To be clear on the definition, the annual pelvic exam is that part of the yearly gynecology appointment where your doctor (family doctor, internist, or gynecologist), nurse practitioner, or midwife looks at and feels around in your cooch with a couple of gloved and lubed fingers to make sure everything is just as it should be. Sometimes a speculum, that plastic or metal duck-billed looking thing (featured in the above image), is also used to facilitate the looking part.
Most of us gals put going to the doctor for an annual pelvic exam up there with going to the dentist for a root canal! Frankly, I’d rather do just about anything else.
Well guess what, ladies, according to the American College of Physicians in a July 1, 2014 report, the annual pelvic exam can go the way of the dinosaur!
Their data on the usefulness, risks, and benefits of the annual pelvic exam, demonstrates that the practice should be abandoned. In fact, according to ACP recommendations, in women who are otherwise healthy and have no pelvic symptoms, routine pelvic exams are not only unnecessary and uncomfortable – they do more harm than good, leading to false positive findings, anxiety, and unnecessary subsequent testing.
Not everybody agrees. The American College of Obstetricians and Gynecologists (ACOG) has expressed their concerns about the ACP guidelines, standing by its current recommendation that pelvic exams be done routinely at annual visits. They do state, however, that the choice to perform pelvic examinations is one that should be made on the basis of a woman’s individual needs, requests, and preferences. If you can pick and choose whether to do it based on personal preference, that doesn’t sound like it’s based on medical necessity to me!
ACOG also states that the primary reason for doing exams is to be able to diagnose urinary incontinence and sexual dysfunction. However, in reality, both of these can be diagnosed on the basis of a good health history with a woman still fully clothed! A woman can tell her doctor if she’s leaking urine, and if asked (which most doctors don’t), she can also tell her doctor how things are going in her sex life. A pelvic exam isn’t going to help her doctor diagnose sexual dysfunction – most of which actually has nothing to do with physical problems!
What about needing to have a pelvic exam to get tested for sexually transmitted infections (STIs)? It’s true, usually a fluid sample is collected from the cervix during the pelvic exam to check for gonorrhea and chlamydia, though the data is clear that these can be tested for just as well via a urine sample and low-risk women don’t need this testing anyway. So hmm… pee in a cup in the privacy of the bathroom if you’re at risk for sexually transmitted infections, or drop your drawers, lie down on your back, and pop your legs into stirrups for an exam….
I personally say good-bye and good riddance to the routine annual pelvic exam! It’s about time. They should only be done when medically indicated – meaning you have pelvic symptoms or pelvic health concerns.
But what about Pap smears and HPV (Human Papilloma Virus) testing? Do you need those? And if so, how often?
Why Paps & HPV Testing?
I definitely do recommend getting regular Pap smears, and if appropriate, HPV testing, according to the 2012 guidelines. (That reminds me, I need to schedule an appointment for myself, too!).
While in general, the risk of cancer is very low for women in the US, representing only 1.5% of all deaths related to cancer in women, it’s not zero. In the US in 2014, there will be an estimated 12,360 new cases of invasive cervical cancer, and 4,020 cervical cancer-related deaths are expected. About half of the cervical cancer is late-stage when it is found, usually in older women who have not been getting any screening. It is much more prevalent in developing countries.
Pap smears, also called Pap Tests or Cervical Cytology, are done to check for early changes in your cervix* that could indicate a risk for, or the presence of cervical cancer. HPV testing for the specific strains that are associated with increased cancer risk (16, 18, 45, 31, 33, 52, 58, and 35), is done at the same time in women over 30, or as further testing in women 21-30 years old with abnormal results on recent Pap testing.
Because cervical cancer progresses very slowly, and requires the presence of one of the cancer-promoting HPV strains to be active continuously for years, frequent testing is no longer considered necessary, and periodic testing with a Pap (and HPV screening in women over 30) can catch potentially cancerous cervical changes and the presence of high risk HPV early. Most of us wouldn’t mind getting this exam once every 3-5 years – and in truth, pelvic exams can (and should!) be done gently and respectfully, with you even participating by optionally inserting your own speculum, for example.
The Pap smear, however, is a more controversial test than most of us realize. Its effectiveness in screening for cervical cancer has never been demonstrated in randomized trials, and there remains uncertainty about the most effective methods for collecting and analyzing the cells. That said, we do know rates of advanced cervical cancers are much higher in countries where women lack access to testing.
