Everything You Need to Know About the Pap Test, HPV, and Pelvic Exams


The Pap test, HPV screening, pelvic exams. As if hopping onto an exam table butt-naked wasn’t stressful enough, knowing what to do about these tests can be super confusing. I’m going to break it all down so you know what to say yes to, when and why, and when to say, “Thank you, but no!”

Ready to dive in? Listen to the audio version, or read the blog below.



Bye, Bye Routine Annual Pelvic Exams

The pelvic exam is that part of your gynecology appointment where your doctor (family doctor, internist, or gynecologist), nurse practitioner, or midwife looks at and feels around in your cooch with a couple of gloved and lubed fingers to make sure everything is just as it should be. Sometimes a speculum, that plastic or metal duck-billed looking thing is also used to facilitate the looking part. Most of us gals put going to the doctor for an annual pelvic exam up there with going to the dentist for a root canal!

Well guess what, ladies, according to the American College of Physicians in a July 1, 2014 report, the annual pelvic exam can go the way of the dinosaur! The ACP data on the usefulness, risks, and benefits of the annual pelvic exam, demonstrates that the practice should be abandoned. According to ACP recommendations, in women who are otherwise healthy and have no pelvic symptoms, routine pelvic exams are not only unnecessary and uncomfortable – they do more harm than good, leading to false positive findings, anxiety, and unnecessary subsequent testing.

Not everybody agrees. The American College of Obstetricians and Gynecologists (ACOG) has expressed their concerns about the ACP guidelines, standing by its current recommendation that pelvic exams be done routinely at annual visits. They do state, however, that the choice to perform pelvic examinations is one that should be made on the basis of a woman’s individual needs, requests, and preferences. If you can pick and choose whether to do it based on personal preference, that doesn’t sound like it’s based on medical necessity to me!

ACOG also states that the primary reason for doing exams is to be able to diagnose urinary incontinence and sexual dysfunction. These have nothing to do with cervical cancer. Both urinary incontinence and sexual dysfunction can be diagnosed on the basis of a good health history with a woman still fully clothed! A woman can tell her doctor if she’s leaking urine, and if asked (which most doctors don’t), she can also tell her doctor how things are going in her sex life. A pelvic exam isn’t going to help her doctor diagnose sexual dysfunction – most of which actually has nothing to do with physical problems!

What about needing to have a pelvic exam to get tested for sexually transmitted infections (STIs)? It’s true, usually a fluid sample is collected from the cervix during the pelvic exam to check for gonorrhea and chlamydia, though the data is clear that these can be tested for just as well via a urine sample and low-risk women don’t need this testing anyway. So hmm… pee in a cup in the privacy of the bathroom if you’re at risk for sexually transmitted infections, or drop your drawers, lie down on your back, and pop your legs into stirrups for an exam?

I personally said good-bye to the routine annual pelvic exam in my practice some years back! Pelvic exams  should only be done when medically indicated – meaning you have pelvic symptoms or pelvic health concerns.

But please read on because we still need that Pap test. But there have been some big changes in how often to get that, too.

Why the Pap Test is Valuable, and Where HPV Testing Fits In

While in general, the risk of cervical cancer is very low for women in the US, representing only 1.5% of all deaths related to cancer in women, it’s not zero. In the US in 2014, there were an estimated 12,360 new cases of invasive cervical cancer, and 4,020 cervical cancer-related deaths.

Pap smears, also called Pap tests, also called Pap smears or Cervical Cytology, are done to check for early changes in your cervix that could indicate a risk for, or the presence of cervical cancer. HPV testing for the specific strains that are associated with increased cancer risk (16, 18, 45, 31, 33, 52, 58, and 35), is done at the same time in women over 30, or as further testing in women 21-30 years old with abnormal results on recent Pap testing.

Since the 1950s in the United States, when we adopted the Pap test for cervical screening, the number of new cervical cancer cases decreased by 70% in just the first three decades of use. This is due to early detection and treatment of precancerous changes.

