To (Pap) Smear or Not to Smear, That’s the Question

During the first National Women’s Health Week since the American College of Obstetricians and Gynecologists (ACOG) announced revised Pap test guidelines, many are wondering whether or not to have a Pap smear as part of our annual exams. Not enough questions have been asked about how the under-publicized (and under-scrutinized) new guidelines are impacting the health of women in our nation.

A little history: ACOG previously recommended annual screening for sexually active women under 30.  Then, last November, ACOG  issued new guidelines for pap test and cervical cancer screening. As a sexual health researcher, I was shocked to read ACOG now recommended that:

…women should have their first cancer screening at age 21… Most women younger than 30 should undergo cervical screening once every two years instead of annually, and those age 30 and older can be rescreened once every three years.

ACOG also recommended 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.

With U.S. senior citizens’ STD/HIV rates on the rise, why ignore research findings and assume that women 65 and older are either celibate or monogamous, with 100-percent faithful partners?

At the heart of this debate is the question of how these guidelines will impact cervical cancer rates.  ACOG acknowledged that the Pap test could be credited for falling U.S. rates of cervical cancer and that,

The majority of deaths from cervical cancer in the U.S. are among women who are screened infrequently or not at all.

So, why revise guidelines that have been working and might reverse this positive trend?  The main focus is reducing cervical treatments which may be unnecessary and/or increase risks of other unhealthy outcomes:

A significant increase in premature births has recently been documented among women who have been treated with excisional procedures for dysplasia.

Let’s remember: (1) not all women want to or can biologically become mothers, and (2) cervical dysplasia is often effectively treated by non-excisional/less-invasive options.

Here’s another reason behind ACOG’s new recommendations, as per a November 2009 press release quoting 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.

Speaking of possible causes for anxiety, ACOG acknowledges that the rate of HPV infection is high among sexually active adolescents, but counters that, “the large majority of cervical dysplasias in adolescents resolve on their own without treatment.”  Okay, but why should those girls and young women whose pre-cancerous lesions do not resolve without treatment miss an annual opportunity to catch these infections at early, more treatable stages?

The Pap test–not cervical treatment procedures–has NOT been linked to negative health outcomes; in fact, it may be your first chance to learn about a possible cervical HPV infection which often leads to getting a colposcopy as part of a thorough sexual health exam.  When test results show abnormal cellular changes, practitioners should discuss benefits and costs of the range of diagnostic and treatment options. Female patients have the right to decline exams, testing and treatments that they deem unnecessary.

A recommendation for less frequent Pap tests does not mean a recommendation for less frequent pelvic exams, yet I cannot help but wonder: How many girls and women will interpret the new guideline of “No cancer screening until 21″ as “No need to get an annual exam until 21″?

There’s been little media coverage differentiating Pap tests from pelvic exams. CBS Care’s Christmas 2009 campaign (promoting the rather odd idea that the best gift one can give a woman is to schedule her Pap smear for her) remains one of the few mainstream efforts to critique the revised guidelines. Here, from their campaign letter:

…We debated whether this project was still important…it is actually more important and timely than ever… because an announcement that recommends less frequent pap smears could cause some women to mistakenly conclude that pap smears are not important…while the experts may hotly debate ACOG’s findings, they all agree on one thing – a pap smear remains one of the most important health screenings a woman can have. And skipping them costs lives. CBS Cares stands by the pap smear!

It’s vital that we do not confuse a recommendation of less frequent cervical cancer screenings with the unchanged recommendation of annual pelvic/sexual health exams.  So, in the words of Kathy Griffin, who recently had her Pap smear filmed, let’s “TELL CANCER TO SUCK IT!

[This post was inspired by my previous two-part series for the Girlw/Pen blog.]

Above: Pap test stain.