One of the problems with Pap smears is that abnormal test results are quite common – even when there is no medical problem. They can be misinterpreted or misclassified, and even when there are some actual abnormal cells present, in most cases, these resolve on their own.
Between 50 and 60 million Pap tests are done annually in US. Approximately 3.5 million of these are read as abnormal, and an estimated 2.5 million women undergo further diagnostic testing (colposcopy) as a result. This is time consuming and positive results that often end up being false positives still cause a great deal of anxiety while you’re waiting and getting follow up testing.
How Often Should Pap and HPV Screening Be Done?
Until recently, Paps were done annually, as part of the whole pelvic exam. However, it was discovered that the emotional and physical risks of finding “false positive” results outweighed the benefits of annual screening. In fact, it sometimes did more harm than good. For example, it was found that screening in women younger than 21 years old, despite the fact that the body almost always clears up cervical abnormal cells and the HPV virus on its own, but young women with positive results were getting invasive treatments, like LEEP procedures and cone biopsies, which were leading to cervical damage and problems in future pregnancies!
So in 2012, new Pap smear and HPV testing guidelines became standard, and endorse a less frequent schedule for women with no history of abnormal cells on prior Paps.
Below are the current (2012) American Cancer Society Guidelines:
- Cervical cancer screening (testing) should begin at age 21. Women under age 21 should not be tested. (AVIVA’s NOTE: AND THAT MEANS EVER!)
- Women between ages 21 and 29 should have a Pap test every 3 years. Now there is also a test called the HPV test. HPV testing should not be used in this age group unless it is needed after an abnormal Pap test result.
- Women between the ages of 30 and 65 should have a Pap test plus an HPV test (called “co-testing”) every 5 years. This is the preferred approach, but it is also OK to have a Pap test alone every 3 years.
- Women over age 65 who have had regular cervical cancer testing with normal results should not be tested for cervical cancer. Once testing is stopped, it should not be started again. Women with a history of a serious cervical pre-cancer should continue to be tested for at least 20 years after that diagnosis, even if testing continues past age 65.
- A woman who has had her uterus removed (and also her cervix) for reasons not related to cervical cancer and who has no history of cervical cancer or serious pre-cancer should not be tested.
- A woman who has been vaccinated against HPV should still follow the screening recommendations for her age group.
Reducing Your Risk of Cervical Cancer
Pap smears don’t prevent cancer – they just detect it. When abnormal cells are caught early, proper treatment can prevent them from turning into cancer. But we can also take steps to keep our cells maximally healthy and prevent cervical cancer!
Here are the key steps to cervical cancer prevention:
- Prevent HPV Infection: While as many as 4-20% of women with HPV have only one sexual partner, your risk of getting HPV goes up with the number of sexual partners you have over your lifetime. Condoms don’t necessarily prevent HPV transmission.
- Eat a diet high in fruits and vegetables. Some studies have found that women low in vitamins and minerals may be more at risk of developing cervical cancer. Fruits and vegetables contain powerful cell-protective antioxidants and phytochemicals including vitamins A, C, and E, all of which have been shown to help prevent cervical cancer and other forms of cancer. Folate deficiency is thought to increase the risk of cervical cancer. Folate is found abundantly in leafy green vegetables. A natural ingredient found in broccoli-family vegetables including broccoli itself, kale, collard greens, and Brussels’s sprouts, called indole-3-carbinol (I3C) may even help to reverse cervical dysplasia when taken as a supplement in a dose of 200 – 400 mg per day.
- Maintain a healthy weight: Women who are overweight are at greater risk for developing cervical cancer.
- Don’t Smoke: Smokers are 2-4x more likely to develop cervical cancer.
- Consider Alternatives to Birth Control Pills: There is a very small increase in cervical cancer in long-term oral contraceptive pill users. Consider an IUD, natural family planning, or speak with your primary care provider about other birth control options.
Pap Smear/HPV Q&A
Thank you for all of your questions on my Facebook page! Questions about what to do about abnormal Pap and HPV testing results will be addressed in my blog: Abnormal PAP or HPV Results: What’s a Girl to Do?, coming soon.
Q. Is it OK to never get one?
A. Not getting a Pap is certainly an option as a personal choice. However, having seen and treated women with advanced cervical cancer, it’s not an option I’d personally choose or recommend. Even with the stress of false positives, the new recommendations aren’t too demanding and knowing early is better than knowing late when it comes to cancer.
Q. Cervical cancers in younger women can sometimes be more aggressive – will we find later that waiting 3-5 years between Paps is too long?
