Abnormal Papsmears and Human Papilloma Virus (HPV)
The Pap smear is a test performed to screen for cervical cancer. According the American College of Obstetrics & Gynecology (ACOG) 2009 Guidelines, Pap screening should not begin before 21 years old. This is because the risk of cervical cancer in this age group is about one in a million and Pap screening in this age group and may lead to unnecessary and harmful evaluation. However, sexually active adolescents still need a consultation with a doctor for birth control and safe sex counseling and screening and counseling for sexually transmitted diseases (STDs). According to the ACOG guidelines, a Pap test is recommended every 2 years for women aged 21-29 years old. Women 30 years and older who have had 3 consecutive normal Pap tests may be screened every 3 years. Your doctor can determine if you have symptoms or risk factors that would require more frequent Pap testing. There is no definitive guideline for when to stop testing women with Pap smears. However, it is reasonable to stop testing women who still have their cervix between the ages of 65-70 years old, when they have had at least 3 normal Pap tests in a row, no abnormal Pap tests in the past 10 years, and no new sexual partners. In women who have had a total hysterectomy (cervix removed too) for benign indications and have no prior history of CIN 2-3, routine Pap testing should be discontinued. Since there are no screening tests for ovarian cancer, a woman who still has her ovaries should undergo a pelvic exam annually even if the Pap test is not due that year. These guidelines are just recommendations and risk factors should be assessed at the annual gynecological visit to determine if Pap testing should be performed that year.
Abnormal Pap smear results are common to a gynecological practice. However, they create a lot of anxiety and stress for the patient who has an abnormal result. There are many different types of abnormal Pap smears including ones with atypical cells, low-grade dysplasia and high-grade dysplasia (pre-cancer), non-invasive cancer, and invasive cancer. The way an abnormal Pap test is managed depends on patient’s age and the specific result and ranges from observation or a follow-up Pap smear to performing a colposcopy or referral to a gynecologic oncologist. A colposcopy is a minor procedure performed in the office which looks more closely at the cervix with a microscope and sometimes includes a cervical biopsy and/or an endocervical curettage. Occasionally, high grade dysplasia (CIN2-3) is discovered and a patient needs a Loop Electrosurgical Excision Procedure (LEEP). A LEEP procedure removes a piece of the outer portion of the cervix to eradicate the disease. This procedure is usually done under local anesthesia (numbing of the cervix) in the office and is 90-95% curative.
Most of the time, an abnormal Pap test result is caused by infection from the Human Papilloma Virus (HPV). Sometimes the cause is unknown and your healthcare provider can explain this further. Briefly, HPV is a sexually transmitted DNA tumor virus that is carcinogenic to humans. It can infect both men and women and is transmitted via vaginal intercourse, anal intercourse, or skin to skin contact. The HPV virus can cause abnormal Pap tests, genital warts, and cervical cancer. Rarely, it can also cause vaginal, vulvar, anal, penile, throat and head/neck cancers. HPV is very common in sexually active women. Approximately 50% of women are infected by HPV within 4 years of initiating sex and up to 60-80% have been exposed during their lifetime. There are more than 100 types of the virus identified. The virus types are broken down into two groups: low-risk and high-risk types. Low risk HPV types can cause genital warts. The high risk types of HPV are the ones that can cause cervical cancer, the most common being HPV 16. To put this in perspective, if a woman tests positive for HPV 16, her risk of cervical cancer is over 400 times greater than a woman who tests negative. The risk of lung cancer in a male smoker is 8 times that of a non-smoker, and the risk of breast cancer in a woman taking hormone replacement therapy (HRT) is 1.3 times greater than a woman who does not take HRT according to the WHI (Women’s Health Initiative) study. The good news is that the incidence of HPV 16 infections in young women is only 5%. Of the women infected, 70% clear the virus within 36 months and only 20% have persistent disease. A small percentage will progress to high-grade disease or develop cervical cancer. Progression of HPV to cervical cancer is extremely rare in young women and if it occurs it generally takes years to develop. Young, healthy, non-smoking women are more likely to clear the infection without surgical intervention.
HPV testing is used in cervical cancer screening as a triage test in women 21 years and older that have an ASCUS Pap test result and in postmenopausal women with an ASCUS or LSIL Pap test result. It is also used in conjunction with the Pap test as a screening test in women 30 years and older and can be used as a follow-up test to certain abnormal results. It is not helpful in women/adolescences younger than 21 years old since HPV is very common, the majority of HPV infections clear without intervention, and cervical cancer is extremely rare in this population. Testing for low risk HPV typing is not recommended since these HPV types do not cause cervical cancer, and treatment for genital warts is based on a patient’s symptoms, not based on a positive screening result.
The bottom line is that it is important for women to get routine Pap smear screening with or without HPV testing for high risk types according to the American College of Obstetrics and Gynecology (ACOG) guidelines. Women should have an annual gynecologic exam by a healthcare professional unless the cervix, uterus and ovaries have been surgically removed for benign reasons. If you receive an abnormal Pap test result, you need to be monitored and managed by a healthcare professional. The best way to decrease your risk of HPV is to limit your number of sexual partners, use condoms every time you have sex, abstain from smoking, and if you are 26 years old or younger, get vaccinated with the HPV vaccine series.
To learn more about HPV and Pap smear screening guidelines, please visit the following website address. http://www.arhp.org/hpv-tool/