Making Sense of Pap Smear Recommendations

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In the past, getting your pap smear was an annual event. Most women believe this is still the case. However, new guidelines were released in 2012 that increase the interval between paps. This can be confusing, or scary for those who don’t understand the change in recommendations. This post will discuss the recommendations made by the United States Preventative Task Force and hopefully bring some clarity.

In 2010 in the US, there were an estimated 12,200 new cases of cervical cancer diagnosed, and 4,210 deaths from cervical cancer. Cervical cancer is most frequently caused by certain strains of the human papilloma virus (HPV). HPV is a common sexually transmitted infection; other strains of this infection can cause genital warts, throat, or anal cancer. Pap smears are a cervical test used to detect changes in the cells of the cervix. These abnormal cells appear on a continuum, ranging from what amounts to “slightly abnormal, probably just due to the presence of the HPV virus/ ASCUS” to “appear pre-cancerous/ LSIL” to “highly suspicious of cancer/ HSIL”. Old guidelines recommended a pap every year, and if abnormal pre-cancerous cells were detected, treatment was typically offered. Treatment involves a biopsy of the cervix, and removal of the abnormal cells. This can be done by cutting, burning, or freezing off the part of the cervix with the abnormal area. In severe cases that show cancer, the entire uterus needs to be removed with a hysterectomy. Research has now shown that many of the minor cell abnormalities that had been aggressively treated would not have turned cancerous, and that the body would have fought off the virus on its own if given time. Because of this, many women have had procedures done that were unnecessary and that can potentially cause complications while pregnant. This has been especially true of young women, who are frequently exposed to the virus but who usually recover completely from the virus on their own.

In 2012, the United States Preventative Task Force (USPTF) released guidelines for cervical cancer screening. There are two screening options available: cytology (the pap smear) and HPV testing. When used together, this is called co-testing. They recommend that pap smears begin at 21 years of age, regardless of sexual history. Pap smears should be done every 3 years. In women under 30, HPV testing should not routinely be done. HPV will frequently come back positive in this population and can lead to over treatment of abnormalities that would have otherwise cleared on their own. If there is an abnormal pap result, reflex HPV testing can be ordered to guide management. If a woman is 30 or over, HPV testing should be routinely added to the pap smear (co-testing). In this population, the body is less likely to clear the HPV infection, and the infection is at higher risk of causing cancer. If both the pap smear AND the HPV test are negative, the pap interval can be extended to every 5 years. Screening can be stopped when the women has reached 65 years of age as long as she has had 3 consecutive negative pap tests or 2 negative co-tests within the last 10 years, with at least 1 test being in the previous 5 years. Routine screening should continue for at least 20 years after the regression of a high-grade lesion, even if that means screening continues past 65. Pap tests can be stopped in women who have had a hysterectomy, as long as they do not have a history of a high-grade lesion or cervical cancer.

The USPTF recommendations can be found at: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening#citation1

If a pap test comes back abnormal, or the pap is normal but HPV has come back positive in a woman over 30, please refer to the ASCCP algorithms for management at: http://www.asccp.org/Guidelines-2/Management-Guidelines-2.

Even though guidelines for healthy women have increased the interval between pap tests, it is still recommended that you go in for a yearly annual exam. This will allow your provider to check for infections, screen for chronic infections, or address new problems you may be having. One other common misconception that I’d like to clarify: the pap smear is a swab done through a speculum exam (the metal or plastic “duck-bill” instrument). Just because your provider inserts a speculum, doesn’t mean they are doing a pap smear. Swabs to check for infections can be done through the speculum without doing a pap smear (a pelvic exam and cultures). It is important to check with your provider which tests are being done so you can keep track. I frequently have patients who say their last pap smear was done in the ER. This is a misunderstanding on their part- paps are never done in the ER. They had cultures done, and assumed the pap was being done also. This could lead to missed testing if you give a date of last pap that is incorrect.  It is always important to check with your provider which tests are being done, and to ask them to explain what the test is and why it is being done if you are not familiar with it.

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