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Pap Smears by Elizabeth Walsh, MD
Pap smears are a critical part of a woman’s health care and should be initiated at
age 21. Cervical cancer incidence has decreased greater than 50% due to the
widespread use of pap smears. Furthermore, approximately half of all women who are
diagnosed with cervical cancer have never had a pap and an additional 10% of women
with cervical cancer did not have a pap in the 5 years prior to their diagnosis. This test is
essentially a red flag raiser. An abnormal pap does not tell us how extensive a cervical
problem is. It does tell us that further testing needs to be done to make certain cervical
cancer or pre-cancer is not present. This next test is a colposcopy which allows for
better visualization of the cervix and biopsy of abnormal areas. Cervical cancer and
precancerous cells are caused by a very common sexually transmitted virus, Human
Papilloma Virus (HPV). This virus has the potential to cause damage to cervical cells, yet
if that damage occurs it generally occurs relatively slowly starting with mild abnormality
that then worsens over time. The goal of a pap smear is to catch pre-cancer cells so that
they can be removed to prevent the development of cancer.
Having one pap smear is not enough for lifelong cancer surveillance. This is due
to the fact that a pap can be falsely normal. For this reason yearly pap smears have
traditionally been recommended. A series of normal paps statistically takes away the
risk of having a falsely normal pap. Recent research has changed this yearly
recommendation by the American College of Obstetricians and Gynecologists. A lady
who has always had normal paps, has the same sexual partner, and has no chronic
illnesses that affect the function of the immune system can space her pap smear test to
every three years (see guidelines). It is important to note that these new
recommendations are for the pap test only. Every woman still needs to be seen for a
yearly gynecological exam to evaluate the breast, uterus, ovaries, and her overall health.
Pap Smear Screening Guidelines
North Florida OB/GYN physicians follow the American College of Obstetricians and
Gynecologist (ACOG) Nov. 2012 Practice Bulletin Screening of Cervical Cancer
Age to begin Screening
Age 21, regardless of the age of initiation of
sexual intercourse. Both liquid-based on
conventional methods of cervical cytology
collections are acceptable for screening.
Screening intervals for ages 21-29 years
Every 3 years, with cervical cytology alone.
Co-testing should not be performed.
Screening intervals for women between
the ages of 30-65 years
Every 3 years, screening with cytology alone
is acceptable. Co-testing with cytology and
HPV testing every 5 years.
Age to end screening
Discontinue after age 65 years in women
with evidence of adequate negative prior
screening results and no history of CIN 2 or
higher. Adequate negative prior screening
defined as 3 consecutive negative cytology
results or two consecutive negative co-test
results within the previous 10 years, with the
most recent test performed within the past 5
years
Screening intervals for women with total
hysterectomy (removal of cervix)
May discontinue all screenings
(cervical/vaginal) if hysterectomy was done
for a benign condition and no prior history of
high-grade CIN. If there is a history of CIN II,
CIN III or cancer, or endometrial cancer,
annual screenings should continue for at
least 20 years after treatment and after post
treatment surveillance.
Women who have a history of cervical
cancer, have HIV infection, are
immunocompromised, or were exposed to
diethylstilbestrol in utero should not follow
routine screening guidelines.
Who falls outside these guidelines
The annual gyn exam and pap smear does often lead to a great deal of anxiety for
women.
I feel that it is important for women to know that they are not alone in that common
anxiety. It is our job as providers to make the experience of the annual exam as free of
stress as possible to enable our patients to effectively utilize preventive measures such
as the pap smear.