What do you mean I don’t need a Pap? Understanding this test and the changing guidelines

In the last few years, there have been a lot of changes in the medical world around the need for Pap exams. For many women, the phrase ‘You don’t need a pap’ is met with both relief that the oft-uncomfortable procedure is not needed, as well as confusion about what that means in terms of accessing a health care provider for an annual exam.

While I cover the difference in the October Newsletter article “Pap or Annual: Know the Difference”  I feel it is important for women to fully understand what a Pap exam actually is/does and why not everyone needs one every year.

The Pap smear/exam (The Papanicolaou test) looks for unhealthy changes to the cells of the cervix, which is the lowest part of the uterus.

The test is useful in finding cell changes associated with precancer–cell changes on the cervix that might become cervical cancer if not treated appropriately. It can also detect cell changes associated with cervical cancer as well as infection from common sexually transmitted infections.

What we have learned in the last few years is that there are more than 40 types of HPV and it is the most common sexually transmitted infection in the United States. It is also one that most people never know they have or even that they have been exposed to it. As an aside, unlike some sexually transmitted infections a new HPV diagnosis doesn’t mean a new exposure. This virus can be asymptomatic, unrecognized and subclinical for a long time. The CDC estimates more than 50% of sexually active people have become infected with HPV at least once in their lifetime- most without ever being aware of it.

Some types of HPV cause warts on genital areas of men and women, including the skin of the penis, vulva (area outside the vagina), and anus, and the linings of the vagina, cervix, and rectum. These types can also infect the lining of the mouth and throat. These types of HPV do NOT cause cancer.

Other types of HPV, types that do NOT cause warts, can cause cell changes that result in cancer. These are called ‘high risk’ HPV types.

These are the types of HPV that are associated with –and tested for- in a Pap test.

So why would anyone tell you to wait several years between Pap exams, why not test every year?

The answer is that usually, the body’s immune system clears the HPV infection on its own within a few years.  This is true for the HPV types causing warts (but not cancer) AND the types causing cancer (but not warts).

When the body’s immune system doesn’t clear the ‘high risk’ HPV infection, it can linger and cause normal cells to become abnormal and potentially cancerous. These types of HPV have no other outward sign or symptom.

However, that process of turning normal cells to precancerous cells or cancerous cells is generally very slow.

Research supports the slowness of this process and in the absence of any abnormal Pap or HPV results, it suggests that routine annual pap exams are unnecessary and may cause high rates of intervention when, given some time, the body may well clear the virus on its own.

I like to explain the process using a twist on the Aesop’s fable of the tortoise and the hare.   The body’s immune system is like the hare, quick and fast it most often clears the ‘high risk’ HPV virus from the body- with the body never showing sign it was even there.  Only occasionally is the ‘high risk’ HPV type like the tortoise- slow and steady enough to outmaneuver the immune system to make cell changes.

While that is a rather simple analogy (and maybe not a great one, at that), it gets to the point of why Pap exams- in the absence of anything abnormal- are not needed for every woman, every year.

BUT, that does NOT mean women shouldn’t come in for- at a very minimum- an annual exam each year.

Pap exams are a useful tool to evaluate cervical cell health, but women’s health care should NOT be reduced to simply these exams, something that has happened far too frequently over the years.