“Do I need to get pap smears forever? I am 70, do I still need pap smears?” These are common questions I hear in the office. Since January is Cervical Health Awareness month, let’s review the guidelines for pap smears.
A Pap smear is a screening test for cervical cancer. A brush-like swab is used to obtain a sample of cells from the cervix to evaluate for abnormalities. It does not provide screening for uterine or ovarian cancer. Although there are instances when some cells from the uterine lining could show up on a pap smear and give additional information…I will talk about this later.
Human Papilloma Virus (HPV) is the cause of cervical cancer so knowing high-risk HPV (hrHPV) status is also important. High-risk HPV (hrHPV) sampling is added onto the pap smear. Another option is obtaining a hrHPV sampling alone using the same swab we use for pap smears. There are over 100 strains of HPV, low-risk strains that cause genital warts and these are not included on a pap smear. High-risk types can cause abnormal cervical changes that could be precancerous or cancerous.
A quick summary of the guidelines are as follows:
1)Pap smears should start at age 21 and obtained every 3 years until age 29.
-You may be wondering why pap smears are no longer done annually? Many studies have shown that it can take years for cervical cancer to develop. In the past, many young women were also susceptible to subsequent procedures after having false-positive results which caused unnecessary anxiety for these women. So, since we know so much more about HPV and the development of cervical cancer, spreading out the frequency of pap smears was deemed appropriate.
2)Women aged 30-65 should have a Pap smear and an HPV test every 5 years. This is called cotesting.
-Or they can have a Pap smear alone every 3 years.
-Or they can have an HPV test alone every 5 years.
3)Women 65 and older can stop having Pap smears if they have never had abnormal cervical cells that were high-grade in nature or cervical cancer AND have had 3 negative Pap smears in a row. They can also stop screening if they have had 2 negative Pap and HPV tests in a row in the past 10 years, with at least one in the past 5 years.
Now who are the exceptions to the rules…some women need more frequent screenings if they…
-have a history of cervical cancer
-have a history of treatment of high-grade abnormalities of cervical cells which is called Cervical Intraepithelial Neoplasia (CIN) 2 or 3.
-are HIV positive
-Immunocompromised or have a weakened immune system due to HIV or liver disease, or taking drugs that suppresses their immune response
-were exposed before birth to diethylstilbestrol (DES, a hormone that was given to pregnant women between 1940 and 1971)
Now, these are guidelines that I am obligated to review when managing patients, but I must remember every woman is different and some may require testing that may not fully follow the guidelines stated above. Every physician is different too, some may feel differently about a particular guideline. Personally, I think cotesting every 5 years is too long, so I do every 3 years instead. And I still look at your cervix every year…. you still must get that dreaded speculum exam! The guidelines state that you can stop having pap smears after age 65 but I personally offer this option after age 70. I also prefer doing a pap smear and HPV instead of HPV alone for screening because like I mentioned earlier, sometimes a pap smear can give us additional information. You may have seen on your pap smear result the presence of “endometrial cells.” These are cells from your uterine lining and can be seen on a pap smear of a menstruating woman. This is usually a benign finding however it could report that these cells are abnormal and may indicate an abnormality within the uterine lining. Or if noted in a postmenopausal woman or in a woman with abnormal vaginal bleeding, then would require further investigation with a biopsy from the uterine lining.
As a patient, you can express your thoughts when it pertains to these guidelines. If you do not feel comfortable waiting for 3 years or 5 years, then talk to your physician about it and make a shared decision about how often you should be getting pap smears based on your history.
Other things you should know….
-if you have had a hysterectomy that includes removal of your cervix for benign reasons, then you no longer need pap smears.
-if you have had a hysterectomy but still have a cervix, then the same guidelines listed above apply.
-if you have had the HPV vaccine, you follow the same guidelines because the vaccine does not protect you against every type of HPV.
Whether you are getting pap smears every 3 years or 5 years or stopped having them due to age or hysterectomy, you still need an ANNUAL exam. It is important to get your breast and pelvic exams. It is important to get a blood pressure check and discuss any other pertinent tests or vaccines to address your overall health. This is also an opportunity to discuss any issues regarding pain, bleeding, signs of infection or any other symptoms that affects your overall health. So back to the original question, “when can I stop having pap smears?” If you are considered low to average risk, then the pap smears stop after age 65. But again, have this conversation with your physician to come up with a shared decision that you both are comfortable with.