Countries with higher rates of cervical cancer screening have dramatically lower rates of cervical cancer deaths. The great majority of cervical cancer cases occur in resource poor countries where there is almost a complete absence of cervical cancer screening. How much does the test actually have to do with this? Put it this way: as many as 65% of all women who develop cervical cancer have never been tested, or have not been tested adequately. About half of the cervical cancer is late-stage when it is found, usually in older women who have not been getting any screening. It is much more prevalent in developing countries.

Because the Human Papilloma Virus (HPV) is now thought to be the main protagonist in at least 93% of cases of cervical cancer, HPV testing has been added to the repertoire of cervical cancer screening option. However, because cervical cancer progresses very slowly, and requires the presence of one of the cancer-promoting, or high-risk HPV (hrHPV) strains to be active continuously for years, frequent testing is no longer considered necessary. The new screening guidelines, which I share below, can catch potentially pre-cancerous cervical changes and the presence of high-risk HPV early.

Further, studies show that routinely screening for HPV in women under 30 results in a lot of unnecessary colposcopies and invasive further testing when it’s almost always detecting transient HPV infection that will clear on its own and

Most of us wouldn’t mind getting this exam once every 3-5 years – especially if the exam to get the samples is done, as it should be, gently and respectfully, by a woman provider if that’s more comfortable for you, and with you even participating if you’d like, by optionally inserting your own speculum, for example.

Not Completely Without Controversy

The Pap smear is a more controversial test than most of us realize, for example,  there remains uncertainty about the most effective methods for collecting and analyzing the cells. One of the problems with Pap smears is that abnormal test results are quite common – even when there is no medical problem. They can be misinterpreted or misclassified, and even when there are some actual abnormal cells present, in most cases, these resolve on their own.

Between 50 and 60 million Pap tests are done annually in US. Approximately 3.5 million of these are read as abnormal, and an estimated 2.5 million women undergo further diagnostic testing (colposcopy) as a result. This is time consuming and positive results that often end up being false positives cause a great deal of anxiety while you’re waiting and getting follow-up testing.

Further, until recently, we were told we needed a Pap annually, from the first time we opened our legs for a gynecology appointment in our teens or early 20s, until in our 60s. The awkward annual ritual of feet in stirrups followed by cervical scraping and probing fingers was believed to be a critical life-saving part of our all-important annual gynecology exams. In reality, for most of us, it wasn’t. And for many, more harm was done than good.

A Scarred History

When it comes to the history of cervical cancer screening, it’s not all roses and sunshine.

For decades, those of us challenging the ob-gyn status quo, particularly midwives, observed an alarming phenomenon: many  women who’d previously been subjected to LEEP procedures and Cone biopsies to burn, freeze, or cut out potentially pre-cancerous cells after “a bad Pap” (Note: false positives were notoriously high with the older version of the Pap smear) went on later to have difficulty with cervical dilatation during labor when they had babies. This was due to cervical scarring and stenosis as a result of the aforementioned procedures. Many of these women ended up with cesareans because of “failure to progress” as a result. The failure was not in the women at all, but in an imperfect and often over-zealous gynecology system that tended to slash and burn first, ask questions later. I’d like to think the intentions were good, and some were, but big money has been made in the name of cancer prevention.

Well, ladies, it seems that in the past few years, someone’s been asking better questions and the low-down on Pap and pelvics has been changing, practically in front of my very eyes. It’s about time!

First, about 10 years ago, the relationship between cervical procedures and later problems with childbirth was recognized and acknowledged, including increased risk of second-trimester pregnancy loss, preterm rupture of membranes, preterm delivery and difficultly dilating in labor due to a problem called cervical stenosis, leading to cesarean sections that otherwise wouldn’t have been required. Along with the fact that most women under the age of 21 will spontaneously revert to a normal Pap and will naturally clear the HPV virus (several strains of which are associated with cervical cancer) without any treatment, the risk of the Pap leading to an invasive procedure leading to later childbirth problems outweighed the benefit of the Pap.

Unfortunately, this new information came too late for the hundreds of thousands of young women who were subjected to potentially damaging cervical procedures based on the results of tests that should never have been done.

Cervical procedures still pose these same risks. It’s also been discovered that the emotional and physical risks of finding “false positive” results outweighed the benefits of annual screening. Therefore, and especially for women in their childbearing years, it’s critical to find the sweet spot between enough screening to catch early cervical changes and high-risk HPV, and not over testing and treating.