Comments

  1. Make An Appointment says:

    Interesting that this is what I stumbled on to read today. Today, of all days. My partner just learned – this very morning – that she has a growth in her ovary that has to be removed immediately. Of course, we both worried instantly about what this mass might be, what it might mean for her. We've both been lax about getting examinations because we're in such a low risk group – lesbians. So, I'm posting. Mostly to remind lesbians to have regular gynecological exams. If it's been awhile, my sisters, don't wait. Call today and make an appointment, or tomorrow. No later.

  2. NYCprochoiceMD says:

    I love this blog, but you’re way off the mark here. This is based on sound science. The truth is that we’ve been overtesting, overdiagnosing, and overtreating. If you look at who gets cervical cancer, it is not teenagers. In addition, abnormal paps in teenagers and young adults are more likely to recede spontaneously than they are to turn into anything worrisome. Even if they turn into something worrisome, it takes years for it to grow into anything that would cause problems, so beginning screening at age 21 is reasonable. Of note, this has been standard of care in the UK for years, and they don’t have a higher cervical cancer rate than we do.

    You state: “Okay, but why should those girls and young women whose pre-cancerous lesions do not resolve without treatment miss an annual opportunity to catch these infections at early, more treatable stages?”

    The early, more treatable stage of these abnormal cells takes years and years to turn into anything that is difficult to treat. In other words, if she is one of the 20% of young women whose abnormal cells fail to resolve spontaneously when she’s 18, when her pap is done at age 21, the time lost is inconsequential in terms of the course of the disease and its treatment. The chances of a 21-year-old actually having cervical cancer are extremely low; almost all cases of cervical cancer happen in women in their 40s, 50s, and 60s, and they occur mostly in women who have not undergone screening with pap smears.

    Our culture always thinks that more testing is better; in fact, it leads to many harms, and the treatments for abnormal cells that may go away on their own can lead to significant problems, such as difficulty conceiving or maintaining a pregnancy.

    You’re correct that the pap test itself is not linked to negative outcomes, but it definitively has been linked to many unnecessary colposcopy procedures, which sometimes lead to more invasive procedures.

    As to your concern that women will think they don’t need an “annual exam” until age 21, I wonder what you mean by annual exam? For me an “annual exam” is discussing contraception, checking blood pressure, checking for STIs, and discussing any other concerns a woman has. I often don’t have to examine her at all. Annual pelvic exams are unnecessary and overly invasive, and worries about them often keep teens away, keeping them away from a valuable opportunity to get tested for STIs and discuss all of their contraceptive options.

    I know that this new recommendation feels like a slap in the face to some in the women’s movement, after all the time they’ve put in to ensure that women are represented, cared for, and studied equally. But it’s not a scheme to restrict care or save money; it’s meant to decrease the burden of unnecessary testing and unnecessary treatment. It’s meant to protect women, not harm them.

  3. Thank you, NYCprochoiceMD, for your thoughtful comments. I agree that it’s important to factor research findings from a variety of respected sources into evaluating any policy recommendation.

    First, I take issue with ACOG’s recommendation “to start screening at age 21 years regardless of the age of onset of sexual intercourse” and encourage readers to consider another respected U.S. organization, The American Society for Colposcopy and Cervical Pathology. They publish a patient education sheet titled “Adolescents and HPV – What Young Women Should Know” which (as of today) continues to feature a statement in line with ACOG’s previous recommendation: “The vast majority of HPV infections in adolscents go away on their own within a couple of years, and don’t cause any serious health problems. This is why many experts do not advise having a Pap test done until about 3 years after a woman’s first intercourse or by age 21, whichever comes first.”

    In their online publication “Protect & Detect: What Women Should Know About Cancer,” ACOG recommends that “HPV vaccine be routinely given to all girls ages 11-12.” It’s optimal to be vaccinated prior to exposure, so ACOG seems to be acknowledging that some girls as young as 13 are having their first sexual intercourse experiences. In this case, ASCCP disagrees with ACOG by wanting to make sure those teens gets their first Pap smear at 16 rather than at 21 (8 years past a hypothetical initial HPV infection). ASCCP has good reasons for this concern: “…sometimes, depending on the type of HPV and the length of time of the infection, HPV can cause serious changes. These changes are called ‘dysplasia’ and some have the potential to become precancerous. Both harmless and serious changes can be found on a Pap test. But, if several years go by and the serious changes are not found and not treated, some ‘high-risk’ HPV infections of the cervix can cause these precancerous changes to turn into cervical cancer.”

