Fewer pap smears? Yes, please.

January is Cervical Health Awareness Month and an opportunity to discuss how to protect yourself (and your children) from the effects of HPV and cervical cancer. So, let’s celebrate with fewer pap smears (yes, fewer), and vaccinations for both boys and girls.

We women have been subjected to the dreaded annual exam for years. Our birth control held ransom until we had our pap smear. Well, there’s freedom at last! In March 2012, the American Cancer Society (ACS), American College of OB/Gyn (ACOG), and the US Preventive Service Task Force (USPSTF) made unprecedented history and agreed on cervical cancer screening recommendations. No small feat, and a huge step forward for women’s health (unlike conflicting guidelines for mammograms). Here’s what you need to know:

  • Screening begins at 21 years of age.
  • Women 21 – 65 years old should have a pap smear every 3 years.
  • Women ages 30 – 65 can extend their pap smear interval to every 5 years with HPV co-testing.
  • Women over 65 years old no longer need pap smears.
  • Women who’ve had a hysterectomy including the removal of the cervix (some surgeons leave the cervix, “partial hysterectomy”), do not need pap smears.

Why the changes? The Papanicolaou test (“pap” for short) takes cells from the cervix during the speculum exam and then “smears” them onto a slide for microscopic examination. Changes of the cells are apparent to trained professionals that are indicative of abnormal cells (e.g. cancerous cells) and those infected with the human papillomavirus (HPV). A large majority of cervical cancer is caused by certain types of HPV (there are over 100 different types of HPV, most of which do not cause cancer). But, as it turns out, the human papillomavirus is ubiquitous in the population. According to the CDC, nearly all sexually active people are infected with HPV at one time or another (even if you’ve only had one partner). Fortunately, most young, healthy people clear the infection without any intervention. So while screening women for cervical changes due to HPV with a pap test detected lots of “disease”, recent studies show that treatment is often not necessary. HPV infection or other cervical abnormalities that are not successfully warded off by our body’s immune system usually progress slowly, thus the every three years recommendation.

By definition, screening is to detect disease that may otherwise go undiagnosed. Therefore, the cervical cancer screening recommendations only apply to women who have previously had normal pap results. Even though your results are normal and the 2012 guidelines recommend cervical cancer screening every three years, your provider may still recommend pelvic exams annually. Unfortunately, opinions still differ among medical specialties and societies about pelvic exams for evaluation of the vagina, uterus, and ovaries (this does not include cervical cancer screening with pap tests). For example, the USPSTF recommends against ovarian cancer screening (i.e. internal bimanual exam for women) and makes no recommendations for vaginal/vulvar screening (external genital exam). However, the ACOG makes the following statement: “[women] Aged ≥21 years, no evidence supports or refutes the annual pelvic examination or speculum and bimanual examination. The decision whether or not to perform a complete pelvic examination should be a shared decision after a discussion between the patient and her health care provider. Annual examination of the external genitalia should continue.”

How about prevention? In 2009, the groundbreaking vaccine against HPV became available (known commercially as Gardasil or Cervarix). It is now FDA approved for both boys and girls. Why, you ask? Boys don’t have cervices, but they certainly do contribute to the spread of HPV disease. The vaccine confers immunity for two types of HPV (16 and 18) that cause about 75% of cervical cancer cases. The Gardasil is a quadrivalent vaccine that has the additional benefit of protecting against genital warts, HPV types 6 and 11, that cause about 90% of genital warts cases (good news for both genders). The HPV vaccine is recommended in childhood at age 11 because the immune system is more robust when we are young and may confer a greater immunity in addition to longevity. At some point we all hope that our children will have happy and healthy sex lives, why not give them all the protection we can?

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