So, How Often Should a Pap Test and HPV Screening Be Done?

The guidelines for Paps and HPV testing have been in flux over the past 8 years, as various professional groups have been sorting out that ‘best use’ sweet spot.

In August 2018, the US Preventive Services Task Force issued the latest set of cervical cancer screening guidelines. Following these is currently the best way to avoid over-testing and over-treatment.

While it would be ideal if your care provider was up on these, the guidelines have been changing every few years as more information about testing evolves – and not all practitioners are keeping up with the changes fast enough. This is nothing new in medicine – studies also show it can take up to 17 years for the latest research to trickle into most clinical practice, and by then it may have changed again! From what I’m seeing, this certainly seems to be a problem with Pap and HPV guidelines. I can’t count the number of women who have shared stories of being told erroneously that they need a colposcopy or biopsy against the recommendations of the guidelines.

Here are the guidelines:

  • Cervical cancer screening (testing) should begin at age 21. Women under age 21 should not be screened.
  • Women between ages 21 and 29 should have a Pap test every 3 years. HPV testing should not be used in this age group unless it is needed after an abnormal Pap test result.
  • Women to 30 and 65 years of age should have a Pap test only every 3 years OR a Pap plus hrHPV testing every 5 years OR a new option which is hrHPV testing alone every 5 years. It’s your choice.
  • Women over age 65 who have had regular cervical cancer testing with normal results should, and no personal high risk for cervical cancer should not be tested for cervical cancer as long as she’s had 3 normal Paps, or 2 normal HPV tests in the past 10 years, with the most recent testing within the last 5 years. Once testing is stopped, it should not be started again. Women with a history of a serious cervical pre-cancer should continue to be tested for at least 20 years after that diagnosis, even if testing continues past age 65.
  • A woman who has had her uterus plus her cervix removed for reasons not related to cervical cancer and who has no history of cervical cancer or serious pre-cancer should not be tested.
  • A woman who has been vaccinated against HPV should still follow the screening recommendations for her age group.

Note that these guidelines are for women with a normally functioning immune system.  If you are immunosuppressed (i.e., you have HIV, are on immunosuppressive medications or corticosteroids, or if your mom used DES when she was pregnant with you, or you have a history of a high-grade precancerous cervical lesion (HSIL) or cervical cancer, your guidelines are slightly different so  discuss your specific situation with your care provider. Additionally, any woman with symptoms that are suspicious for cervical cancer should get appropriately tested.

To summarize:

  • Under Age 21: no Pap smear, no HPV testing, even if you’re sexually active
  • Age 21-29 Pap every 3 years, hrHPV testing only if Pap results aren’t normal
  • Age 30-65 Pap only every 3 years OR Pap + hrHPV every 5 years OR hrHPV testing alone every 5 years

So gals, you can stop worrying about the “shave and a haircut” and your top drawer panties every time you go in for your annual physical (and frankly, that annual exam itself might not be entirely necessary either).

Of course, if you have concerning symptoms such as abnormal vaginal bleeding, signs of infection, a history of highly suspicious cells on your past Paps, or persistent HPV, speak with your primary care provider about appropriate screening and follow-up.

Cervical cancer screening is an effective tool for detecting cervical cancer. When used appropriately, the benefits outweigh the harms. Overused, the harms outweigh the benefits.

Reducing Your Risk of Cervical Cancer

Pap smears don’t prevent cancer – they just detect it. When abnormal cells are caught early, proper treatment can prevent them from turning into cancer. But we can also take steps to keep our cells maximally healthy and prevent cervical cancer!

