Spokane Journal of Business

Pap guidelines change

Healthy women 30 and older should be tested every five years, new recommendations say

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Pap guidelines change
-—Staff photo by Treva Lind
Spokane obstetrician-gynecologist Dr. Jody Hechtman says the new rules can be confusing to some women.

U.S. medical groups' guidelines now call for longer intervals of between three and five years between Pap tests to screen for cervical cancer, counter to what women have heard for decades.

These guidelines also have a new provision recommending that healthy women age 30 and older have what's called co-testing to include the human papillomavirus test and Pap test every five years as preferred to solely the Pap. If only the Pap test is done, the guidelines call for those 30 to 65 to repeat the Pap once every three years.

Women 21 to 29 should be screened with the Pap test alone every three years, and younger females don't require the Pap or HPV screening at all, they say. Previously, the standards called for annual Pap tests for most all age groups of women.

A Pap test, also called a Pap smear, is a procedure that can detect abnormal cervical cells and involves the removal of a small number of cells from the cervix with a tool. Cervical cancer is caused by certain cancer-causing strains of HPV, a common sexually-transmitted infection. Most women with healthy immune systems effectively eliminate HPV infections, medical groups say, and only a small fraction with persistent HPV infection will develop cervical abnormalities that lead to cancer.

Spokane-area health professionals say they're following the newer recommendations, with the caveat that women still need annual checkups that include pelvic exams and breast cancer screening.

"It's a very confusing time for women right now as far as the Pap smear; we have very new and different guidelines," says Dr. Jody Hechtman, an obstetrician-gynecologist and partner at OB/GYN Associates of Spokane PS. "A lot of women haven't heard these guidelines because they are so recent. We spend quite a lot of time explaining why the guidelines have changed, and the sensitivity of the tests now."

Hechtman adds, "What we really still want to emphasis is that having an annual physical is still important for women. The Pap smear is just one small part of the annual examination."

Leanne Zilar, a family nurse practitioner and certified nurse midwife at the Rockwood Clinic OB/GYN Center, adds that women still need to be checked each year for factors such as breast health, and to have the pelvic exam to check for uterine and ovarian cancer, among other potential health concerns.

"Our concern is if women hear they don't have to have an annual Pap smear, they won't come in for their annual exam," Zilar says. She handles about 10 annual exams a day for OB-GYN patients.

Dr. Heather Brennan, a family doctor in Group Health Cooperative's Riverfront center here, says the guidelines were implemented last fall, but it's important for women to know they still need to keep yearly appointments.

"That's how we got women in before was they knew they had to do their annual Pap smear," Brennan says. "We have electronic medical records that tell us when the last Pap smear was, but it's going to be challenging to do that recall. We have to educate women that the yearly exam isn't just about the Pap smear."

In 2012, several prominent medical groups aligned in recommending the new cervical cancer screening guidelines. Those groups included The American College of Obstetricians and Gynecologists (ACOG), American Cancer Society, and American Society for Colposcopy and Cervical Pathology.

The recent preventive strategy is tied to better medical knowledge about cervical cancer and HPV, emerging science showing that screening intervals can be safely lengthened, and improved screening tests themselves. Many of the groups also said that limiting tests could reduce distress caused by false positives and potential harm resulting from unnecessary procedures.

For healthy females, the guidelines don't recommend that those younger than 21 have a Pap or HPV test regardless of sexual activity. HPV-vaccinated women should follow the same screening guidelines as females who aren't vaccinated, the guidelines say.

Although the prevalence of HPV is high among sexually active teens and young adults, invasive cervical cancer is rare in women younger than 21, and typically the immune system clears the HPV infection in an average of eight months, the OB-GYN college says. Generally, women now can stop having Pap smears at age 65 if they've had a healthy screening history, when previously it was at 70.

Dr. Benjamin Wood, a Rockwood Clinic OB-GYN Center physician, adds that women who have had a total hysterectomy also can stop cervical cancer screening. Under the guidelines, he says those 65 and older still need interval screening for 20 years from the point of detection of any moderate to severe cervical dysplasia, which refers to abnormal-appearing cervical cells, he adds.

So far, some older patients are reluctant to veer away from an annual Pap, he says. "If the patient isn't comfortable, I still encourage them to come in, but I tell them that frequency is not required."

He adds, "At this time, insurance providers are still paying for annual Pap tests."

Wood says the new guidelines really are targeted to the general healthy population of women, and that if they have regular screening intervals, it's rare for cervical cancer to develop.

"To me, the most important thing is this is a screening exam, just like a colonoscopy is for colon cancer," he says. "We are not trying to prevent cervical dysplasia. The vast majority of women will clear that dysplasia without any treatment, so really what the screening is looking for is people with severe dysplasia, because that's the real risk factor for developing cervical cancer."

The shift recognizes that patients under age 21 don't need the frequent screenings, Brennan says. "A good reason why is we were overtreating teenagers. If they do get those abnormal cells, most likely those issues resolve themselves. For the ones that don't, you're going to catch at a Pap smear at 21."

She adds, "The problem about overtreating at that age group is you can cause fear and discomfort, and perhaps discourage them from coming in for future Pap smears. They're more likely to need them in the future. Cervical cancer is very slow growing, and by spacing out the intervals, it's just reducing unnecessary tests."

Hechtman says she's often asked about screening requirements after the HPV vaccination, adding that there are more than 30 types of HPV. "If women have the HPV vaccine, it drastically reduces the chances of having these abnormal cells, but the screening guidelines are the same. There are many types of HPV; the vaccine covers the four most common."

Overall, Hechtman says women should encounter fewer false alarms under the new guidelines.

"What has happened is Pap smears have become more sensitive," she says. "We know much more now about the human papillomavirus, so Pap smears have become more accurate in a sense. This new science is the reason we're able to reduce the number of Pap smears required."

She adds, "In the past, women's Pap test results might have been read as abnormal because of a yeast infection or other type of inflammation. Now that is rare."

Brennan says she just started recommending the new co-testing to patients 30 and older.

"If you can go longer when you co-test, then that makes sense," she says. "If you've had the testing and come back negative for both, the chance you will have problems in the next five years would be extremely small."

However, all of the doctors say some patients still require more frequent screenings.

As an example, Wood says the new intervals aren't recommended for those taking immunosuppressive medication, such as those who have rheumatoid arthritis or have had an organ transplant.

"There are populations this doesn't apply to," Brennan adds. "It's important for women to talk to their own physicians about the screening recommendations."

Zilar says when cervical dysplasia is detected, often further screening such as a biopsy and more frequent Pap tests are recommended.

She agrees that Pap tests are more accurate today. However, she also says individual cases may vary, such as for some women 65 and older.

"I think the reasoning is if they've had all normal Pap smears, they would have been exposed at some point in their life," she says. "However, the concern some of us have is if a spouse dies or they divorce and they become sexually active again, they could be exposed to the high-risk HPV."

Hechtman says she also recommends that females in their teens and twenties have an OB-GYN assessment.

"We can do a general physical examination while they stay mostly dressed," she says. "Most STDs (sexually transmitted diseases) we can test through blood in the urine or with a physical. We can also talk about preventing unintended pregnancies."

Hechtman adds that interval Pap tests are still crucial for women starting at age 21.

More than 11,000 new cases of cervical cancer are diagnosed each year in the U.S., and about 4,000 women die from the disease, largely because they weren't screened and their cancers were caught too late.

Treva Lind
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