    My second objection stems from discounting female patients’ abilities to assess risks and benefits of HPV treatment options. Informed consent is essential: no girl or woman should feel pressured to consent to a biopsy or treatment for an abnormal Pap Test result without being fully informed of the potential health costs and benefits. We don’t need to be protected by revised guidelines but rather to be better informed about the pro’s and con’s of medical screenings, diagnostic procedures, and treatment options.

    Third, my research and others’ studies have found that a STI diagnosis, like finding out about a HPV infection following an abnormal Pap smear, can lead to behavioral and attitudinal changes which decrease risks of contracting other STIs, including HIV. For these reasons, a Pap smear that leads to a diagnosis of a sexually transmitted cervical HPV infection can bring unintended positive consequences. And, does not have to result in any medical treatments if the patient and practitioner agree that it is best to take a wait-and-see approach.

    Most research studies are based on large samples; each of us is a sample size of 1.
    Even ACOG agrees that “Women with certain risk factors may need more frequent screening,” so we all need more sexual health education in order to better assess our risks and give our healthcare providers the detailed patient histories they need to advise each of us on the Pap test schedule that will best protect our health.

    References:
    - ACOG’s publication: http://www.acog.org/from_home/misc/protectanddetect.pdf
    - ASCCP’s bulletin: http://www.asccp.org/pdfs/patient_edu/adolescents_and_HPV.pdf

    • It is unrealistic to say that once a woman gets an abnormal smear she can sit and wait or decide to have a biopsy or treatment.
      The reality is women are terrified when they get an abnormal result – abnormal results are very common with this inaccurate test and that's why many women think this cancer is common, it's never been common, always rare….abnormal smears are very common, cancer is rare.
      I've seen it myself…a woman gets an abnormal result and ends up being referred…few women are brave enough to sit and wait.
      This situation has been caused by the scare-mongering that has always gone on in women's cancer screening also, the propaganda and censorship that surrounds the topic. If you post facts or a bad experience on some sites especially a government, medical or women's health site, your post is usually deleted and the thread closed.
      I will never accept that women should be kept ignorant – we should all be given risk information and clear facts and left to make our own informed decisions.
      I have never screened, as a low risk woman the risks exceed the benefits for me.
      Even high risk women though should have the opportunity to assess the evidence and protect themselves, as far as possible, from false positives and unnecessary & potentially harmful over-treatment.
      I know a high risk woman who is content to accept a 1% risk of cancer rather than risk more traumatic "treatment" (that turned out to be a false positive) – as she says, "there is a 99% chance I won't get cervical cancer and even with testing, I'd still have a 0.35% risk of cancer (false negatives) BUT she'd also have a 77% lifetime risk of colposcopy and another biopsy. (that's with 2 yearly screening)"
      That is her right…to make that value judgement – every woman will feel differently about the amount and type of risk she accepts in her life.
      The paternalistic attitudes that prevail must be broken down and the unethical and illegal practice of holding a woman's pills hostage UNTIL she has a smear must be stopped – that is coercion and negates consent.

