By now most of you have probably heard that ACOG (The American College of Obstetricians and Gynecologists) has made new recommendations as to how often and when to start doing Pap smears. Despite the timing, I don’t feel these are either economically or politically inspired by the currently debate on health care reform. The reasons behind these new recommendations are scientifically sound. I would like to share some of them with you…

It’s extremely difficult for women to reconsider their Pap priorities; after all we have been told for decades that we must have a yearly Pap smear. Indeed we were lead to believe that the Pap was the foremost reason to visit our gynecologist. (When I went to work in Israel after finishing my residency in the US, I tried to explain the importance of Pap smears. My colleagues and residents were puzzled…they had seen very few cases of cervical cancer and thought it only occurred in women with uncircumcised partners…. I’m not sure why it was uncommon, perhaps at the time the population was more monogamous. But a sexually active circumcised penis can spread the viruses that lead to cervical cancer as well as one that is “uncut”. Today Israeli gynecologists routinely do Pap smears. If you continue to read below however, you will see that “routine” has changed for everyone.) But I digress…

Many women believe that the Pap smear can, in its mythological and histological wonder, pick up every type of cancer “down there” including endometrial and ovarian cancer. Unfortunately, it usually won’t. The Pap can detect cells that herald the presence of cervical precancer and cancer caused by sexually transmitted HPV (human papilloma) viruses. There are more than 100 types of these ubiquitous HPV’s. They are all very contagious and easily transmitted during sexual intercourse. At least eighteen of them are deemed high risk. The high risk HPV’s are oncogenic agents which, if not cleared by the immune system, can enter the DNA and cause mutations in the cells of the cervix. These mutations can lead to the development of a precancerous lesion termed high grade squamous intraepithelial lesion or HSL and in turn this can go on to become invasive cancer.

Although an astounding proportion of young women (50 to 70%) are found to have HPV present in their cervix within 2 to 3 years of onset of intercourse, the majority have an immune response that is strong enough to clear the viruses within 8 to 24 months. Before they do, however, they may develop minor or low grade squamous intraepithelial lesions (LSL) that can then appear as an abnormality in a Pap smear. But as the virus is cleared, so usually is the low grade lesion. Patience is all that is needed to “cure” most of the early changes (termed dysplasia) caused by HPV in these young women.

Until recently doctors responded to mild and moderate Pap abnormalities in a sexually active adolescent or young woman with immediate reaction and action….we notified her that there was something “off” in the Pap smear and further testing was needed. (And she then called her Mom who invariably became hysterical.) We did colposcopy (an exam of the cervix with a microscope) and often followed this with biopsies. Then if the latter confirmed even mild changes we were taught to “catch and treat” immediately. We froze the offending cervix with cryotherapy to destroy the superficial “bad” cells or tried to destroy them with laser. (None of this killed the offending virus….we were treating the result not the cause.) And if the cells showed a more worrisome lesion we removed a part of the cervix with a procedure termed a LEEP or did a cone excision.

Well it turns out that early treatment in very young women was, in many cases, unnecessarily aggressive and harmful. The treatment could scar the cervix and lead to problems getting pregnant, maintaining a pregnancy to term (i.e. cause premature labor) and finally increase the risk of cesarean section.

Research on sexually active young women to see “what would happen if we left these early lesions alone” has shown that invariably the lesions do clear. Hence ACOG now recommends that gynecologists begin performing Pap smears in all women at the age of 21. The risk of missing a serious lesion in sexually active young women and adolescents is estimated to be 1-2 cases in a million. If Pap smears were done earlier, tens of thousands of minimally abnormal changes would be found and result in unnecessary procedures that could harm the future fertility and pregnancy in these young women.

ACOG also addressed the frequency of Pap smears in women who are older… No one wants to ignore the harm that high risk and non-cleared HPV’s can do over time. Hence the organization recommends Pap smears be performed every 2 years in women ages 21 to 29. And for women over 30, they feel it is probably sufficient to do the Pap smear every 3 years. (These women should already have a Pap history and are more likely to be in a mutually monogamous relationship.) To qualify for the 3 year rule a woman over 30 should have had 3 negative Pap’s. And negative Pap smears are most reassuring if HPV testing is also negative. (Note, I routinely order HPV testing in my patients when I do their Pap.)

Exceptions are made and Pap testing should be done more frequently for women over the age of 21 if they are immunocompromised, have been HIV infected, were treated for CIN2 or CIN 3 (high grade lesions) in the past or are DES exposed (their mother took DES while pregnant).

