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- Pap Test, What, When, Where, Why & How or why NOT?

Last Updated: 12/29/2012

The Pap smear is a screening test which is performed to detect potentially cancerous or pre-cancerous changes to the cervix.  Named after its inventor, Dr. Georgios Papanikolaou, it first reported as diagnostic testing in 1928.  However, it was not widely recognized until his work with Herbert Traut, Diagnosis of Uterine Cancer by the Vaginal Smear was published in 1943.

The Pap test is a collection of cells from the outer portion of the cervix which are collected when the provider opens the vaginal canal with a speculum and scrapes the cervical opening with a small brush and then transfers the cells collected for observation under a microscope.  The test is looking for cervical dysplasia (CIN, cervical intraepithelial neoplasia) which is usually caused by one of the HPV viruses. 

Cancer is a leading cause of death in the United States and accounts for about 25% of the total.   Among women, an estimated 11,000 cervical cancer cases are detected each year and a little over 4,000 deaths are from cervical cancer.  Cancer is certainly not a laughing matter or something to be taken lightly.  Symptoms of cervical cancer include:  unusual vaginal discharge,  vaginal bleeding at any time other than during menstruation, such as between periods, after intercourse, or even very heavy bleeding during her period.  Vaginal bleeding after menopause is also not normal.

Each year over 3 million Pap smears are done in the US and approximately 5% of these are read abnormal.  About 20% of American women have had at least one abnormal test result.  Most of these are either atypical squamous cells of undetermined significance (60%) or low-grade squamous intraepithelial lesions (33%).  The majority of these transient lesions would resolve spontaneously without treatment.  Abnormal cervical cells can be attributed to normal harmless things like puberty, hormone imbalance, menopause, pregnancy, tampon use, use of vaginal preparations and recent sexual intercourse.  This makes one wonder why it is pushed as imperative to identify so early.  The history of cervical cancer changes is between five and ten years from the first cellular changes in the lining to the crossing of the membrane beneath the lining, making it invasive.  Many times there is great and at the same time, needless anxiety from these questionable results.  Many of these women go on to have more invasive, painful and expensive diagnostics and treatments needlessly.

Stages of Cervical Cancer - Stage 0: cancer cells found only on the surface of the cervix.   More invasive cancers are separated into four stages. Stage I:  cancer has not spread beyond the cervix.  Stage II: tumor has spread to the upper part of the vagina.  Stage III:   tumor extends to the lower part of the vagina and may block urine flow.   Stage IV:  the tumor has reached the bladder or rectum, or cancer cells have spread to other parts of the body and formed new tumors.

Current guidelines (updated March 2012) recommend that women should have a Pap test every 3 years beginning at age 21, however, there is little or no benefit to screening women who have not had sexual contact. For example (USPSTF) recommends waiting at least three years after first having sex.  According to the updated guidelines, women ages 21 through 29 should be screened with a Pap test every 3 years. The guidelines further recommend that women ages 30 to 65 should have HPV and Pap co-testing every 5 years or a Pap test alone every 3 years. Women with certain risk factors may need to have more frequent screening or to continue screening beyond age 65.

According to the National Cancer Institute at the NIH " Like any screening test, cervical cancer screening is not completely accurate. Sometimes a patient can be told that she has abnormal cells when the cells are actually normal (a false-positive result), or she can be told that her cells are normal when in fact there is an abnormality that was not detected (a false-negative result).  Cervical cancer screening has another limitation, caused by the nature of HPV infections. Because most HPV infections are transient and produce only temporary changes in cervical cells, overly frequent cervical screening could detect cervical cell changes that would never cause cancer. Treating abnormalities that would have gone away on their own can cause needless psychological stress. In addition, follow-up tests and treatments can be uncomfortable, and some treatments that remove  cervical tissue, such as LEEP and conization, have the potential to weaken the cervix and may affect fertility or slightly increase the rate of premature delivery, depending on how much tissue is removed."  The woman may experience loss of sexual sensitivity, and/or severe pain which interferes both with daily living and with intimacy with her partner. 

Yet, even with current guidelines recommending the Pap test every 3 years, many OB/GYNs recommend and many women feel more comfortable and therefore comply with annual testing. You have to wonder why that is. 

Stress weakens the immune system in such a way that the screening and subsequent interventions may actually cause or contribute to contracting the disease which is ironic as it is the reason she is there in the first place, trying to avoid cancer by submitting to a Pap test.

Each woman must decide for herself what her risk factors are and what testing, if any, she wants to subscribe to.  It is not a one-size-fits-all.  She may prefer to limit her exposure to toxins in the environment and adopt a healthy lifestyle and enlist testing if or when she has symptoms or concerns.




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