LET'S TALK PAPS!

Over the last year and a half, I’ve noticed that many women coming in for their yearly well-woman exam aren't entirely sure why I'm getting their pap smear. And they certainly don't know how often to get them... which is not their fault, given how often the guidelines have changed in recent years {even we OBGYNs can get confused sometimes}.

However, our current guidelines now reflect the improvements that have been made in our testing technology. We no longer need to get paps every year, which I'm sure is devastating to all you ladies who look forward to your pap smears every year, right?

Before you read any further, let me just say that this can definitely be an embarrassing topic for women but it's an important one to discuss. I want to shed light on what the average woman may not know about her body or why we get pap smears at all.

Now, let's review the basics shall we?

What does a pap smear test for?

A pap smear is a screening test for cervical cancer. The test provides a sample of cells from the inner and outer part of the cervix (the bottom of the uterus/top of the vagina through which a baby emerges). A pap can detect cell changes that are indicative of cervical cancer as well as changes that could mean that cervical cancer may develop in the future. On occasion, paps can also indicate the need for further evaluation for endometrial cancer (cancer of the lining inside the uterus) if a particular type of cell is found on screening in postmenopausal women.

How often do I need to get a pap smear?

According to the American College of Obstetrics and Gynecology (ACOG), having a pap test annually is no longer recommended by leading medical organizations. It is now standard of care to perform a pap test every 3 years for women ages 21-65. There is also the option of spreading pap testing to every 5 years for women ages 30-65 when screened with both a pap and HPV test. And no testing for women less than 21 or over 65.† So just to reiterate:

age 21-30: just a pap smear (no HPV cotesting) every 3 years age 30-65: pap + HPV cotesting every 5 years (or just a pap every 3 years)

The reason for the time spacing is because we now know that cervical cancer grows at a slow rate and the pap and HPV together have a high predictive value. If a woman tests HPV positive for the more high risk strains, she will absolutely be screened more often for cervical cancer and dysplasia. However, if her pap is HPV negative, there is almost a 0% likelihood of developing cervical cancer within 5 years.

So if I don’t need a pap this year, do I still need to go to my OBGYN for an annual? And will my insurance cover it?

YES! A pap test is only one part of your annual gynecological exam. The pelvic and breast exams screen for ovarian and uterine growth abnormalities and breast abnormalities, respectively.

Annual well-woman visits are {almost always} 100% covered by insurance companies. If your insurance is Medicare, we sometimes have to space these visits to every 2 years. BUT, your primary care provider should still be performing a yearly pelvic exam and you should stay up to date on your mammograms as well.

What is HPV?

The human papilloma virus is a set of over 100 related viruses, some of which cause warts and some of which cause cervical cancer. If you’ve ever had a wart on your finger, you have a strain of the HPV virus. About 40 of the 100 affect the genital areas.
Once you have HPV, it cannot be cured per se. However, it can go down to such low levels that it becomes dormant and therefore less likely to cause health problems.
Each strain has a number and is called a type. Of the 40 types mentioned above, some are known as "high-risk" strains, meaning that they can cause cancer. High-risk HPV strains are well established as the culprit of nearly all cervical cancer and cervical dysplasia (cellular changes that could become cancer). The most high-risk strains are HPV 16 and HPV 18--almost 70% of all cervical cancers are related to types 16 & 18. Other high risk strains include types 31, 33, 35, 39, 45, 51, 52, and 58.
The other strains are considered low-risk strains and cause genital warts. Types 6 & 11 are the two low risk strains that are responsible for 90% of genital warts.
The HPV cotest that is done with your pap smear only looks for the high-risk strains.

There's a ton of information about HPV* out there, but here’s a crash course:

HPV is a virus that is spread via contact. The types that we are concerned about are spread via sexual contact.
DNA co-testing for HPV starts once you turn 30 while pap smears begin at age 21. We do not screen women under the age of 21 regardless of sexual activity.
HPV is very common in women (and men) younger than 30. However, most HPV that is found in these women will be cleared by their immune system in about 2-3 years and will never cause them any health problems so it's not useful for us to test for HPV in that age group.
HPV is less common in women older than 30 and it tends to stick around, indicating that their immune systems have not been successful in clearing the virus from their cells.
Pap smears by themselves are still excellent screening tests for cervical cancer for any woman age 21-30.
A positive HPV test DOES NOT mean you have or will ever have cervical cancer. So please don't freak out! Almost half of women have HPV in their cells past the age of 30, but only a small portion of those women develop cervical cancer. The importance of screenings stems from trying to avoid cancer ever developing in that small group!

How can I prevent cervical cancer?

There are several ways to avoid cervical cancer:

Abstinence
Mutual monogamy
Get the HPV vaccine if between the ages of 9-26! This protects against MANY of the high risk HPV types. Even if you already have HPV, you can still get the vaccine since it will provide protection against the other strains of HPV.
Use barrier methods like condoms. These are helpful but not entirely preventive.
And of course, see your OBGYN regularly!

If you have already had a positive HPV, there are definitely things you can do to build your immune system in the hopes that it will clear the virus. Again, this does not mean that HPV is completely cured from your body.

Do not smoke! Smoking and HPV together only increase your risk of cervical cancer.
Get 7-9 hours of sleep nightly
Exercise regularly
Minimize stress
Eat a balanced diet with lots of fruits and vegetables
Take EXCELLENT care of your body because it's the only one you have!!

Can I have a pap while on my period or should I reschedule my appointment?

You can most definitely have a pap while on your period as long as it’s not an extremely heavy day. Do not worry about it! We're used to it and honestly don’t really think about it! In addition, paps nowadays are liquid suspended (not actually a smear) which allows the blood cells to be spun out of the sample before the pathologist looks at it.

Phew, that was a lot! Hopefully this was helpful rather than confusing for y'all . If so, there is TONS of information available regarding pap smears, HPV and cervical cancer. This is just the highlights! If you have more detailed questions, please feel free to comment below and I’ll be happy to answer as best I can!

The information provided above includes my personal opinions but is also based on the sound research and clinical findings of the CDC, ACOG, and the National Institute of Health.

Cover image source: https://geneticliteracyproject.org/2016/11/04/pap-smear-provides-women-noninvasive-alternative-prenatal-genetic-screening/