefit considerations.
In 2006, everything changed – cervical cancer screening guidelines have been revised several times in the past decade – based on a ton of data. There are over 20 algorithms for how to handle abnormal Pap smears. Most cervical cancer detected through screening is found in the early stages and survival is high. The recent revisions have balanced cancer detection with harms of screening by incorporating the powerful negative predictive value of HPV testing and lengthening screening intervals.
Current guidelines are based on performing cervical cytology every 3 years.
3 YEARS! I know. Let’s look at why.
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What’s the deal with HPV?
Cervical pre-cancerous cells become abnormal VERY slowly.
Human Papilloma Virus (HPV) is a known cause of abnormal cervical cells, so if we can determine it’s presence, we have a handle on the level of risk.
HPV is divided into two classes: 1) cancer causing (high-risk) and 2) non cancer causing (low-risk). HPV is a very common virus, passed from one person to another during skin-to-skin sexual contact, including vaginal, oral and anal sex. It is most common in people in their late teens and early 20s, and almost all sexually active people will get HPV at some time in their lives, though most will never even know it.
Low-risk HPV causes genital warts. Only a small fraction of women infected with high-risk HPV will develop significant cervical abnormalities and cancer. Most HPV infection is transient and has little risk of progression. Only a small fraction of infections are persistent. That’s right – your body clears the HPV; but, a persistent infection at 1 year and 2 years after initial infection strongly predicts subsequent risk of higher grade cervical abnormalities or cancer regardless of age.
*It is important to note that current screening recommendations are for average-risk women. It does not apply if you have abnormal Pap smears – in this circumstance, closer follow-up and testing will be required.
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When should I have a Pap smear?
The simple answer – check out this graph from USPSTF for average-risk women.
What if my pap is abnormal?
Depending on several factors – age, pap result, HPV status, and/or colposcopy results – there are algorithms to help determine the next course of action. If a pre-cancer is found, it can be treated and the cervical cancer can be stopped in its tracks.
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Prevent cervical cancer: The HPV Vaccine
HPV infection can cause cervical, vaginal, and vulvar cancers in women; penile cancer in men; and anal cancer, cancer of the back of the throat (oropharynx) and genital warts in both men and women. Many of these cancers could be prevented with vaccination.
HPV vaccines can prevent infection from both high-risk HPV types that can lead to cervical cancer and low-risk types that cause genital warts.
The CDC recommends all boys and girls get the HPV vaccine at age 11 or 12. The vaccine produces a stronger immune response during preteen years. For this reason only two doses are required up until age 14.
The vaccine is available for all males and females through age 45 but, for those 15 or older, a full three-dose series is needed.
Clinical trials have shown HPV vaccines provide close to 100% protection against cervical pre-cancers and genital warts.
NOTE: Even after you are vaccinated against HPV, you still need to have regular Pap tests to screen for cervical cancer.
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Lowering your risk for cervical cancer:
In addition to regular Pap and HPV tests and getting the HPV vaccine, there are other things you can do to prevent pre-cancerous cells from developing:
• Don’t smoke.
• Use condoms during sex. (The HPV vaccine does not protect against other Sexually Transmitted Infections (STIs) such as HIV, Chlamydia, and Gonorrhea).
• Limit your number of sexual partners.
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Take away:
The Pap smear is an excellent screening tool for prevention and early detection of cervical cancer. While you may not need a Pap smear every year, I still recommend an annual physical exam with your gynecologist every year – we check your breast, pelvis, screening labs and so much more.