April 2, 2017 Liza Colimon, MD Honoring Health Vow # 5 I choose to be “In the Know” by keeping record of important medical events in my life Don’t panic when you visit your gynecologist and you are told you don’t need a Papanicolaou (Pap) every year. The decision to change the frequency at which you have a Pap test was research led. The goal in mind is to decrease over treating and subjecting you to more invasive procedures and biopsies required when investigating an abnormal result. The guidelines have changed and have been based on studying the outcomes and incidence of cervical cancer diagnoses in hundreds of thousands of women. Also remember as your Doctors we are with you. We do not want you to have cervical cancer just as much as you don’t want the diagnosis. There are two types of cervical cancer, squamous cell carcinoma and adenocarcinoma. By having regular screening we can detect and find abnormal cells before they grow into cancer. Infection with Human Papilloma Virus (HPV), persistent infections, and particularly infections with high-risk strains of HPV 16 and 18 are the biggest risk factors for developing cervical cancer. Pap test screening is recommended more frequently in women who are at an increased risk of acquiring HPV infection in the first place. Your risks of acquiring HPV or indications you may still need more frequent testing are as follows: -If you began having sex at an early age -You or your partner has multiple sexual partners -You or your current partner has sex with prostitutes or other types of sex workers -Your immune system is weakened by medications or an illness and therefore you have difficulty clearing an HPV infection. Examples are HIV, chronic kidney disease, and organ transplant recipients or individuals diagnosed with cancer on chemotherapy. Regarding the frequency of Pap testing, some institutions vary in their recommendations and interpretation of the guidelines published and adapted by the American College of Obstetrics and Gynecology and the American Society for Colposcopy and Cervical Pathology(ASCCP). There are also international guidelines published by the European Cervical Cancer Association. It is important to remember, various practices and physicians may interpret the guidelines with slight modifications. If you have concerns or questions be sure to clarify with your doctor. Here are guidelines to follow: Pap test screening is not recommended in women under the age of 21 unless there is an abnormal exam finding. However we do recommend testing for gonorrhea and chlamydia every year if sexually active. Undiagnosed sexually transmitted infections could lead to pelvic infections, inflammation causing infertility, and chronic pain. For Women ages 21-29 we recommend Pap test screening every three years, with testing for HPV if your pap smear is abnormal. I also test women in this age group every year if they have multiple sexual partners or have had recent abnormal pap smears or HPV. Your doctor should interpret the guidelines based on your individual medical and sexual history. Again, regular annual testing is recommended for Chlamydia and Gonorrhea if you have new sexual partners, are in a non-monogamous relationship, use drugs, or are pregnant. Women ages 30-64 should have a Pap test every three years with a “co-test” at the same time for HPV virus. The test for HPV is performed from the Pap test. This is why it is called a “co-test.” Repeat testing every three years is recommended for women with normal a Pap test and negative HPV. I modify my testing interval to every year if you are in a non-monogamous relationship, dating and have multiple sexual partners, or if you have a health condition compromising your immune system. Remember, if you are in a truly monogamous relationship your risk of contracting HPV is very low. Therefore, your risk of developing cervical cancer is very low. We do see exceptions. This is why the guidelines have changed. According to the ASCCP, Pap test screening can be extended to every five years with co-testing for HPV in this age group only if you've had a lifetime history of normal, HPV negative Pap smears. You may no longer need a Pap test if: You are over the age of 65 and have had negative Pap tests with no evidence of HPV for the past 5-10 years. You’ve had a total hysterectomy (meaning both your uterus and cervix have been removed) and you had normal Pap tests prior to your procedure You have not had any abnormal cells diagnosed or confirmed by biopsy in the past 20 years You have no medical problems that would weaken your immune system An important point to remember is that your health is ultimately your responsibility. It is up to you to keep track of when you were screened and make regular appointments. Many offices will not remind you or schedule the appointment for you. Most women who are diagnosed with cervical cancer have not had a Pap test in 5 years or had an abnormal Pap smear they never had evaluated. Also, over one third of diagnosed cervical cancers are in women over the age of 65. Not every doctor is thorough asking about your sexual history. And not every primary care provider is excited about doing vaginal exams and pap smears. It has not been uncommon for me to care for women who have been seeing their primary care physician regularly for years, but have not had a Pap test. I recall vividly caring for a woman and diagnosing her with cervical cancer when she presented with bleeding years after menopause. She had been seeing her primary doctor more than once a year for heart and kidney disease but was never given a pelvic exam. If you have been having regular exams and check ups but your doctor has not addressed your sexual history or performed a Pap test you should advocate for yourself and inquire why. Better yet, find a physician who is comfortable caring for women and takes a proactive interest in your health. And remember, just because you have a vaginal exam with a speculum, this does not mean a Pap test was performed. Be sure you know what screening tests are being performed during your visit.