Remember if you are not in this risk group, if your Pap smears have been normal for many years, you do not have HPV and you are in a mutually monogamous relationship, nor have you had HPV in the past….you are not going to get cervical cancer unless you have a new “source” of HPV!

When it comes to stopping Pap smear testing….it’s a bit more complicated. Women aged 65 and older represent 14.3 % of the US population and have 19.5% of new cases of cervical cancer. In white women in the US the rates of new-onset of cervical cancer peaks in the 5th decade of life then decreases, in Hispanic women it is in the early 70’s and in Asian and Pacific Island ethnicity the incidence peaks in the late 70’s. The American Cancer Society recommends discontinuing Pap smears at 70; the US Preventive task Force has set the age at 65. ACOG suggests that if a woman over 65 is sexually active, and has more than one partner that she is still at risk and should get Pap smears. (Albeit she is less at risk than a younger woman because her cervical cells have undergone changes that make them less accessible to HPV caused mutations.) And women with a past history of abnormal Pap’s should continue screening until results are negative for 10 years.

Finally what about the women who have had a hysterectomy? If the cervix was not removed (a subtotal hysterectomy) you still need Pap smears with the same frequency as a woman who had not had this surgery. If however, the cervix was removed during the procedure (a total hysterectomy), then the only reason to continue having Pap smears is if the hysterectomy was done for a cervical high grade lesion or cancer. In this case the Pap can check for recurrence of the lesion in the vaginal cuff.

I know this all seems complicated. What I want to emphasize is that less frequent Pap smears does not mean less frequent pelvic, breast, or general exams. You will still receive annual reminders to come to see me (or whomever you go to for your gynecologic care). At that time we can discuss how often your Pap smear should be done. The rest of your exam can ascertain possible pathology in your breasts, uterus, endometrium, ovaries and hormones as well as any issues related to your general health (weight gain, diabetes, coronary vascular risk, hypertension, and bladder problems to name a few).
Women younger than 21 still need to discuss contraception, and if sexually active should be checked for STD’s, and taught how to prevent them. And if any woman has menstrual problems she should seek diagnosis and treatment. Women who plan to conceive should be seen and given appropriate preconception tests and advice.

The era of reproductive health sets the status for our entire lives. Once we enter menopause there are many more health and well-being issues we have to deal with. (Please note I haven’t even begun to talk about hormonal issues.) The cervix is just one part of our reproductive system. Pap smears save lives….but we are more than a cervix and need to maintain the health of the rest of our body.

We could ask our kids (rarely works), speak to the school administrators (they are probably the last to know),  read Seventeen and Cosmo or just look with despair at the promiscuous styles offered to and requested by young girls (and boys).

In my perusal of journals, I found a fascinating study which addresses this question. It comes from the National Youth Risk Behavior Survey conducted from 1999 though 2007. (Remember it takes a year or two to collect, analyze and publish information of this sort, hence it did not include ‘08 and ‘09.) Researches analyzed data from this survey to determine age at first intercourse in 66,882 black, Latino and Latina, white and Asian students in grades 9 though 12. According to the students’ anonymous self reports, the probability for “coital debut” by their 17th birthday (I’m assuming they meant vaginal intercourse, the use of euphemisms in medical reportage is astounding!) was: 82% for black males, 74% for black females, 69% for Latinos, 59% for Latinas, 53% for white males, 58% for white females, 33% for Asian males and 28% for Asian females

Now before we take this report and approach our children or grandchildren with queries as to whether they fall into the above listed statistics (“did you or didn’t you?”), I should point out that the survey was based on self-reported data. Girls are more likely to underreport sexual activity, whereas boys tend to over report. The survey did not stratify the groups by parental income or educational level, nor did it differentiate between public or private school attendance. And the study did not include youths who had dropped out of school (who would, most likely, skew early coital debut to higher probability).

I realize that parents don’t always like to look at gross statistics when it comes to their own progeny. But this large study does show us that a majority of teens self report that they were sexually active before the age of 17. It’s way better than rumors… and should help parents decide when to make sure that their daughters have access to appropriate contraception. (This may have the appearance of a plug for Planned Parenthood and I should disclose that in the past I was on the board of the LA chapter of this organization). We know that timing is important for HPV vaccination. The best results will be achieved if the vaccine is given before a girl becomes sexually active. Hence most pediatricians now discuss this with parents at a time when they are not quite ready to consider that their “little girl” will engage in sexual activity. But they will… Finally this survey emphasizes what we already know; all young teens should be taught about STD’s and the need for protection before they have that first, often too early, sexual encounter.