  4. Lowest rates of cervical cancer in the world: Finland – no screening before 30 and then 5 yearly – 5 to 7 tests in total – they also have the lowest rates of colposcopy/biopsies (and false positives)
    Low risk women often choose not to screen…the risks outweigh the benefits for them.
    Still even with responsible screening that protects the health of the majority of women, somewhere between 30%-55% of women will still be referred for colposcopy/biopsies in their lifetime – approx 95% are unnecessary or false positives. These procedures (LEEP and cone biopsies) can leave women with problems – infertility, miscarriages, problems during pregnancy, more c-sections, premature delivery and babies, psychological issues.
    This is an unreliable test for a rare/uncommon cancer and that is a bad combination for a screening test.(it was never properly evaluated before being released)
    The risks of over-treatment are real and serious and at the moment few of you are capable of giving informed consent. Many of your women are actually coerced into testing – your doctors unethically and illegally refuse the Pill until you agree to smears and a host of gyn exams that are not evidence based, are of poor/low value and carry risk – pelvic exams are unnecessary in an asymptomatic woman and carry the risk of more diagnostic testing even surgery.
    CBE’s – no evidence they bring down the death rate, but they cause biopsies – some believe biopsies are a risk factor for cancer. (Google, Hands off my chest Doctor!)
    Mammograms – risk, risk, risk…don’t even think about them until you’ve read “The risks and benefits of mammograms” at the Nordic Cochrane Institute website – produced because they were concerned at the misleading and incomplete information being released to women.
    You have a HUGE number of hysterectomies as well – a massive 600,000 a year!
    When you think only 1% of women get cervical cancer in an unscreened population and 0.35% STILL get this cancer if every woman screened, informed consent is vitally important – 99.35% of women derive no benefit from smears, but all are exposed to risk.
    There is a great site that seeks to inform women, a rare thing: Dr Joel Sherman’s medical privacy blog and under women’s privacy concerns you’ll find articles by Dr Angela Raffle, UK expert (1000 women need regular screening for 35 years to save ONE woman from cervical cancer) printed in the BMJ and articles by Prof Michael Baum, UK breast cancer surgeon and Dr Richard DeMay, US pathologist (stats taken from his article)
    Protect your health and make informed decisions about screening and “preventative” exams.

  5. Just wanted to add: screening doesn’t work at all in women under 25, but exposes them to great risk/harm. Screening tends to miss the rare case of cancer, but 1 in 3 smears will be “abnormal” and these women are usually referred for colposcopy/biopsies. Cancer is incredibly rare in young women.
    We know the cervix is changing over these years and these normal changes are picked up as abnormal by the smear. Also, HPV infections may affect the smear, but most are cleared by the immune system within 2 years and don’t need medical treatment.
    There are many articles from Finland, UK and the Netherlands on this point.
    Another interesting article that appeared along with Dr Raffle’s research is “Why I’ll never had another smear test” by Anna Saybourn which appeared in the “Guardian” in the UK. (on line) This was the first time many women were even aware of the uncommon nature of the cancer and the risks of testing and that is unacceptable.

  6. Elizabeth says:

    Asymptomatic women don't need "annual" or any gyn exams – that is a practice that was started in the States without assessing it's clinical value.
    Our doctors don't recommend routine breast, pelvic or rectal exams EVER in symptom-free women – they are of low/poor clinical value, are not evidence based (no evidence of benefit) and expose you to the risk of more harmful interventions. I suspect these exams are why American women have more cervical treatments and hysterectomies than any other country in the world….a horrifying 600,000 hysterectomies a year!
    Around 95% of American women are referred for colposcopy and some sort of biopsy during their lifetime thanks to over-screening and inappropriate screening – huge numbers of unnecessary interventions to cover a small risk – in a unscreened developed nation only 1% of women would get cervical cancer. With your screening practices, 95% of women get referred after "abnormal paps" – most are false positives.
    American women should look closely at the advice they're receiving – you don't need these awfully invasive exams, in fact, they're more likely to harm you.
    Pap smears – doctors should be asking for your informed consent…only 0.65% of women benefit from smears…therefore 99.35% (incl the 0.35% of women who get false negatives) derive no benefit at all, but around 95% of American women will at some stage go through the trauma of a referral….
    Protect yourself from harm – if you choose to have testing, adopt a sensible program – Finland has the lowest rates of cc in the world and sends the fewest women for colposcopy/biopsies – they offer screening from age 30 and 5 yearly to 60. (5 to 7 tests in total)
    The excess in the States is terrifying – women who've had complete hysterectomies for benign conditions being tested every year, also, women who are not yet sexually active, the over-screening of all women, testing women under 25, testing elderly women….it defies common sense.
    Any woman who's been through the trauma of a cone biopsy or LEEP and didn't give her informed consent (wasn't told this cancer is rare/uncommon or the risks of testing/treatment) get your pathology report and see a lawyer – you have an open and shut case. Sadly, I suspect it will take legal action to halt the enormous harm being done to healthy women and without their informed consent. Cancer screening has nothing to do with contraception, if your Dr required a smear before giving you a script, that amounts to coercion and is no consent at all….the Dr may be fully liable for any negative outcomes.
    The unethical practice of tying birth control to screening is another disrespectful tactic to deny women informed consent – something men have always enjoyed with prostate screening – screening for a VERY common cancer. CC is uncommon, always was….and was in decline before screening started.
    Any woman interested in the truth – go to Dr Joel Sherman's medical privacy under women's privacy issues or the blogcritics site under unnecessary pap smears. Also, google research by Dr Angela Raffle, "1000 women need regular screening for 35 years to save one woman from cc" – also, "Why I'll never have another smear test" by Anna Saybourn published in the Guardian in 2003. (responding to Dr Raffle's research)

