PAP smear and High Risk HPV – Why both? How often?

Recently the American Cancer Society revised their recommendations for the frequency of PAP smears (a test used to screen for cervical cancer). Ever since liquid-based PAP smears were introduced into the market in 2002, the quality has improved. The addition of computer readers and sexually transmitted disease testing off of the same vial of solution have made modern PAP smears an excellent screening tool. We can now look for abnormal cells as well as a test for high-risk human papillomavirus (HPV). Here’s the problem. Many of us were exposed to HPV years ago but have not yet cleared the virus. How do we follow those people who don’t currently have a problem on their cervix?

The good news is that 90% of the time our immune system will clear or suppress the HPV virus and that’s the end of it. A small percentage of women remain positive and it’s those women that may go on to develop cervical cancer 10-20 years down the road. So, when you get a call from our office regarding your PAP smear we will now let you know your HPV status (if your between 30–65). If you are HPV negative that’s very good. A negative PAP and HPV tells us that there is almost no chance of developing cervical cancer within the next 5 YEARS! And guess what? Although, you still need a physical with a pelvic exam, you don’t need a PAP smear for 5 years. (This assumes that you don’t have a history of cervical problems, dysplasia, previous surgery on your cervix, etc.) If your PAP is negative and the HPV is positive that’s a different story. You will need yearly follow up and perhaps a colposcopy (microscope exam of your cervix) if the virus persists. We have no idea when you were exposed to HPV so confronting your current partner doesn’t make a lot of sense. They should be told of your exposure and realize that you have both been exposed. It is unclear if this virus affects men at this time.

Other changes in the PAP smear frequency were issued. No one under the age of 21 needs a PAP smear! Regardless of sexual activity, you can’t get cervical cancer < 21 years old. It takes 10–20 years after you are infected with HPV to develop this cancer. Again, this is rare, the majority of the time you will clear the virus. This is the reason why 21 -29 year olds only need PAP smears with no HPV testing and then only every 3 years. Although many people in there 20’s are exposed to HPV, it won’t develop into cervical cancer for a while, if ever. No need to test for HPV until you are 30 years or age. Previously, if we found you were HPV positive after an inflammatory PAP smear (ASCUS – atypical squamous cells of undetermined significance), we were instructed to ignore it by several medical organizations. That’s tough for patients and doctors, so we won’t do that, but we will follow you without treatment for as long as we can – it sometimes takes up to 3 years for women to “clear” the virus. The most important recommendation is to not over treat young women who will more than likely cure themselves. Some of our treatments can affect you ability to get pregnant and that we don’t want.

And you know what else? – you may not need PAP smears after age 65! You still need a physical exam and a pelvic exam. If you have had normal co-testing (PAP with HPV) for 10 years or normal follow up for 20 years since your cervical dysplasia (pre-cancerous changes) was treated, then you may not need PAP smears anymore. Women who underwent hysterectomy for benign disease, no longer need PAP smears either.

This is hard for gynecologists and patients to accept. We have all grown very comfortable screening for cervical cancer every year and this has provided us with reassurance. “More testing is not necessarily better surveillance” the American Cancer Society tells us. A negative High Risk HPV test is very reassuring – perhaps more reassuring than a PAP smear – so are PAP smears a thing of the past?

Stay tuned!

Doc O

p.s. a word of caution – there are 200 sub-types of HPV – only about 13 are high risk and can cause problems with your cervix. If you Google: “HPV”, be ready to read about venereal warts (HPV 6 and 11). These are two low-risk viruses that cause problems on the outside of the vagina (the vulva) and do not cause cancer. See the health library section on our web site for more information on this sexually transmitted disease.