It used to be that simple. You went to your gynecologist once a year. Your breasts would be checked, you’d have the dreaded pelvic exam that included STD testing and a pap, and then you’d be on your merry way. Phew, check that off the list until next year!
But in recent years things have gotten a little more confusing. When to get your pap smear has changed (and continues to change). There’s even growing research that says you may, in fact, not need to get that dreaded pelvic exam at all. These changes, while based on solid science, can leave women very confused about when to plan their “year” and what will actually happen while they’re there.
Let’s start by discussing what PAP IS NOT:
Women still commonly (and incorrectly) believe that when they have a gynecological exam they are getting a “Pap.” Not so much. The Pap test is not a pelvic exam, STD test, or ovarian cancer screening test. Clinicians can easily add STD tests (such as chlamydia or gonorrhea) to the Pap test. But it’s important to know that if you get a Pap smear, you may not necessarily get tested for STDs. If you want to include STD screening, let your provider know.
So what is pap?
The pap test (short for pap) is a screening test for cervical cancer. It was created by the Greek physician George Papanicolaou in the 1920s. Cervical cancer was the leading cause of cancer death among women in the U.S. Since the widespread implementation of the Pap test in this country, this has changed dramatically. Unfortunately, in developing countries where women do not have easy access to Pap smears, cervical cancer is still the leading cancer for women.
And why is it sometimes called a pap smear?
Well, back then, when a woman went to see her grandfather, the doctor would take a sample of cells from her cervix with a tiny spatula and ‘smear’ them on a glass microscope slide. He then sprayed the slide with a fixing solution to “coagulate” the cells. Today, about 99.9% of Paps in the US are done in a liquid medium, often called a ThinPrep test or liquid-based cytology.
What is the relationship between HPV and cervical cancer?
The most important risk factor for developing cervical cancer is infection with the human papillomavirus (HPV). There are over 100 different types or strains of HPV. However, most strains of HPV do not cause cancer. About 80% of women are exposed to HPV at some point in their lives. Most of the time, a woman’s immune system clears the virus before it can cause damage.
HPV is transmitted by direct skin-to-skin contact. Many women mistakenly believe that if they haven’t had sex with PIV that they can’t get HPV. It’s not true. HPV is easily transmitted through oral sex, anal sex, or even hand-to-hand contact with genitals without vaginal penetration. Condoms only provide partial protection as there is still genital contact with intercourse. Studies show that smoking can increase the risk of cervical cancer by up to four times. If a woman is immunocompromised (either due to a medical condition or medication), this also increases her risk of cervical cancer.
Also important to know – you can’t get HPV by touching an object like a toilet seat.
I had the HPV vaccine. How does this affect me?
As women who have received the HPV vaccine grow older, we will likely see another set of management guidelines emerge. Those who received the HPV vaccine are expected to have a significantly reduced risk of cervical dysplasia and cancer compared to the unvaccinated group, so we may see future screening recommendations further divided into guidelines for vaccinated versus unvaccinated women.
I am confused about when to go for my grandfather. I hear so many different things. I did it every year.
The recommendation was to get a pap every year, hence “the annual exam”. However, because new scientific advances in testing technologies have improved at such a rapid pace, testing guidelines have also changed. With the advent of HPV genotyping, scientists have been able to identify the type of HPV present. This is based on HPV DNA/RNA testing and has had a significant impact on the sensitivity of cervical cancer screening.
For example, new guidelines resulting from the recent 2019 consensus of the American Society of Colposcopy and Cervical Pathology (ASCCP) are based on screening In total risk of cervical dysplasia, not just test results. So, in other words, the Pap test is now based on more individualized, patient-specific recommendations.
So when should I start getting paps?
The screening guidelines listed below apply to asymptomatic, immunocompetent women.
Age 21. Across the board, all organizations agree on this Paps should NOT be done on women under 21, regardless of when they became sexually active. If you are under 21 and sexually active, we recommend that you see your gynecologist for an STD test, to discuss birth control methods, and to discuss any concerns or questions you may have about your sex life. But you don’t have to get a Pap test until you’re 21.
21-30 years: For this age group, a Pap test is recommended every 3 years. Your clinician will order a pap smear with HPV reflexes. With the “reflective” test, a pap is first done (the cells are examined under magnification for any changes). If the cells show something atypical then an HPV test and typing is done (from the same sample as the pap).
But what if I’m over 21 and have never been sexually active?
The guidelines recommend that all women over the age of 21 be screened even if they report sexual abstinence. Women may have a variety of reasons for not disclosing past sexual activity, including social, religious, or cultural norms or expectations. Also, women who have been sexually abused or raped may be reluctant to acknowledge this history. Additionally, many women do not consider past hand-to-genital or skin-to-skin contact to be sexual activity, although this is a common method of HPV transmission.
30-65 years old: Women 30-65 with a previous history of normal paps may have:
●Co-testing (meaning Pap test and HPV test) or HPV test every five years
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●Pap test only every three years
Patients with abnormal, unsatisfactory, or satisfactory but limited findings require further follow-up, which is individualized based on risk and test history.
65 years and older: For women over 65, recommendations currently say you can stop having a Pap test if:
• You had regular Pap smears until you turned 65.
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•You have had 3 normal Pap tests in a row or 2 normal combined Pap and HPV tests in the last 10 years (with the most recent test in the last 5 years).
If you’ve had an abnormal Pap/colp smear, your provider will recommend a follow-up Pap test at an interval based on your history.
If you have had a hysterectomy with removal of the cervix for benign reasons (such as fibroids), you can stop having a Pap test. However, if you have had a hysterectomy with removal of the cervix due to cancer of the uterus or cervix, continued testing is recommended. If you had a supracervical hysterectomy (meaning you still have your cervix), you follow the same instructions as women who have not had their uterus removed.
Some health societies recommend continuing Pap smears until age 75. We will likely see clearer recommendations come out in the future about when to stop Pap smears.
Is there anything special I should do (or not do?) before the Pap test?
No. There is nothing special you need to do or avoid before your grandpa. He used to recommend not having sex for 2 days before a pap, but new developments in testing have eliminated that suggestion. And if you use a vaginal lube, suppository or cream, that’s fine too.
Also, you can still have your duckling if you have your period. Many women would rather not do it while having a heavy bleeding day, but the liquid-based test should work.
What if my grandfather relapses?
First, don’t panic. Abnormal pap smears are very common and do not mean you have cancer or pre-cancer. However, this means you need extra monitoring. Depending on your age and the result of your Pap smear, your clinician may order HPV typing on the sample they originally collected. Or he may recommend that you get a Pap smear sooner than listed above (such as in 6-12 months). Or, he may recommend that you have something called a colposcopy, which will allow the clinician to look at the cervix under magnification. He or she may want to take a tiny sample of tissue during the colposcopy, called a biopsy, to send to the lab for review.
As mentioned above, guidelines are becoming more individualized, so there is no “one size fits all” with Pap smears. If you have any questions about when your next pap day will be, we recommend that you contact your healthcare provider. If you’re switching to a new provider, it’s best to get your previous pap results to review. For more information about your sexual health, contact us for a free phone consultation.