  7. Women should forget all they've been told about gyn exams, cervical and breast cancer screening.
    Having just returned from Finland, I can tell you we have all been deceived about the benefits and
    risk of these exams and tests.
    We often live medical lives devoid of modesty and dignity because as women we're told we need constant medical surveillance throughout our lives and all these things are "for our own good"…even using coercion to get our "consent" is acceptable.
    The facts: the annual gyn exam is harmful and unnecessary.
    Pap smears are a long shot, they help around 0.65% of women and to achieve that end they send around 90% or more for biopsies or treatment – almost all of these procedures are completely unnecessary.
    Now that I know the risk of this cancer is tiny and the risks of testing vast, I'll pass….
    The risks of mammograms are terrifying – I won't be having them at any age.
    We've all been conned to satisfy money-hungry doctors…the dishonesty and self-serving statements are sickening.
    I'm looking forward to a life free of stirrups, biopsies, scans, ultrasounds and all the other useless and harmful stuff.
    I no longer respect our medical profession, the harm they do is enormous with no concern about patient care or medical ethics.

  8. I'm a survivor of cervical screening.
    Abnormal pap tests, colposcopies and 4 normal biopsies – all in my early 20's.
    I got off this nightmarish cycle 5 years ago, the damage is done, but at least my quality of life has returned.
    I have lost a fair bit of my cervix and have been told it's unlikely I could carry a baby to full term without
    cervical stitching.
    I read recently that this cancer is rare….yet almost all women go through the hell of biopsies.
    How can we call this screening for a rare cancer when it's basically the systematic destruction of the healthy cervix? When does over-treatment become unethical?
    I didn't consent to pap tests either, my Dr refused to prescribe birth control pills unless I agreed to them.
    Why is it permissible for doctors to misuse their prescriptive powers to force something that should be voluntary?
    I will never understand….but thankfully, don't need pills anymore and will never test again.

  9. Some of the above comments state that doctors force patients to have Pap smears before providing birth control prescriptions. What doctor do you go to? I don't force my patients to have a pap smear before prescribing birth control. My own doctor doesn't either. Find another doctor!

    • ?????????? says:

      is this….true? why do so many doctors refuse to prescribe it unless there has been a recent pap?

      • My doctor told me that there’s a higher likelihood of cervical growths with regular and prolonged use of birth control (Tri Nessa). Not necessarily cancer, but certainly cervical cysts. Was she mistaken?

        I’d probably still gravitate toward caution, considering that my mom had to have a hysterectomy at 45 because of recurring precancerous cervical growths. I believe my maternal grandmother died of cervical cancer as well. I’ve never had an abnormal pap, but family history indicates that it might be more likely in my case, at least where cysts are concerned.

  10. Does anyone know of a doctor in Arizona that is "pro-choice" on the issue of pap smears? I have always gone to doctors that refuse to prescribe birth control without a pap. I want the right to choose not to be screened.