Here are the key steps to cervical cancer prevention:

  • Prevent HPV infection: While as many as 4-20% of women with HPV have only one sexual partner, your risk of getting HPV goes up with the number of sexual partners you have over your lifetime. Condoms don’t necessarily prevent HPV transmission.
  • Eat a diet high in fruits and vegetables. Some studies have found that women low in vitamins and minerals may be more at risk of developing cervical cancer. Fruits and vegetables contain powerful cell-protective antioxidants and phytochemicals including vitamins A, C, and E, all of which have been shown to help prevent cervical cancer and other forms of cancer. Folate deficiency is thought to increase the risk of cervical cancer. Folate is found abundantly in leafy green vegetables. A natural ingredient found in broccoli-family vegetables including broccoli itself, kale, collard greens, and Brussels’s sprouts, called indole-3-carbinol (I3C) may even help to reverse cervical dysplasia when taken as a supplement in a dose of 200 – 400 mg per day.
  • Maintain a healthy weight: Being significantly overweight puts women at greater risk for developing cervical cancer.
  • Don’t smoke: Smokers are 2-4x more likely to develop cervical cancer.
  • Consider alternatives to birth control pills: There is a very small increase in cervical cancer in long-term oral contraceptive pill users. Consider an IUD, natural family planning, or speak with your primary care provider about other birth control options.

Pap Smear/HPV Q&A

Thank you for all of your questions on my Facebook page!

Is it OK to never get a Pap?

Not getting a Pap is certainly an option as a personal choice. However, having seen and treated women with advanced cervical cancer, it’s not an option I’d personally choose or recommend. Even with the stress of false positives, the new recommendations aren’t too demanding and knowing early is better than knowing late when it comes to cancer.

I’ve Had the HPV Vaccine – Do I Still Need Testing?

The answer is yes because the HPV vaccines s not 100% effective at preventing cervical cancer, and because the vaccine only protects against high-risk strains you’ve never been exposed to, and it’s possible you were exposed prior to receiving the HPV vaccine.

Can’t you just tell if you have HPV without getting testing?

Unfortunately, no. Most high-risk type HPV infections don’t cause symptoms. If you have genital warts, you most likely have HPV, but those are caused by HPV Types 6 and 11, which are considered low-risk because they are not linked to cervical cancer.

Cervical cancers in younger women can sometimes be more aggressive – will we find later that waiting 3-5 years between Paps is too long?

Women of all ages are at risk of cervical cancer, but it occurs most often in women 30 and over because they are more likely to have persistent HPV infections. All the studies looking at cancer progression and detection show that there is virtually no change in outcomes or missed cervical cancer with the new screening guidelines, and that women were much less likely to be subjected to additional unnecessary testing under the new model. 

Do you need a Pap just to get a birth control prescription…and how about if you are TTC, should you get a Pap then?

You do not need a Pap smear to get a prescription for birth control, for an IUD to be placed, or if trying to conceive (TTC), unless you are due for one.

If there is a history of cervical or ovarian cancer in your family, should you continue to get them yearly?

Family history does not necessarily change the recommended Pap schedule, however, it would be important to be diligent about following the schedule, discussing your concerns with your primary doc, and making sure your diet is rich in fruits and vegetables, and that you avoid smoking.

If you had a complete hysterectomy do you need to still see a gynecologist?

If you’ve had a complete hysterectomy, including removal of your cervix for reasons other than cancer, you do not need Pap smears. However, there may be other reasons for seeing a primary care doctor or a nurse practitioner – for example, annual breast exams or just having a woman you can trust with whom you can discuss your health.

For women who have been violated, what is a good way to get over that aversion/fear? How can we feel empowered for a very vulnerable situation?

This is a tough situation, and sadly, not uncommon. I recommend finding a woman practitioner – maybe not even a gynecologist, but rather a nurse midwife or nurse practitioner who may be better skilled in providing a considerate and gentle exam. I recommend also letting your care provider know that sexual abuse is part of your history, so she can be even more sensitive. Being involved in the process of your exam, for example, asking your care provider to teach you how to insert the speculum (make sure it is warm first so it is less startling on insertion) so you can do it yourself will help you take the power back into your own hands – especially because the position on your back with legs in stirrups is already one that makes most women feel vulnerable. I hope this helps…

Does having given birth affect the schedule?

A Pap smear is generally recommended as part of the 6-week postpartum exam; there seems to be less value in a Pap smear earlier in pregnancy if a woman has been following the recommended Pap schedule and has had normal Paps in the past. Keep in mind, though, that abnormal Paps are more common at the 6-week postpartum visit, and this can dramatically add anxiety to the often already overwhelming new momma experience. Of course, if you have a medical problem, it’s important to know, but more often than not, it’s a false positive or mild cervical change that will clear spontaneously.

