It used to be so simple. You went to see your gynecologist once per year. Your breasts would be checked, you’d have the dreaded pelvic exam that included STI testing and the 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 become a little more confusing. When to have your pap done has changed (and continues to change). There is even increasing research saying that you may not, in fact, need to have that dreaded pelvic exam at all. These changes, while based on solid science, can leave women quite perplexed about when to schedule their ‘annual’ and what will actually happen while they are there.
Let’s start by discussing what a pap ISN’T:
Women still routinely (and incorrectly) think that when they have a gynecologic exam they are ‘getting a pap.’ Not so. The pap test is not a pelvic exam, an STI test, or an ovarian cancer screening test. Clinicians can easily add STI tests (such as chlamydia or gonorrhea) to the Pap test. But it’s important to know that if you’re having a pap done, you may not necessarily be tested for STI’s. If you want to have STI testing included, tell your provider.
Well then, what is a pap?
A test (pap for short) is a screening test for cervical cancer. It was created by Greek physician Georgios Papanicolaou in the 1920’s. Cervical cancer used to be the leading cause of cancer deaths in women in the U.S. Since the widespread implementation of the pap smear in this country, this has dramatically changed. Unfortunately, in developing countries where women do not have easy access to pap screenings, cervical cancer continues to be the leading cancer killer for women.
And why is it sometimes called a pap ‘smear?’
Well, back in the day, when a woman went for her pap, her healthcare provider would take a sample of cells from the cervix with a tiny spatula of sorts and ‘smear’ them on a glass microscope slide. She then sprayed the slide with a fixative solution to ‘set’ the cells. Nowadays, about 99.9% of paps in the U.S. are done in a liquid medium, often called ThinPrep testing or liquid-based cytology.
What’s the link 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 the HPV virus at some point during their lifetime. The vast majority of the time, a woman’s immune system clears the virus prior to it causing harm.
HPV is spread by direct skin-to-skin contact. Many women incorrectly think that if they haven’t had PIV intercourse that they can’t get HPV. Not true. HPV is easily transmitted via oral sex, anal sex, or even just with hand-to-genital touching without vaginal penetration. Condoms provide only partial protection, as there is still genital contact with intercourse. Studies show that smoking can increase the risk of cervical cancer up to four times. If a woman is immunocompromised (either due to a medical condition or a medication), this also increases the risk of developing cervical cancer.
Also important to know – you can’t become infected with HPV by touching an object like a toilet seat.
I got the HPV vaccine. How does this impact me?
As the women who received the HPV vaccine get older, we will likely see another set of management guidelines emerge. Those who received the HPV vaccine are expected to have a significantly decreased risk of developing cervical dysplasia and cancer than the unvaccinated group, so we may see future screening recommendations further divided into guidelines for vaccinated vs. unvaccinated women.
I’m confused about when to go for my pap. I’m hearing so many different things. I used to have it done every year.
The recommendation used to be to have a pap every year, hence ‘the annual exam.’ However, because new scientific advances in testing technologies have improved at such a rapid pace, the screening guidelines have also changed. With the advent of HPV genotyping, scientists have been able to pinpoint the type of HPV that is present. This is based on HPV DNA/RNA testing and has had a major impact on the sensitivity of cervical cancer screening.
For instance, the new guidelines that came out of the recent 2019 American Society of Colposcopy and Cervical Pathology (ASCCP) consensus, are basing screening on overall risk of developing cervical dysplasia, not just test results. So, in other words, pap testing is now based on more individualized, patient-specific recommendations.
So, when should I start to get paps done?
The screening guidelines listed below apply to asymptomatic, immunocompetent women.
Age 21. Across the board, all organizations agree that paps should NOT be done on women younger than 21 years old, regardless of when they became sexually active. If you are younger than 21 years old and sexually active, we still recommend visiting your gynecologic provider for STI testing, to discuss birth control methods, and to discuss any concerns or questions you may have related to your sexual life. But you don’t need a pap test until you are 21.
21-30 years old: For this age group, pap testing is recommended every 3 years. Your clinician will order a Pap with Reflex HPV testing. With ‘reflex’ testing, a pap is done first (the cells are examined under magnification for any changes). If the cells show something atypical then HPV testing and typing is done (from the same sample as the pap).
But what if I’m older than 21 and have never been sexually active?
The guidelines recommend that all women over 21 years be screened even if they report sexual abstinence. Women may have a variety of reasons for not disclosing prior sexual activity, including social, religious, or cultural norms or expectations. Also, women who have been sexually abused or raped may be hesitant to acknowledge this history. Furthermore, many women do not consider prior hand-to-genital or skin-to-skin contact as sexual activity, although this is a common method of HPV transmission.
30-65 years old: Women 30-65 with prior history of normal paps can have either:
●Co-testing (Meaning a Pap test and HPV testing) or HPV testing every five years
OR
●Pap test alone 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 over: For women over 65, the recommendations currently say that you can stop pap testing if:
•You had Pap tests done regularly until you turned 65.
OR
•You had 3 normal Pap tests in a row, or 2 normal combination Pap and HPV tests over the past 10 years (with the most recent test within the past 5 years).
If you have had an abnormal pap/colposcopy finding, your provider will recommend continuing pap testing, at an interval based on your history.
If you had a hysterectomy with your cervix removed for benign reasons (like fibroids), you can discontinue pap testing. However, if you had a hysterectomy with cervix removed due to uterine or cervical cancer, ongoing testing is recommended. If you had a supracervical hysterectomy (meaning, you still have your cervix), you follow the same guidelines as women who haven’t had their uterus removed.
Some health societies are recommending continuing pap testing until 75 years of age. We will likely see clearer recommendations come forth in the future regarding when to stop pap testing.
Is there anything special I need to do (or not do?) prior to my pap test?
Nope. There’s nothing special you need to do or avoid prior to your pap. It used to be recommended to not have intercourse for 2 days prior to a pap, but the new developments in testing have eliminated that suggestion. And if you’re using a vaginal lubricant, suppository, or cream, that’s fine too.
Also, you can still have your pap if you have your period. Many women would prefer not to have it done while they are having a heavy day of bleeding, but the liquid-based testing should still yield a result.
What if my pap comes back abnormal?
First, please don’t panic. Abnormal pap tests are very common and it doesn’t mean that you have cancer or pre-cancer. It does mean that you need additional follow-up, though. Depending on your age and your pap result, your clinician may order HPV typing on the sample she originally collected. Or she may suggest that you have a follow-up pap test at a sooner interval than listed above (like in 6-12 months). Or, she may recommend that you have something called a colposcopy, which will allow the clinician to look at the cervix under magnification. She may want to take a tiny sample of tissue during the colposcopy, called a biopsy, which she will send to the lab for review.
As mentioned above, guidelines are increasingly becoming more individualized, so there’s no ‘one size fits all’ with pap testing. If you have any questions about when you are next due for your pap, we recommend contacting your health care provider. If you are switching to a new provider, it’s best to obtain your prior pap results for her to review. For more information regarding your sexual health, contact us for a free phone consultation.