    • Good luck, it's a huge battle in the States and Canada, prepare yourself for a major scene.
      Don't be fooled by HOPE at Planned Parenthood, most offices really pressure you to have well-woman exams after 6 months, they basically get you through the door and then put you on the spot.
      I get my pills through an online pharmacy, never had a problem and I can stay miles away from our doctors which is always good for your health.
      I refuse to be forced into useless and degrading pelvic, rectal and breast exams and annual smears.
      Most of my friends are still forced to have annual paps even though the recommendations now say that's unnecessary and risks your health.
      I agree, this is about control of women and using us as money generating lumps of meat.
      Isn't it amazing that in 2010 most women are faced with the same birth control options as their grandmothers if they don't want to be coerced into harmful exams? The good ole condom.

  11. I cannot believe this article claims to be pro-women!!! There is nothing more patriarchal and backwards than subjecting them to humilliating medical surveillance based on previous sexual history, the excuse “it is very prevalent” ran out long ago, it is an extremely outdated and unreliable test, (not to mention that its efficacy was never properly assessed) that will harm millions to benefit only a few, that are not necessarily those we deem “high risk”.And don’t get me started on the anguish and despair that an all too often false positive can bring about.

    Believe it or not, there is a lot of greed and control behind this test. the father of Ginecology, Marion Sims, was indeed a criminal that impregnated and kept captive many of the unfortunate women on which he operated as much as thirty times. Not a role model as far as I’m concerned. governments must find better things to do rather than wasting money on a very romanticized and politicized cancer that will affect too few people.

  12. also thank you to everyone elso who commented YOUR comments were very informative…a s for those saying just find another doctor if yours requires a pap for birth control, it is very difficult where i live to find a doctor who is excepting new patients so your kind of stuck with what you have.

  13. Whether or not a women gets a pelvic exam should be her choice, birth control or not, regardless of the guidelines.

  14. I am 17 years old and started birth control at 16. My doctor offered me 3 months to try out the nuvaring and when I went back in and said I did not want a pap she said she would give me one more year. That year was up a little while ago and desire coming to that appointment armed with the new guidelines saying not to test until 21 she still said I needed one and called me childish for refusing. She gave me a few more months worth and told me to find a gynocologist who would give me a prescriptions without a test and good luck. Now I’m very concerned about trying to find one seeing as apparently guidelines aren’t actually followed.. I will resort to lying and swearing I have never had sexual contact if that’s what it takes, I am not getting a completely useless and uncomfortable test just because some doctor thinks they know better than me when i have done extensive research to come to my decision.

  15. Elizabeth (Aust) says:

    Peyton, I’d make a formal complaint to the Medical Licensing Board…the guidelines have been changed for a very good reason. Pap testing does not help women your age, but they carry risk from false positives and over-treatment…and the risk is high, young women produce the most false positives. Your doctor is putting you at risk with her ultimatum and the test has nothing to do with contraception or anything else, it’s an elective cancer screening test. Holding the Pill or anything else to force a woman to have cancer screening, IMO, amounts to medical coercion.
    Actually the UK does not test before age 25 and countries with evidence based programs like Finland and the Netherlands do not test before age 30. There are numerous articles online confirming pap testing is risk for no benefit in young women. (before 30) also, now we know the only women who should be offered a pap test are the roughly 5% of women aged 30 or older who are HPV+
    Sadly, most countries still have population pap testing, so the best way to protect yourself when HPV primary testing is not available, is to make an informed decision about pap testing and if a woman wants to test…avoid over-screening and early screening which will reduce the risk of over-treatment. The Dutch and Finns have 7 pap test programs, 5 yearly from 30 to 60 – the Finns have the lowest rates of cc in the world and refer far fewer women for colposcopy/biopsy. (fewer false positives)
    If the doctor will not listen to reason and intends to ignore the guidelines, make a complaint or find another doctor, but you’re wise to protect your body and health from this testing, it can only worry and ham you.

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