Does the HPV vaccine help if you have early cancer detected in a Pap and will the vaccine make a positive Pap result?

Getting the HPV vaccine doesn’t help prevent you having HPV or cervical cancer from any strains you might already have picked up before you got the vaccine, and also won’t reverse any changes seen on your Pap. It protects against only some of the strains that can lead to cervical cancer, but does not provide immunity against HPV types responsible for 30% of cervical cancers.

Do you believe the recent FDA approval of HPV testing only (replacing the Pap as a primary screen) is the best choice for women’s cervical health?

In 2014 the FDA approved the Roche HPV test for primary cervical cancer screening in women aged 25 and older, and the Society for Gynecologic Oncology then said they thought that primary high-risk HPV screening every three years after an initial negative test can be used considered as an alternative to Paps. The USPTF concluded with high certainty that the benefits of screening every 3 years with cytology alone, every 5 years with hrHPV testing alone, or every 5 years with both tests (co-testing) in women aged 30 to 65 years outweigh the harms. So this is an option – though in my practice at this time, I still recommend the Pap every 3 years, or Pap + hrHPV every 5 years. 

How often do you need a Pap if you have an ovarian cyst or does it make a difference? The presence of an ovarian cyst doesn’t change your Pap schedule.

How much is the reduction in an annual Pap smear because of the push for Gardasil vaccine? I don’t think this has had any impact on the recent Pap recommendations; the vaccine hasn’t been out long enough or been given widely enough to impact enough women to have changed the recommendations. Current recommendations are for women who have received HPV vaccines to receive the same screening as those who have not. Also it is estimated that 30% of cervical cancers would not be prevented by HPV vaccination.

My Test Results Came Back Positive for HPV or Cervical Changes – What Do I Do? And How Worried Should I Be?

Getting positive results on any test can be super scary. The good news is that invasive cervical cancer is rare, and most cervical changes and HPV positive results resolve spontaneously on their own without any treatment. Stay tuned for Questions about what to do about abnormal Pap and HPV testing results will be addressed in my upcoming podcast/blog: Abnormal PAP or HPV Results: What’s a Girl to Do?, coming soon to find out what positive results mean and what to do, and the natural approaches to cervical health and HPV.

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Additional References – also see links in article.

Castle PE, Katki HA. Benefits and risks of HPV testing in cervical cancer screening. Lancet Oncol 2010; 11:214.

Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol 2016; 128:e111. Reaffirmed 2018.

Feldman S, et al Screening for cervical cancer. Up to Date.Apr 02, 2019. lesions and consequences for cervical-cancer screening: a prospective study. Lancet 1999; 354:20.

Gray NM, et al. Psychological effects of a low-grade abnormal cervical smear test result: anxiety and associated factors. Br J Cancer. 2006;94(9):1253.

 

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thanks for this, aviva.
i'm spreading the word to my various facebook groups.
i wonder how current canadian standards compare, tho...
jae

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Great article and so wonderful to read a positive health story in this day and age where negative, fear inducing stories abound. I was wondering - does one need to request the hpv test separately or does it 'come' with the new pap test? Also if you test negative for hpv are you always negative assuming you remain in a monogamous relationship?

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I am one of those women who had an abnormal pap, a leep, then a cone biopsy which led to threatened preterm birth, cerclage, bed rest and failure to progress in labor. It was a very traumatic experience--an unnecessary one! I'm glad to know protocol is changing now. Thanks for sharing Aviva!

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I had a mild to severe cervical dysplasia followed by a freezing - before my first child. I recently found out that even severe dysplasia has a 34% chance of clearing without treatment.
I did have a hard time dilating with my first birth, but it could have been caused by the pitocin/epidural combination, I will never know for sure.
I had normal paps in the past 7 years since my freezing and even my HPV came back negative the last time but still it is too scary not to do the yearly pap smears because I had a normal pap in 2004 and every time before that and then boom - all of the sudden in 2005 I was HPV positive and had mild to severe dysplasia. All this change in just one year, in spite that I was with the same man(my husband) since 1998.
Initially I oposed the freezing because I wanted to get pregnant and I knew that the freezing can damage the cervix but then one of my acquintances died of cervical cancer when her child was 1 year old and I was so afraid that it will happen to me too, that I took the chance.
I think that quitting smoking, eating organic and dumping out chemicals from my house definitely contributed to the normal paps that I have been having since. Still, every year, when I do the test and I have to wait a week for the results - I am a nervous wreck.

