By Dr. Victor Sierpina
Most women look forward to their annual pelvic examination and Pap smear as much as most men look forward to their visit with “Dr. Jellyfinger” for a prostate check. Now there is good news for women who have been avoiding medical care because of their aversion to the embarrassment or discomfort of this annual ritual. New screening guidelines have made the annual Pap smear a thing of the past.
According to the latest U.S. Preventive Services Taskforce Guidelines on routine pap screening for women at low and average risk include the following:
1) Stop pap smears for women under 21 years old.
2) Stop pap smears for women who have had a hysterectomy for non-cancer causes.
3) Stop annual pap smears for low or normal risk women between 21-65.
4) Stop pap smears for women over 65.
Pap smear screening has reduced invasive cervical cancer rates 70 percent since the current guidelines for annual screening were introduced in the 1940s. This is a great medical success but recent research and improved technology has allowed us to reduce the frequency of screening. In large part, this is because we now know that the human papilloma virus (HPV), the most common cause of abnormal cytology and cancer is very slow growing and even preventable.
The new recommendations by the US Preventive Services Taskforce and major medical societies for Pap smear cytology screening have now been modified by the availability of DNA testing for the HPV virus and better understanding of the natural history of cervical cancer. This allows us to extend the screening interval to as much as five years. These recommendations are for general screening in low or normal risk women:
1) Perform cytology (pap) testing every three years on women 21-30 years old.
2) Perform co- testing (pap and HPV) on women between 30-65 every five years, if both tests are normal.
3) Co-testing is preferred to performing pap every three years between 30-65.
4) For women over 65, stop testing if they have had three normal paps or two normal paps and two negative HPV tests in the last 10 years.
If you have had abnormal paps, a positive family history of cancer, are immune compromised, are virginal or have sex only with other women, you should counsel with your family doctor or gynecologist as your screening intervals may be different.
Vaccinations against HPV are now available and are most effective before women become sexually active. This is the only vaccine we have that really prevents cancer, and it is now recommended for administration between 9 and 26 years old. Although we may not even want to think of our 9-to-12-year-old daughters or granddaughters, or boys becoming sexually active, this is the ideal window for vaccine administration, before sexual activity commences. The vaccine is thus recommended to prevent HPV infection and resultant anogenital and oral cancers and genital warts in both women and men.
It is important to clarify one thing, a pap and a pelvic are not synonymous. The pelvic exam is a visual and manual inspection of the female genitalia and may or may not involve sampling of the cells of the cervix for microscopic evaluation (the Pap smear). A pelvic exam is not just for a Pap smear but should be done for women with symptoms of lower abdominal or pelvic pain, infections, recurrent urinary problems, discharges, abnormal bleeding,and pregnancy. It is not an effective method to detect ovarian cancer.
So what becomes of the annual “well-woman” exam? Perhaps we can now spend more time focusing on other health issues. Cervical cancer is now relatively rare, with only about 4,000 cases in the U.S. annually, making it the 11th most common cancer in women.
More efficient use of the annual exam would be determining risk of and the optimal screening for breast cancer, still the second most common cancer in women. Colon cancer screening also starts at age 50 or sooner.
Beyond cancer risk, it is important to remember that more women die of heart disease than cancer. Therefore, counseling on smoking cessation, obesity, exercise, nutrition, cholesterol and iabetes are more essential to reduce disease and mortality risk.
So relax. Get your “annual well woman” exam with less anxiety and discomfort and focus on what is more likely to really benefit your long-term health. In fact, for another discussion is the fact that an annual exam may not even be evidence-based as beneficial for most low risk adults without known chronic disease.
Dr. Sierpina is the W.D. and Laura Nell Nicholson Family Professor of Integrative Medicine at the University of Texas Medical Branch.