pap smear

January is Cervical Health Awareness Month, making it the perfect time to post a follow-up to Part I which featured my concerns about potential unintended consequences of new Pap test guidelines (from ACOG, the American College of Obstetricians and Gynecologists). To recap, it is vital that we do not confuse a recommendation of less frequent Pap tests with the unchanged recommendation of annual pelvic/sexual health exams (see the National Cancer Institute for explanations of both).

So, let’s look back at a letter dated November 20, 2009, in which the President of ACOG clarified:

Cervical cancer screening should begin at age 21 years (regardless of sexual history). Screening before age 21 should be avoided because women less than 21 years old are at very low risk of cancer. Screening these women may lead to unnecessary and harmful evaluation and treatment.

Medically speaking, why should this recommendation disregard an individual woman’s sexual history? His letter continues on to state:

Cervical cytology screening is recommended every 2 years for women between the ages of 21 years and 29 years. Evidence shows that screening women every year has little benefit over screening every other year.

Doesn’t this depend on how many new sexual partners a woman has in a given year? Are the revised guidelines assuming monogamy (or at least long-term, serial monogamous relationships) which decrease odds of a woman contracting a new cancer-causing strain of HPV in less than a 2-year period? Where are the conclusive findings of large-scale sexual-behavior surveys to support this assumption?

ACOG’s November 2009 press release featured these quotes from Alan Waxman, M.D.:

Adolescents have most of their childbearing years ahead of them, so it’s important to avoid unnecessary procedures that negatively affect the cervix. Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.

I agree with GWP reader anniegirl1138 who commented on my previous post that over-treatment is no joke. However, we have not been presented with data that a Pap test — the test, itself, not over-treatment based on test findings — is directly linked to significant increases of any negative health outcome.

Cervical HPV infections can be detected by Pap tests: ACOG acknowledges that, “the rate of HPV infection is high among sexually active adolescents, but counters with, “the large majority of cervical dysplasias in adolescents resolve on their own without treatment.”

Why should that smaller group of girls and young women (whose pre-cancerous lesions do not resolve without treatment) miss the annual opportunity to receive an early diagnosis? Early-stages of cervical HPV infection can often be resolved with less-invasive treatment options.

More-invasive treatment options, such as the “excisional procedures for dysplasia” that have been linked to increased risk of premature births, are one of several medical treatments for cervical HPV.

And, what about the possibility that an increased risk of premature births may not be the paramount concern for every female patient? Not all women want to or can biologically become mothers. What if an individual female patient would rather seek medical treatment for a HPV infection that has resulted in cervical dysplasia so that she has greater peace of mind in knowing that she has reduced her risk of cervical cancer and reduced the likelihood of transmitting HPV to her sexual partner(s) and/or future babies?

Call me a feminist, but I still believe that knowledge is power and that every sexually-active girl and woman should be encouraged to consider the benefits of annual Pap tests. When Pap smear results show “abnormal” cellular changs, then healthcare practitioners should explain the potential for false-positives and discuss the pro’s and con’s of moving forward with different diagnostic and treatment options.  

ACOG acknowledges that, “HPV also causes genital and anal warts, as well as oral and anal cancer.” A Pap test may be a girl/woman’s first chance to learn of a cervical HPV infection, which can result in her having a colposcopy exam. This procedure helps a practitioner find HPV-infected cells not only on the cervix but also in other anogenital areas (the vaginal canal, the labia, the perineum). Beyond the cervix, a Pap test that is positive for HPV may be a wake-up call to get a thorough oral screening for serious oral cancers which have been linked to sexually transmitted HPV.

In addition, my research and others’ studies have found that STI diagnoses can lead to attitudinal and behavioral changes which can decrease risks of contracting other STIs, including HIV. For all of these reasons, a Pap test that leads to a diagnosis of a sexually transmitted cervical HPV infection can bring unintended positive consequences.

In light of the new Pap smear guidelines, I hope that U.S. girls and women who get less frequent Pap tests will more frequently ask their healthcare practitioners to educate them about cervical cancer, about the full range of STIs, and about FDA-approved vaccines against viruses that can be sexually transmitted (HPV and Hepatitis B).

For the medical facts about HPV and HPV vaccines, check out the book The HPV Vaccine Controversy by Shobha Krishnan, M.D., a member of the Medical Advisory Board of the National Cervical Cancer Coalition. 

The Bottom Line: a recommendation for less frequent Pap tests does not mean you should forgo your annual pelvic exam. In our busy lives, e-reminders can make the difference:  PromiseToMe.com allows you to schedule an annual email reminder. [Note for boys/men: make sure to get an annual sexual health exam, too!]

On this national day of gratitude, I find myself giving thanks for many things — including my family, my friends, and my health. I owe my sexual health to the now outdated norm of getting annual gynecological exams, with Pap smears, from the time I became sexually active. As a 20-year-old, in the mid-1990’s, I benefited from U.S. medical guidelines that supported my gynecologist in recommending cryosurgery (application of liquid nitrogen) to kill/remove the HPV-infected cells on my cervix. Early detection and early treatment afforded me a quick recovery from a potentially cancer-causing and highly contagious sexually transmitted infection. Following that treatment, I never had another abnormal Pap test result, got pregnant the first time I tried, and gave birth to a healthy baby. For all of those outcomes, I give thanks.