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I have never had a bad pap or hpv but found a lump on my cervix and it turned out to be stage 1b2 cervical cancer with metastasis to the lymph. That was in less than 2 years. It makes me sick to see these new guidelines.

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    Tonia

    I agree, with The new Obama care comming. into effect it Make me wonder if they Are doing This To cut back for funds and ofcorse more women will have hpv and overtly The. ideale idea Is that they being The government because they Are now in control dont care ... This Sounds rediculas and absurd. I really would like To read about These so called statts on more women being harmed Then Good. i grew up believing that Its better To be safe than sorry.

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I have never had a bad pap or hpv but found a lump on my cervix and it turned out to be stage 1b2 cervical cancer with metastasis to the lymph. That was in less than 2 years. It makes me sick to see these new guidelines.

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    Tania

    This only proves that Pap smears are extremely unreliable and useless in cancer prevention, regardless of how often they are done. They tend to miss the most dangerous and fast growing cancers even if done annually. But they are very "good" at detecting harmless, self-healing abnormalities, and lead to unnecessary biopsies and treatments. More harm than good indeed.

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      aviva

      This is not my experience, nor the evidence for pap smears. Feel free to cite your references, though. Best, Aviva

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admin

Your doc or midwife or nurse practitioner will order the hpv if you are over 30; under 30 it will come as a reflex test. That means if you have any abnormal cells on your pap, HPV will be done automatically. ~Aviva
 

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admin

Thank you for sharing this! This is one of the reasons that I have concerns about women abandoning self-breast exams. I've worked with dozens of women who "found a lump" that turned out to be something that nobody else would have found... I am a strong proponent of women continuing to have paps. I think that we just have to keep in mind how many women are harmed by the overuse of procedures and interventions and find a healthy balance. I hope you are long recovered and thrivingly well! ~Aviva

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admin

Yes this is very stressful and of course, do the paps! Peace of mind is priceless! And for the ladies reading this, smoking is a huge risk for cervical cancer. HPV migrates and collects in cells affected by cigarette smoking, and cervical cells are especially vulnerable to the effects of cigarette smoking.

 

 

 

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YES!!! I just went to Dr. last week. He wanted to do a PAP. I said NO. I'm 67 years old had a TAH at 42(cuz I had a few fibroids & wanted it), have never had a suspicious exam & no history of any female organ cancers back thru great-grandmothers on both maternal & paternal sides, & I am not sexually active & quit smoking 6 or so years ago. The test is always painful & have had excessive bleeding. Dr. had fit out of my presence but within earshot. I hope he got some new guidelines on this by now.

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Aviva, do you agree with these new guidelines?
Love,

