Paps and Pelvics: A Lot Has Changed

My patient, a 50-year-old mother of two, looked at me suspiciously. “Is this an Obamacare thing?” she asked. I had just told her that I was not going to do a pap smear. No, this wasn’t an Obamacare thing, this was evidence-based medicine in action. This was our patriarchal medical community implementing a change that was kinder to women and supported by our most current understanding of the HPV virus and cervical cancer. Women of the United States, rejoice!

That’s not exactly what I said to my patient, but it’s what I was thinking.

In 2012, the American College of OB-GYN (ACOG) made a bold new change to the standard of care: Pap smears (if normal) would be every 3 years for women in their 20s and every 5 years for women from age 30 to 65. Not only that, we would not start screening until a woman was 21 and would stop at age 65! We would not make judgement recommendations based on sexual history (“Oh my, you have had ten partners in the last year? You need lots of uncomfortable pelvic exams!”), and a woman could have a birth control pill without a pelvic exam.

These changes have lead to a lot of questions, which I’m more than happy to answer.

“Aren’t paps and pelvic exams the same thing?

For many years pap smears and pelvic exams were annual, so the terms became synonymous. But a pap smear is just one element of the pelvic and NOT the same thing.

“Why don’t we need paps every year?”

A pap smear is a very old-fashioned screening test for cervical cancer. By old-fashioned, I mean it is looking at cells under a microscope and deciding if they look normal or have a funny shape or big nucleus. The pap was developed in the 1940s by Dr. Georgios Papanikolaou.

We now know that the vast majority of cervical cancer is caused by the HPV virus, 13 strains in particular. (An excellent story that happens to explain this is “The Immortal Life of Henrietta Lacks.” Highly recommended!) Women ages 30 to 65 are automatically tested for this with their pap. If the pap smear (old-fashioned looking under a microscope) and HPV test (high-tech molecular screen) are both normal, then your chance of developing cervical cancer in the next 5 years is close to zero.

Women ages 21 to 29 only need the pap smear and are not routinely checked for HPV. The reason for this: HPV is soooo common that we do not want to know about it unless it is causing changes to the cell structure.

Many decades have now made it clear that 1) actual invasive cervical cancer is very rare before age 30, and 2) once the abnormal cells are detected, it still takes years to become actual cancer.

“But what about ovarian cancer, STDs and all that other stuff that can affect my lady parts?”

A pap smear does not screen for this and never has. If you are sexually active and have a new partner and do not use condoms every single time, you probably should be tested for STDs every 6 months. Luckily, this no longer requires a pelvic exam. Just pee in a cup!

Regarding ovarian cancer, this is not typically picked up on a pelvic exam. That is a whole other topic for a future blog post.

“I went to the ER last month for pelvic pain, and I think they did a pap smear while I was there.”

No, they definitely did not do a pap smear in the ER. Women often assume that they are getting a pap smear if a pelvic exam is performed.

An important point: pap smears are screening exams. What exactly does that mean? Screening tests are used to detect conditions that have no symptoms. High cholesterol has no symptoms until it causes a stroke. Mammograms detect lumps before we can feel them. Cervical dysplasia (pre-cancer) has no symptoms until it becomes cancer. Just like one would not get a mammogram in the ER, one does not get a pap in the ER.

“So I don’t need an exam every year?”

This is where things get complicated.

New pap smear guidelines have become universally adopted — if your provider says you need a pap every year, find a new provider — but the frequency of pelvic exams and wellness visits is being hotly debated by various organizations. The US Preventative Services Task Force (USPSTF) states “there is insufficient evidence to weigh balance of benefits versus harm for pelvic exams in asymptomatic women.” (USPSTF is very wishy-washy on a lot of these issues.)

There is so much contradictory information and recommendations by different medical groups with different agendas. This is what I tell my patients: You should have an annual check-in versus check-up. What I mean by that is you should see a medical professional annually to assess your health status and then go from there. At the very least, it will alleviate some anxiety. (Yes, it is perfectly normal for your period to go from red to brown each month) or alert you to be concerned when maybe you thought you shouldn’t be. (No, it is not normal to start having periods again when you are 60.) You should have a gentle reminder to restart that exercise program or decrease stress in your life or dump the guy that keeps giving you chlamydia. That kind of stuff. And if you have any new symptoms, then you should have a pelvic exam even if your pap was normal last year.


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