Today, many teen girls and women may not benefit from the level of medical care that I received. Last week, the American College of Obstetricians and Gynecologists (ACOG) issued new guidelines for pap smear and cervical cancer screening, and this may prove to have unintended, negative consequences for sexually-active Americans.

Until 2008, ACOG had recommended annual screening for women under 30. This month, ACOG summed up their revised recommendations:

…women should have their first cancer screening at age 21 and can be rescreened less frequently than previously recommended. 

Media coverage of this latest revision has not done as good a job distinguishing that a Pap test is just one aspect of a pelvic/sexual health exam. How many girls and women will interpret the new guideline of “No need for an annual pap tes,” as, “No need to get an annual pelvic exam”?

ACOG admits that the Pap test has been the reason for falling rates of cervical cancer in the U.S.

Cervical cancer rates have fallen more than 50% in the past 30 years in the US due to the widespread use of the Pap test. The incidence of cervical cancer fell from 14.8 per 100,000 women in 1975 to 6.5 per 100,000 women in 2006. The American Cancer Society estimates that there will be 11,270 new cases of cervical cancer and 4,070 deaths from it in the US in 2009. The majority of deaths from cervical cancer in the US are among women who are screened infrequently or not at all.

So, why revise the guidelines such that we are likely to see an increase in the number of U.S. women “who are screened infrequently or not at all”?

And, it’s not just teen girls and young women that are the focus of these revisions. ACOG also recommends that older women stop being screened for cervical cancer:

It is reasonable to stop cervical cancer screening at age 65 or 70 among women who have three or more negative cytology results in a row and no abnormal test results in the past 10 years.

How much of this rationale depends upon women over 65 years old being sexually inactive or monogamous? This argument seems predicated upon ageist assumptions about older women’s sex drives and sexual behaviors (or lack thereof).

As the tryptophan from my Thanksgiving feast begins to dampen my ire, I’ll bring this post to a close. These are just a few of the problematic aspects of this new policy recommendation — stay tuned for “Part II” of this post in the near future.

Welcome to the first official post for Bedside Manners. As a sexual health researcher and book author, I receive a lot of emails from women and men who are dealing with sexually transmitted diseases. Yesterday, I replied to Liza, a 25 year-old married, monogamous woman who had just been diagnosed with a serious cervical HPV infection and treated via LEEP. She could not understand how this had happened, since she had been getting pap smears during her annual gynecological exams for the past 10 years, and her husband had never been diagnosed with genital warts. Her doctor told her it was “bad luck,” and now she is worried about the possibility of having an oral HPV infection, wondering whether her cervical infection is cured, and trying to figure out how to this will affect her marriage.

By getting annual pap smear exams, Liza has been doing the right thing. Unfortunately, most medical practitioners don’t explain that pap smears only sample a small area of a woman’s cervix. So, it is possible to receive a “normal” pap smear result when there are HPV-infected/abnormal cell changes in other portions of the cervix.

With Liza’s husband as her only sexual partner, it’s key for him to get thoroughly examined for HPV/genital warts. If HPV-infected cells are found, then he should have them removed via one of several treatment options. Once both of their bodies have healed from treatments, the couple should strongly consider using condoms during sex (note: condoms reduce but do not eliminate the risk of HPV transmission).

Given Liza’s concern about oral HPV, a ‘HPV test’ can determine the specific strain of the virus. HPV 16 has been linked to cervical cancer and to oral/head/neck cancers. So, an important follow-up exam after receiving a genital HPV diagnosis is to see a dentist: I encouraged her to share that she’s been exposed to HPV orally and request a thorough exam.

As I concluded my reply to Liza, I realized that I needed to address the stress that she was clearly experiencing. Medical sociologists have often written about how disease can cause dis-ease, an illness often causes a patient to lose her sense of wellbeing. In the case of socially stigmatizing and medically incurable infections, like HPV, stress is almost unavoidable for newly diagnosed patients. In my book, Damaged Goods?, I detail specific strategies for handling the variety of stressors that come with a genital HPV or herpes infection, but I’ve decided to wrap up today’s post with a general note about stress.

I was fortunate to attend a talk last night by the authors of a new book, The Inner Game of Stress. Tim Gallwey has teamed up with two physicians, who practice a patient-centered approach to integrative medicine, to combine medical research with his executive coaching techniques. The result is a thoughtful self-help approach to stress management that encourages readers to be assertive patients. As a medical sociologist, I have written about the health impacts of practitioner-patient interactions and was familiar with the body of research showing how stress can weaken a person’s immune system.

For people, like Liza, who are battling a virus, it is important to not only empower yourself with knowledge about your particular illness but also to strategize how to strengthen your immune system. In addition to the obvious recommendations of decreasing unhealthy behaviors and increasing healthy ones, I encouraged her to find sources of emotional and social support. Some who are facing a stigmatizing illness may find comfort by talking with trusted friends, while others may prefer the neutrality of a therapist, and many may find empowerment in a book.