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Actually there is no difference between 5 yearly and annual pap testing as far as benefit is concerned, but the more often you test, the more likely you'll get a false positive and be referred for biopsy/over-treatment. Finland has the lowest rates of cc in the world and send far fewer women for colposcopy/biopsy, they offer 7 pap tests, 5 yearly from 30 to 60. The Dutch have the same program, but are likely to move to a new program, already recommended by their Health Council...women will be offered 5 hrHPV primary triage tests at 30,35,40,50 and 60 and only those positive will be offered a 5 yearly pap test. Those negative will be offered the HPV program or if monogamous or no longer sexually active might choose to forget all testing and revisit the subject if their risk profile changes. Only 5% of women are HPV positive by age 30; most are not destined to get cc, but have a small chance of benefiting from pap testing. HPV negative women can't benefit from pap testing. Sadly, not one country in the world has shown a benefit pap testing those under 30, it doesn't change the tiny death rate, but young women produce the most false positives, 1 in 3 tests for those under 25. HPV testing is not recommended either before age 30 as around 40% of young women would test positive but almost all will clear the infection within a year or two.
The new Dutch program is more likely to prevent/catch these rare cancers and will better protect the vast majority of women who can never benefit from pap testing. (lifetime risk of cc is 0.65%...take out false negatives and consider natural decline and fewer than 0.45% can benefit from pap testing)
The Dutch are also using the Delphi Screener, the reliable self-test HPV option..it was launched in Singapore recently and elsewhere. Australia seriously over-screens women and we have huge referral/over-treatment rates...cone biopsies and laser treatments can damage the cervix and lead to cervical stenosis, infertility, c-sections, cervical incompetence, premature babies, the need for cervical cerclage, endometriosis etc
Our program is excessive and harmful and more than a decade behind the evidence...women are being harmed by this program, yet our doctors are silent...enjoying enormous profits from over-treatment and collecting incentive payments for reaching screening targets.
As a low risk woman, I got to the facts many years ago, my risk of cc is near zero, the risks were too high for me, I have always declined to test and recently also declined breast screening. I believe over-diagnosis is a serious and hidden risk with breast screening and the benefits have been greatly overstated. Women's cancer screening is IMO loaded with political and vested interests...I'd urge every woman to do some reading, understand what you're agreeing to...And look closely at those who aggressively push screening, is there a conflict of interest?
This doctor also declines pap testing...see, "Why I say no to a smear" by Dr Margaret McCartney which appeared in the Independent (UK) recently. This doctor has also written an excellent book on the subject, "Patient Paradox".
Refs: A very important and unbiased brochure for those thinking of breast screening..."The risks and benefits of mammograms" at the website of the Nordic Cochrane Institute, an independent medical research group. Also, Dr Joel Sherman's Medical Privacy Forum - see section on women's privacy concerns parts 1 to 7 and see medical journal references in the side bar. The Dutch program is outlined at the website of the Health Council of the Netherlands and the Delphi Bioscience website contains info on the Delphi Screener. Good luck everyone...

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Lark

I winced at "the shave and a haircut" because it summoned for me visions of tampering with pubic hair and I would never ever ever!!!! Don't wax or trim of slice or shave or snip, leave it alone! Had abnormal Pap 20 years ago, cryotherapy, no recurrence, all normal until this summer (ASCUS), HPV+, had LEEP because colposcopy was impossible. LEEP showed nothing at all, no ASCUS, no dysplasia, nothing. I had tried to persuade both doctors to just wait and do a second Pap. I think LEEP was unnecessary but it was a breeze and I wasn't using those cells anyway (had my one kid). Now when I go for followup I will say I want to wait at least a year for another Pap..... I don't see Paps as invasive; it's the cost that is annoying.

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gauri

I read this again after working in a busy gynae clinic in an area where HIV is 33% and the cervical cancer risk is increased in HIV. What are your thoughts or suggestions in this population, based on the research? Thanks. Gauri

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    aviva

    Hi Gauri, Guidelines for women with high risk should absolutely be followed in a high risk community. This website is a reliable resource for pap and colpo guidelines. Best, Aviva http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx

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Medical Patient Modesty

Dr. Aviva, I appreciate your information about false positive pap smears and the consequences of leep procedures and cone biopsies. However, the guidelines still do not take into consideration that some women may actually not ever need pap smears and that some women may need pap smears more often. For example, virgin women (regardless of age) who have never engaged in any kind of sexual activity really do not need a pap smear. I encourage you to check out this article: Truth About Pap Smears (http://patientmodesty.org/papsmears.aspx). What are your thoughts on the above article? Misty

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    aviva

    Hi Misty, I have not had a chance to read the article, but you are correct, as long as a woman has never had sexual activity she might not need a pap -- though a very small percentage of women can still have contracted HPV (it is unclear how this happens) and develop cervical cancer -- but this would be extremely unlikely!

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      Medical Patient Modesty

      The article mentioned some factors that could slightly raise a true virgin's woman's chance of getting HPV infection or cervical cancer. Number 2 has nothing to do with HPV. I heard that cervical cancer caused by DES is very rare though. 1.) Based on some studies, smoking could possibly cause cervical cancer without HPV infection. 2.) Mother took DES (also known as diethylstilbestrol) during pregnancy with you between 1938 - 1971 to prevent miscarriage and premature delivery. It is estimated that only 1 in 1,000 women who were exposed to DES in the womb will develop cervical cancer. 3.) Mother had HPV infection when she gave birth to you (only applies to vaginal birth). The risk of HPV transmission to the baby during childbirth is very low. Even if babies do get the HPV virus, their bodies usually clear the virus on their own. (Source: HPV and Pregnancy). 4.) You had a Pap smear with an unsterile speculum. I read some sources where some women can get HPV from sharing towels or underwear with HPV infected people.

