The Pap Test: Finally a Consensus on Cervical Cancer Screening

Everyday Health  April 30, 2015

Everyday Health  April 30, 2015

If you have had the experience of your internist telling you only need a Pap every three years, your gynecologist telling you every two years, your hairdresser telling you every five years, and you end up getting a Pap every year because you are confused and just don’t want to get cancer, you are not alone.

The ritual of the annual Pap test has pretty much gone the way of the dial phone as the result of new screening technology and HPV (human papillomavirus) testing. It is clear that low-risk women do not benefit from yearly screening, and, in fact, some women need not be screened at all.

The problem is, there have been so many different recommendations from different organizations, it is not unusual for women to get conflicting recommendations from different doctors, websites, and magazines, leaving women to try and figure out which test is best, and how often to get it.

In a valiant effort to bring consistency to cervical cancer screening, the internists (American College of Physicians), gynecologists (American Congress of Obstetricians and Gynecologists), The American Cancer Society, and other key organizations have finally agreed on the following guidelines:

Cervical Cancer Screening Guidelines

Age to begin screening: 21 years

Screening method and interval:

  • Age 21 to 65 years: cytology every three years


  • Age 21 to 29 years: cytology every three years
  • Age 30 to 65 years: cytology plus HPV testing (for high-risk or cancer-causing HPV types) every five years

Age to end screening: 65 years, assuming three consecutive negative results on cytology, or two consecutive negative results on cytology plus HPV testing within 10 years before cessation of screening, with the most recent test performed within five years.

Screening after hysterectomy with removal of the cervix: Not recommended.

(Note that these guidelines are for average-risk women who have no history of high-grade, precancerous cervical lesion or cervical cancer; are not immunocompromised, not infected with HIV, and had no in utero exposure to diethylstilbestrol (DES).)

So, hallelujah, finally everyone is in agreement that too-frequent or unnecessary screening leads to extra expense and painful unnecessary colposcopies and biopsies. Everyone agrees that women under the age of 21, and low risk women over 65 do not benefit from routine cervical cancer screening. Everyone agrees that adherence to these new guidelines will not result in more women ending up with an invasive cervical cancer.

Why You Still Need Your Annual Gynecologic Exam

But here is what everyone does not agree on:

The American College of Physicians feels that in a non-Pap year, there is no reason for a woman to have a gynecologic exam unless she has a specific complaint.

As a gynecologist, I feel very strongly that even if a woman does not need a Pap test, there is a great deal of benefit from an annual gynecologic exam.

No complaint does NOT translate to “no problem,” and the majority of conditions I diagnose and treat have NOTHING to do with a Pap test. This is particularly true for the midlife-or-beyond woman.

Incontinence, vaginal dryness, pelvic organ prolapse, sexual problems, or new growths on the vulva or cervix are among the very long list of conditions and issues that I address at an annual visit even if my patient does not voice a specific concern, either out of embarrassment or the belief that her problem is just a “normal” consequence of aging.

So yes, these new Pap guidelines make sense and will, theoretically at least, lead to less confusion. But yes, you do still need to see your gynecologist even if it is not a “Pap-test year.”

Who else is going to look in your vagina?


Are Annual Paps to Screen for Cervical Cancer Hopelessly Out of Date?


By Lauren Streicher, MD

Published Jun 11, 2014, Everyday Health

In developing countries, where Pap tests are not done, cervical cancer is still the leading cause of death among women aged 35 to 45. In the United States, the cervical cancer rate has been extremely low since the 1960s, when annual Pap smears were introduced, which is why for most women, the ritual of the annual Pap test is reassurance that all is well in gyno land.

But over the last few years, a number of different pap protocols have been recommended, and this has been, to say the least, confusing. Depending on your age, which test is being administered, and your personal history, you might need a Pap test annually, or every two years, or every 3 years or every 5 years… or not at all.

And now the FDA has come out with a unanimous recommendation that the traditional Pap test should be replaced with a specific high-risk human papillomavirus (HPV) test in order to determine who is most likely to have true pre-cancerous or cancerous changes. Why the change?

What’s Behind the New Recommendation for HPV Testing

Keep in mind that HPV, the cause of cervical cancer, is extremely common; some studies show that it is present in the cervixes of almost 80 percent of sexually active women. There are over 40 subtypes of genital HPV; but only about 10 percent of women infected with high-risk HPV develop a persistent infection, which may put them at risk of cancer. Most HPV gets cleared and has no consequences.

More likely than not, you are one of the women who has received that stomach-dropping phone call, “Your Pap test is abnormal, and you need to come back for further testing,” only to ultimately be told that you did not have cancer. And despite the reassurances that the most likely outcome is that everything is fine, it didn’t make up for the weeks of waiting, the fear of cancer, and the discomfort (and expense) of a colposcopy and biopsy to find out that all was well.

If they’re tested for high-risk HPV first, instead of having a traditional Pap test first, the majority of women who have nothing wrong with their cervix won’t have to go through a lot of additional testing to determine if there is an actual problem.

Specifically, the new recommendation is that, starting at age 25, women should get a cervical swab to check for HPV. If a high-risk HPV (16 or 18) is detected, proceed with colposcopy. If one of the other HPV strains is detected, do a traditional Pap that looks at the cells on the cervix, and then do a colposcopy only if there is evidence of pre-cancerous changes.

While this new HPV test certainly has advantages, what is increasingly clear is that strategies to prevent invasive cervical cancer need to focus on two fronts:

  • HPV Prevention. The HPV vaccine and practicing safe sex are critical to preventing infection with the virus, which is also responsible for vulvar, vaginal, anal and even oral cancers. Mid-life women are particularly vulnerable since they are less likely to use condoms in a new relationship and are also less likely to clear the virus. There are many strategies that will allow you to have a positive sexual experience without testing positive, and my book Love Sex Againgoes through the details.
  • Cervical Cancer Screening. While this new HPV protocol does offer an advantage, the majority of the 12,000 women in the United States women who develop cervical cancer each year didn’t have the “wrong” test. The majority of the women who develop cervical cancer had NO test. Having different recommendations for specific tests and intervals between testing is confusing for patients and doctors and can result in women not getting appropriate testing.

What’s the Answer? Get Screened

In a commentary published in this month’s Annals of Internal Medicineauthors Rebecca Perkins, MD, and Elizabeth Stier, MD, from Boston University School of Medicine agreed and emphasized that any screening is better than NO screening.

So here’s the bottom line:

If your doctor is not offering this new HPV test, not to worry. The most important thing is to get screened, with any test your doctor offers.

And yes, you do need to see your gynecologist even if it is not a “Pap test year.” Even if you don’t need cells sampled from the cervix, your gynecologist (or other healthcare professional) still needs to put a speculum in and take a peek inside to make sure your cervix and vagina look healthy. Face it, who else is going to look in your vagina?