We Need to Talk About Pap Smears
You guys, we need to talk about pap smears.
I’m finding that way too many people don’t know what a pap smear is and isn’t or what it does and doesn’t do.
Someone put a speculum into your vagina at the doctor’s office - that means a pap smear was definitely done, right?
You had a normal pap smear - that means you were screened for ovarian cancer, right?
Every person with a vagina should have a pap smear every year - right?
It’s okay that you’re not sure about this. It’s not your fault. This confusion exists because medical professionals can be really terrible at explaining what we are doing and why.
Let’s sort it out.
First of all, let’s do a quick anatomy review. The cervix is the portion at the bottom of the uterus (aka womb, it’s the organ that can build up blood on the inside to shed as a period or where pregnancies can grow) where it connects to the vagina (has lots of akas, I’m pretty sure you know what a vagina is, but please know it is NOT the part of the genital tract that’s on the outside – that’s the vulva). If you imagine the uterus as a balloon, the cervix is the tied knot at the bottom. When I describe it to patients, I say it looks like a donut on exam – it’s round with a hole in the middle.
A pap smear (or Papanicolaou test, named after Dr. Papanicolaou who helped develop it) refers to when a plastic brush or spatula device is used to brush or gently scrape cells from the surface of the cervix for collection. The cells are sent to a pathologist who looks closely to see if they appear normal or not (this is called “cytology”). The test can sometimes detect infections (like yeast or chlamydia) or suggest a need to evaluate the inside of the uterus, but it is not designed for those issues and is not a reliable test for them (ie if that is specifically what you’re looking for, you would do a different test). It tells us absolutely nothing about the ovaries (where eggs are stored and released and some hormones are made), the fallopian tubes (thin structures that come off each side of the uterus and transport eggs to the uterus), or most of the uterus. It is not a test for uterine or ovarian cancer. Anal pap tests do exist to screen for anal cancer and anal precancerous changes. There are not great guidelines on who should have this test done. It should be considered in patients regularly participating in receptive anal sex.
A speculum (the “duck bills” as many call it) is required to do a cervical pap smear. This device is placed into the vagina so that the cervix can been seen. A speculum exam may be done for many other reasons, and having a speculum exam is not synonymous with having a pap smear.
Almost all cervical cancers are caused by HPV, the human papillomavirus. There are many strains of HPV. Some of them do nothing, some cause genital warts, and some lead to cell changes that can contribute to cancer. Essentially everyone who has ever been sexually active has been exposed to at least one strain of HPV. For many people, their immune systems kick into gear and that exposure is never ultimately a concern. For others, HPV can linger and crop its ugly head over time. Those who have received the HPV vaccination series are partially protected from the highest risk forms of HPV that we know are associated with cervical cancer.
For patients 30-65 years old and in the case of certain pap smear findings for those younger than 30 years old, HPV is specifically tested along with the pap smear. This is called “cotesting”.
Since we know that HPV is so important, we can alternatively test first for the presence of high risk forms of HPV in the 30-65 year old age group. Cytology is only then assessed if high risk HPV is present. This is called “primary HPV testing” and is the main method of testing in many countries other than the United States.
Most pap smears are done for screening purposes. “Screening” refers to when a test is done to potentially identify the presence of a condition that hasn’t been diagnosed yet in someone without signs or symptoms. As long as results are normal, a pap smear alone is recommended for screening purposes every 3 years from ages 21-29, and cotesting or primary HPV testing is recommended every 5 years from ages 30-65. Testing more often than that in the setting of normal results has not been shown to be beneficial due to the generally slow growth of changes that contribute to cervical cancer. Testing more often than that HAS been shown to be HARMFUL as it can lead to more biopsies and cervical procedures than are truly needed. This equates to unnecessary medical care that increases risks of bleeding (the cervix has a ton of blood flow, and out of control bleeding from a large cervical procedure is no joke), infection, injury to other areas (a burn to the vagina, for instance), decreased “strength” of the cervix in the face of future pregnancy in the event that multiple procedures are done, and high medical costs. There has been evidence for decades that yearly pap smears are problematic, and professional gynecology organizations have formally recommended AGAINST yearly pap smears since 2012.
If you’ve had a recent abnormal pap smear or are immunocompromised (HIV/AIDs or chronic steroid use, for instance), however, you should be screened more often than 3-5 years. In those cases, there’s either something that’s been identified that we need to follow up on or we know that the immune system isn’t functioning at full capacity to battle HPV.
People who have had a total hysterectomy (removal of the uterus and cervix) with a previous history of high level cervical changes on a cervical biopsy or procedure specimen should talk to their gynecologist about their potential for requiring pap smears of the top of the vagina where the cervix used to be.
People who have had a total hysterectomy for reasons unrelated to pap smear findings and who have no recent history of high level cervical changes do not require pap smears after that.
If your doctor told you that you had a “partial hysterectomy”, FIND OUT WHAT THAT PERSON MEANT. Make sure you know what parts you have remaining. Sometimes the main portion of the uterus is removed while the cervix is left in place.
Your gynecologist may recommend a pap smear or cotesting based on exam findings. Because there is a problem that needs a diagnosis, the test is no longer being done for screening purposes and the guidelines don’t affect the plan.
Don’t get upset or worried if your doctor says you’re not due for a pap smear. It doesn’t mean that they are being lazy, are stupid, or don’t care about you. It most likely means they are taking your history into consideration and caring for you in the safest possible way.