Several years ago a huge change to our routine practice was introduced and many women are still having a hard time believing that it makes sense. But it really is true, most women really don’t need pap smears every year and some don’t need them at all.
If you are like me, you religiously had a pap smear every year from age 18 on. We were taught that it would be irresponsible not to, so this change in recommendations goes against all that we were taught when we were younger. Here is the explanation. The pap smear is just a cervical cancer screening test. That is all that it tests for. By taking a swab of cells from the cervix that are examined microscopically, we can reduce the risk of cervical cancer by identifying pre-cancerous cells that can be treated before they progress. Until recently, the test just looked at the cells, and a pathologist determined if they were normal or not. If they were normal, there was no way to predict whether they would stay normal, so the recommendation in the USA was to do the test every year to make sure nothing had changed. At the time that made sense.
It has been known for some time that cervical cancer is caused by a virus called HPV (human papilloma virus). Cervical cancer is the only cancer that we know is always associated with a virus. If you don’t have HPV you won’t get cervical cancer. In fact there are certain strains of HPV that are associated with almost all cervical cancers. HPV strains have numbers (there are over 50) and the most common types that cause cervical cancer are types 16 and 18, as well as a handful of others. These more aggressive types of HPV are known as “high risk HPV” strains since they are associated with cervical cancer in some patients. Testing for HPV has now become quite accurate, so in recent years pap smears can test for these “high risk” viruses and if they are not present we can confidently tell the patient that her risk of cervical cancer is negligible. If a patient is HPV negative, meaning she does not carry these high risk strains, then she will remain negative unless she has a new sexual partner. So monogamous women who are HPV negative can be expected to stay that way, and will remain at negligible risk for cervical cancer forever. The only way to be exposed to HPV is through sexual activity.
The current standard is that women under 21 do not need a pap smear, and that women between 21 and 30 should have one only every 2 years (assuming the results are normal). This is because if we are exposed to HPV as a teenager, the virus usually goes away on its own, so testing for it early and often results is a lot of unnecessary treatment. Before age 30 we don’t recommend testing for HPV because it is so common and does not require treatment. The CDC actually estimates that over 75% of women are exposed to HPV and in most cases it clears spontaneously. Testing for HPV is recommended for women over 30 however, because the assumption is if HPV is still there after age 30 it is less likely to resolve on its own.
Women who are HPV positive over 30 require closer followup to evaluate for precancerous cells. Women who are HPV negative over 30 can be screened every 3-5 years since their risk of cervical cancer is extremely low. Really the only reason to check it even every 3-5 years is to make sure that the HPV status hasn’t changed (as in a new sexual partner). After age 65 or after a hysterectomy (assuming the cervix is removed) pap smears are no longer needed at all. This recommendation bothers a lot of our hysterectomy patients, but I always explain that you can’t get cervical cancer if you don’t have a cervix, so there is no need to do a pap smear.
When we tell people they don’t need a pap smear, it is important to remember that we still recommend an annual exam to check everything else; the uterus, vagina, vulva, bladder, breasts, bones and general health. Not having a pap smear does not mean not having an exam; in fact most patients would not notice a difference in the exam if the pap smear is not done, the only thing lacking is that a swab is not sent to the lab.
We do recommend that girls and boys receive the HPV vaccine before becoming sexually active. This vaccine immunizes against the high risk HPV types 16 and 18, and well as the low risk types 6 and 11 that cause genital warts. If all kids got this vaccine before sexual activity began, the incidence of cervical cancer would drop by 80 percent.
I have had many patients ask if the changes in pap smear recommendations are related to cost-cutting or “Obama Care” or are driven by insurance. The answer to that is absolutely not, these are good recommendations that make sense for our health. Sometimes we do too many tests, and when we know what the test will show there is no point sending it. If you are monogamous and HPV negative then your pap smear will always be normal, and it’s OK to cross cervical cancer off the list of things to worry about!
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