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.
- 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.