Your daughter comes to see me…she has a boyfriend or perhaps already had one (or, and I know this is hard, several). She may be going off to college and she (or you) want to make sure she is prepared, not just with books or the latest in fashion, but with birth control. You probably want me to sternly reiterate those warnings about STD’s and the need to use condoms if (oi) she should become sexually active. This admonition may sound more authoritative from me than from either her teachers or you.
But should I do a Pap smear to “make sure everything is alright?” Or when she comes back from school and sees me a year later, and admits to sexual experiences, should I do it then?
We have heard a lot about cervical cancer and its cause, the human papilloma virus (HPV). To be succinct….there is no cervical cancer if there was no prior and usually ongoing HPV infection. (Remember when we were told that women who had never had sex would not get cervical cancer….we just didn’t know why, now we do; they were not exposed to HPV.) Well most of us have been exposed….the current estimate is that 50% of sexually active women in the United States will have a positive test result for HPV within 36 months of the onset of sexual activity. And because recurrent infections are also common, 57% of sexually active female adolescents (defined as a teens up to the age of 20) are infected with HPV at any one time. There are at least 30 types of HPV but thankfully, only some of them are high risk instigators of cervical cancer.
Here comes the good news… Eight months after initial infection the HPV usually becomes undetectable and in most adolescents with an intact immune system the infection resolves within 24 months.
Based on these facts, the American College of Obstetricians and Gynecologists (ACOG) does not recommend the use of HPV testing in this young population. (But they do recommend that adolescent girls and women up to the age of 26 receive the currently available HPV vaccine that builds immunity to 4 types of HPV….see my post on Gardasil). Moreover, there is no rush to do a Pap smear on these adolescents. Once more ACOG has come out with the recommendation that “the first Pap be done 3 years after the onset of vaginal intercourse and no later than age 21 and annually thereafter until age 30”
If perchance a PAP or HPV test was done before that and the HPV was positive, it should be ignored! If the Pap shows minimal abnormal cells (in technical terms ASC-US and LSIL) it should simply be followed since in most cases these changes will simply go away within 2 to 3 years. To make sure, ACOG s recommends doing a repeat Pap every 12 months for a 2 year period. Further testing with colposcopy and possible biopsy should be done only if these mild changes (termed CIN1 and CIN2) persist for 2 years or the Pap indicates more advanced “high grade” lesion (HSIL).
As with any STD diagnosis, the adolescent becomes an “immancipated minor” and parental consent for diagnosis and treatment, although preferred may not be required. (I generally ask my adolescent patients if I am “allowed” to talk to her parents, but will keep her privacy if she insists…especially if the test or therapy is not a threat to her health. Since most parents see the bill from the lab, complete confidentiality may be difficult).
So if you ask me to see your adolescent daughter, I, like most clinicians will sternly advise her about STD’s, the need for birth control and condoms. I probably will not do a Pap or HPV testing…until she is 21. And even at that age, I will “forgive” an HPV infection and/or mild changes in the cervical cells, but not ignore them. The plan will be to follow her with future Pap smears, HPV and STD testing.