Medical Mondays 2Dr. Pat likes to work as a collaborative physician. Her patients, she believes, will be her best partners in providing diagnostic information—as long as they are asked the right questions. She also believes in consulting with the best medical minds on issues that require specialization or unique clinical experience.

This week, during Cervical Health Awareness Month, she calls upon the expertise of Dr. Elizabeth Poynor to clarify the recent recommendations on how often a woman should get a Pap smear. Dr. Poynor a member of the WVFC Medical Advisory Board, is a practicing gynecologic oncologist and pelvic surgeon in private practice in New York City.  She is an Attending Surgeon at Lenox Hill Hospital in New York City.  

 

Dear Dr. Pat:

I am a 47-year-old woman who had an abnormal Pap smear and high-risk HPV when I was 35. I had a LEEP Cone biopsy for “CIN2″ or moderate dysplasia then. I had a few other slightly abnormal Pap smears until I was 40. Since then, all of my Pap smears have been normal. I am not married; I have had long-term relationships and have mostly used condoms. I have been HPV negative for two years now. Recently my gynecologist told me that I needed a Pap smear every three years, based on new recommendations. This makes me very anxious.  What do you think of these new recommendations for a woman like me?

Monica

______________________________________

 

Dr. Poynor Responds:

Dear Monica:

The ability to screen for precancerous changes in the cervix has been a great triumph for women’s health. Indeed, invasive cervical cancer is a relatively uncommon condition in areas where Pap smear screening has been employed; however, cervical cancer remains a leading cause of death in women in areas of the world where Pap testing is not available to them.

For many years the once-yearly Pap testing involved only taking a small sample of cells from a woman’s cervix and looking at them under the microscope in order to determine if precancerous changes exist. Within the past ten years we have also begun to employ more extensive testing of these cells; the presence of the human papilloma virus (HPV), which causes the vast majority of cervical cancers, can also be determined with this sample of cells. While not many women who have the high-risk strains of HPV will develop cervical cancer, the presence of high-risk HPV is necessary for the majority of cervical cancers to develop. Women who have high-risk HPV present on their Pap smears are thus at elevated risk to develop significant precancerous changes of the cervix, and this invasive cervical cancer.

Over the past many years since the Pap smear was first described in 1928, we not only understand the natural history of precancerous changes of the cervix, but we also have better methods to collect and analyze cells from the cervix, and we better understand the molecular biology of the cervical cancer and its precursors. All of this leads to a shifting of guidelines and screening recommendations. Because of this knowledge, Pap-smear screening guidelines have been relaxed over the past few years.

No one can make specific recommendations to you without completely reviewing your medical records, previous Pap smears, and a physical examination. For some women—even those with previous pre-cancers of the cervix—less frequent Pap smears will be recommended. I would encourage you to speak with your physician and let her know your concerns. Even if she continues to recommend less-frequent Pap smears, you still should have your yearly visits with her along with your physical examinations. You should continue to report to her any abnormal bleeding, pain, discharge, or concerns.

You should continue to have a dialogue with your physician about general health concerns, as well as updates to recommended screening guidelines as they evolve. For example, it was recently reported that in some women, current HPV infections may actually be due to remote exposures. Stay tuned for more on the understanding of HPV and cervical cancer.