Pap Smears and Pelvic Exam Screenings

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Dr. David J. Holcombe
Dr. David J. Holcombe

Although women have long ago resigned themselves to the reality of a yearly pelvic exam, recommendations have changed in the last few years which should offer some relief.  The U.S. Preventive Services Task Force (USPSTF) regularly reviews preventive health practices and aligns them with current research findings.  Decisions include factors such as the sensitivity and specificity of screening exams as well as positive and negative predictive values, all somewhat complex statistical notions and difficult for professionals to master.

 

So where do we stand with the dreaded annual Pap smear?  This test diagnoses cervical cancer, hopefully in its earliest stages.  It has proven its effectiveness over the decades and has greatly reduced the rates of late stage cervical cancer in women.  But when should it be started and  how often should it be performed?  The USPSTF now recommends that Pap smears (cytology) be started in women at age 21.  If the test is negative, the test can be repeated every 3 years (and not annually) until the woman reaches 30 years of age.  From 30 to 65, the USPSTF recommends a combination test which included the Pap smear (cytology) and a test for the human papillomavirus (HPV).

 

Why HPV testing?  The fact is that infection with HPV is necessary for the development of cervical cancer.  It is a rare example of a cancer that depends on prior infection with a known virus to develop.  You can certainly get HPV and not develop cervical cancer, but you cannot get cervical cancer without prior infection with HPV.  Before 30 years of age, many women will be infected with HPV (something that can be prevented with appropriate vaccination), but most of them will clear the infection spontaneously without any particular treatment.  After 30, this becomes much less common, so combining the Pap smear and the HPV test increases the accuracy of the testing.

 

The FDA recently approved the use of an HPV test as a primary test for cervical cancer.  If the test is positive for HPV 16 or 18 (two cancer causing strains, identified in over 70% of cases of cervical cancer), then a follow-up colposcopy (a direct exam of the cervix) is recommended.   When other high risk strains (around 14 of them) are identified, then a Pap smear follow up would be required to rule out cancer.

 

Although this sounds like more simplified testing method, the USPSTF still recommends against use of the HPV test alone or in combination in women 30 years of age and younger.  And while speaking of age, between 30 and 65, a negative combination Pap-HPV test means that testing can be reduced to every 5 years (and not annually) after a negative test.  After age 65, no further Pap smears are indicated if there is evidence of a normal exam with prior screening.  In the absence of a high-grade precancerous or previous cervical cancer, women with a hysterectomy (with removal of the cervix) do not need to be screened.

 

In short, the recommendations for cervical cancer screening have become simplified and the tests reduced in number.  In addition, the American College of Physicians has even recommended eliminating routine pelvic exams in asymptomatic, non-pregnant women of average risk during their annual wellness visits.  They feel that the “harms outweigh any demonstrated benefits associated with the screening pelvic examination.”  Women should arm themselves with the facts before going for their annual wellness exam or periodic cervical cancer screening.  You might be in for a pleasant surprise and a less stressful and invasive visit.