A. Women of all ages are at risk of cervical cancer, but it occurs most often in women 30 and over because they are more likely to have persistent HPV infections. All the studies looking at cancer progression and detection show that there is virtually no change in outcomes or missed cervical cancer with the new screening guidelines, and that women were much less likely to be subjected to additional unnecessary testing under the new model.
Q. Do you need a Pap just to get a birth control prescription…and how about if you are TTC, should you get a Pap then?
A. You do not need a Pap smear to get a prescription for birth control, for an IUD to be placed, or if trying to conceive (TTC), unless you are due for one.
Q. If there is a history of cervical or ovarian cancer in your family, should you continue to get them yearly?
A. Family history does not necessarily change the recommended Pap schedule, however, it would be important to be diligent about following the schedule, discussing your concerns with your primary doc, and making sure your diet is rich in fruits and vegetables, and that you avoid smoking.
Q. If you had a complete hysterectomy do you need to still see a gynecologist?
A. If you’ve had a complete hysterectomy, including removal of your cervix for reasons other than cancer, you do not need Pap smears. However, there may be other reasons for seeing a primary care doctor or a nurse practitioner – for example, annual breast exams or just having a woman you can trust with whom you can discuss your health.
Q. For women who have been violated, what is a good way to get over that aversion/fear? How can we feel empowered for a very vulnerable situation?
A. This is a tough situation, and sadly, not uncommon. I recommend finding a woman practitioner – maybe not even a gynecologist, but rather a nurse midwife or nurse practitioner who may be better skilled in providing a considerate and gentle exam. I recommend also letting your care provider know that sexual abuse is part of your history, so she can be even more sensitive. Being involved in the process of your exam, for example, asking your care provider to teach you how to insert the speculum (make sure it is warm first so it is less startling on insertion) so you can do it yourself will help you take the power back into your own hands – especially because the position on your back with legs in stirrups is already one that makes most women feel vulnerable. I hope this helps…
Q. Does having given birth affect the schedule?
A. A Pap smear is generally recommended as part of the 6-week postpartum exam; there seems to be less value in a Pap smear earlier in pregnancy if a woman has been following the recommended Pap schedule and has had normal Paps in the past. Keep in mind, though, that abnormal Paps are more common at the 6-week postpartum visit, and this can dramatically add anxiety to the often already overwhelming new momma experience. Of course, if you have a medical problem, it’s important to know, but more often than not, it’s a false positive or mild cervical change that will clear spontaneously.
Q. Does the HPV vaccine help if you have early cancer detected in a Pap and will the vaccine make a positive Pap result?
A. Getting the HPV vaccine doesn’t help prevent you having HPV or cervical cancer from any strains you might already have picked up before you got the vaccine, and also won’t reverse any changes seen on your Pap. It protects against only some of the strains that can lead to cervical cancer, but does not provide immunity against HPV types responsible for 30%of cervical cancers.
Q. Do you believe the recent FDA approval of HPV testing only (replacing the Pap as a primary screen) is the best choice for women’s cervical health?
A. I think that the data on this is still in process and we have to take a bit of a wait and see attitude. It is reasonable to continue to get a Pap according to the above guidelines until the evidence is clear one way or the other.
Q. How often do you need a Pap if you have an ovarian cyst or does it make a difference?
A. The presence of an ovarian cyst doesn’t change your Pap schedule.
Q. I’ve had years of abnormal Paps due to HPV. They have mostly shown mild dysplasia. I worry that the recommended internal exam, biopsy, and/or colposcopy every 6 months might not give my cervix time to heal. Any thoughts?
A. I’d probably continue to test to make sure everything is ok, and also make sure to follow all of the tips above for preventing cervical cancer. The cells on the cervix change and heal rapidly. The only invasive tests would be if you did need biopsies. But again, if there are abnormal cells, probably better to know for sure that they are not progressing.
Q. How much is the reduction in an annual Pap smear because of the push for Gardasil vaccine?
A. I don’t think this has had any impact on the recent Pap recommendations; the vaccine hasn’t been out long enough or been given widely enough to impact enough women to have changed the recommendations. Current recommendations are for women who have received HPV vaccines to receive the same screening as those who have not. Also it is estimated that 30% of cervical cancers would not be prevented by HPV vaccination.
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* The cervix is the opening to your uterus, kind of like the long end of a balloon without the knot in it, and is where menstrual blood comes out of, and what has to dilate to let a baby out if we’re pregnant.
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