Pap Smear

WHAT IS A PAP SMEAR?

A Pap smear (or Papanicolaou test) is a screening test to look for abnormal cells on the cervix. This test was developed by Georgios Papanikolaou in the 1940s. During the test, a speculum is used to visualize the cervix. Cells are collected from the cervix using small brushes and are then examined under a microscope. The Pap test can identify precancerous or cancerous cells on the cervix. If these abnormalities are detected, appropriate treatment and follow-up can then be initiated.

HOW OFTEN SHOULD I HAVE A PAP SMEAR?

In 2012, several groups including the U.S. Preventative Services Task Force, the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, released new recommendations for cervical cancer screening. Their recommendations which were developed independently but are consistent are as follows:

POPULATION	RECOMMENDATION
Younger than 21 years	Women less than 21yrs. of age should not be screened regardless of whether they are sexually active.
Age 21-29 years	Screen with Pap smear alone every 3 years
Age 30-65 years	Screen with Pap smear and high-risk HPV testing every 5 years OR Pap smear alone every 3 years
>65 years	Do not continue to screen women over 65yrs. of age if they have had adequate prior normal Pap smears and no evidence of moderate or severe dysplasia in the last 20yrs.
s/p hysterectomy	Do not continue to screen women after hysterectomy if the cervix was removed who do not have a history of moderate or severe dysplasia.

WHY IS HPV TESTING A PART OF THE RECOMMENDATIONS?

The human papilloma virus (HPV) has been identified as the cause of the majority of cases of cervical cancer. There are more than 100 subtypes of the HPV virus. There are low-risk and high-risk subtypes in terms of the risk of going on to develop cervical cancer. HPV infection is very common in women who have been sexually active. In most infected women, their immune system will fight off and clear the virus in 9-12 months. 60% of cervical cancers are caused by two of the high-risk subtypes alone, HPV -16 and HPV-18. By screening with a Pap smear and high-risk HPV typing (“co-testing”) women at higher risk for developing abnormal cells on the cervix are identified and will have further evaluation. Young women in the 21-29 year old category are not recommended to do co-testing because of the increased likelihood of HPV infection at this time in life. Clearance rates after infection are high and screening could result in over treatment of a condition that will resolve on its own. Instead, Pap smears every 3 years are recommended until age 30 when co-testing is an option.

HPV VACCINATION

Because of the prevalence of HPV, young women are encouraged to consider the HPV vaccination before initiating sexual activity. This vaccination process currently involves 3 injections given over a 6 month time period. Although the series cannot protect against all HPV subtypes, it does protect against the most common high-risk subtypes. The HPV vaccine is currently approved for use in individuals age 9-26.

IS IT REALLY OKAY TO WAIT 3-5 YEARS BETWEEN PAP SMEARS?

Cervical cancer is typically very slow growing, and most cancers are found in women who have never been screened or who have not been screened in over 5 years. It has been estimated that it often takes 3-7 years for even severely abnormal cells to advance to cervical cancer. The recommendation to extend the number of years between Pap smears is not new because of the science behind the way this disease progresses. In fact, the American Cancer Society has been advocating for less frequent screenings since 1980. All of the groups independently involved in the new 2012 recommendations came to the same conclusions. They believe that it is safe to extend the screening intervals for women at average risk of cervical cancer. Women with HIV or DES exposure in the past, who are at highest risk for cervical cancer, will be followed more frequently. Extending the interval for average risk women will decrease the chance of detecting abnormalities that will regress without intervention. It will decrease the anxiety of a “positive” screen, prevent unnecessary colposcopies, biopsies, and follow-up exams, and will prevent overtreatment that could result in preterm labor and/or preterm delivery in reproductive age women.

IS AN ANNUAL EXAM STILL NECESSARY?

The Pap smear itself is a small portion of the annual exam. It is still recommended that you see your physician yearly. This visit will provide a time for questions, a full physical, and a recommendation for any other recommended preventative health screenings. Some of the benefits of this visit will include:

POPULATION	TOPICS TO COVER
Adolescents	Healthy weight/diet/exercise Menstrual cycle education Safer sex Sexually transmitted disease screening if needed Birth control options if needed HPV vaccine
Reproductive age	Healthy weight/diet/exercise Birth control options if needed Family planning if needed
Later reproductive years and perimenopausal patients	Healthy weight/diet/exercise Education about the perimenopause and symptom relief Mammogram referral
Postmenopausal patients	Healthy weight/diet/exercise Menopausal symptom relief Mammogram referral Colonoscopy referral Bone mineral density referral

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