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Medical Patient Modesty

Dr. Aviva, Have you ever read this article about how informed consent is missing from pap smears by Dr. Sherman at http://www.kevinmd.com/blog/2009/11/informed-consent-missing-pap-smears-cervical-cancer-screening.html? Misty

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    aviva

    Thank you for sharing!

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Dominique

I love this article. It really enlightened me. I'm still a bit confused and a tad lost. If you could help, I would like to know: Girls under 21 cannot get a pap smear or HPV testing. But, girls under 21 can receive a ParaGrad? Which is kind of the same process as a pap smear I believe (Correct me if I'm wrong). I would like to know if this correct, if so, why is that? Please and Thank you ^_^

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    aviva

    It's because almost everyone under 21 will clear HPV naturally and so paps would pick it up in people who shouldn't be treated. Years ago girls were getting LOOPs and cone biopsies, only for gynecologists to discover these were unnecessary and also led to scarring that later prevented many of these women's cervices from dilating for birth! The paragard is a totally different issues -- it's birth control that is inserted into the uterus via the cervix and is safe for young women.

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Benita

Hello, I am almost 37 years old, tested positive for high risk HPV for past five years. Recent pap shows it is still there. For the past five years I had as follows; abnormal pap, normal pap, abnormal pap, colpolscopy, recommended LEEP, declined and treated with herbs and colloidal silver, repeat colposcopy came out much improved after treatment. Then I had two normal paps six months apart. My recent pap last week came back abnormal again HGSIL and so I have another colposcopy scheduled for end of august. I am thinking of treating again before the colposcopy so that I don't get recommended the LEEP again. I don't want to get that because I want to have another baby. I had planned to get pregnant in the next few months. Would you recommend waiting until I get a normal pap?

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Benita

oh, I also had an endocervical currettege last week and that came back normal which was comforting I guess

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Parma Deas

Hello Dr., I am a 72 year old female. Do you feel a pelvic exam, but not a pap smear, at my age is necessary? Should I be concerned about ovarian cancer? Thank you!

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    aviva

    Hi Parma, If you are concerned, it is reasonable to request that your gyne or family doctor do a pelvic exam. However, this would not assess for ovarian cancer, for which there is no routine screening, though a CA 125 can be tested for. Thank you for writing!

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anonymous

I was tested positive for HPV (low risk) 3 years ago and haven't been tested since, though did have an exam 2 years ago (after a D and C). Wondering if I need to schedule a gyn exam and/or pap and/or HPV test or can wait another couple of years? I don't have any red flags (just occasional vaginal itchiness with too much honey or fruit). Aviva, would really appreciate your words of wisdom! I am a big fan!

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Kasey Backman

Savvy post - I am thankful for the points ! Does anyone know where my assistant can get a blank a form document to use ?

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Moira Blythe

I am 26 and have never been to have an exam like this before. I have heard that I need to be going yearly, but I appreciate your advice here that I only need to go once every 3 years. This is great news, and I feel more comfortable with having to go every 3 years instead of every 1.

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Kylee Singh

Thank you for explaining this. About 15 years ago at the naive age of 20, I was told by a nurse practitioner that I had pre-cancerous lesions on my cervix and that I would have to undergo cryo. I was so scared, confused, and ashamed that I underwent the procedure with no questions asked. I continued to live out my 20’s relatively care free and then when I started to try to get pregnant in the last couple years was taken back to that procedure that happened so long ago. The records are gone so I can only guess what exactly the reports contained from that diagnosis. I have been, until now, so worried about what that long ago diagnosis meant to my health and how it impacted my multiple miscarriages and 30 hour labor that resulted in a c section delivery. If only my OB would spend more time explaining these things to me. Thank you so much for the insight.

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