Less Is More: When Can Pap Smears Come to an End?

There are very few areas of medicine that come to a halt or even slow down as we age. Doctors’ visits, medications, check-ups, and those oh-so-pleasant aches and pains just keep on piling up. You need a calendar just to keep track of it all!

That’s why, when your GYN recommends throwing in the towel on Pap smears, it will likely sound somewhat confusing. But the truth is, as we age the frequency with which Pap Smears are performed can be tailored tremendously. In fact, for most of us it can be totally tossed, assuming that your cervix has cooperated and been checked and free of cancer or CIN (the precursor to cervical cancer) for many years. Here’s why.

Pap smear guidelines have changed big time in the past several years. Taking a page out of our friendly Glamour, “yearly is so out,” and every three years or in some cases, never again is so in. The American Congress of Obstetricians and Gynecologists has re-written the Pap smear guideline’s ending, and this is how this story goes…

If chapters 1–5 (that is, ages 21–64 years old) have been pretty clean and clear, once you hit the big 6-5 you can call it quits with Pap smear screening. In the land of cervical cancer screening, clean and clear refer to three consecutive negative (normal) Pap smear results or two consecutive negative co-tests (Pap smears plus HPV testing) within the past 10 years.

To top it all off, the most recent Pap smear test must have been done in the past five years. And while words like co-testing may sound like Swahili, just knowing what to ask your GYN when it comes to Pap smears and when to ask these questions will make sure that they don’t play on and on and on… (#BrokenRecord)

If chapters 1–5 (a.k.a. 21–64 years old) were not totally clean and clear, then you might have to do some editing before you can close the Pap smear chapter. The exception to the “once you turn 65 years old break-up rule” are women who have a history of abnormal Pap smears/cervical screening in the past, specifically a history of CIN 2, CIN 3, or adenocarcinoma in situ. (Think of CIN as a staircase: the higher you get, the closer you are to cervical cancer.) If you fall into this group, you need 20 years of screening after the resolution or treatment of the CIN 2 and beyond, even if it takes you past the 65-year-old mark.

And while there are likely some terms in here that are making you do a double take (a.k.a. CIN and adenocarcinoma in situ), knowing the specifics is really secondary to simply having the knowledge to start the conversation with your doctor. For example, if you know for sure that you have never had any or all of the above (CIN 2, CIN 3, or adenocarcinoma) and your doctor is still performing Pap smears on you at 67…it’s time to start asking questions.

If you had a hysterectomy before reaching the magic 6-5, you might be able to bid Pap smears adieu at an even earlier age. In fact, women who had a hysterectomy with removal of the cervix and never had a history of CIN 2, CIN 3, adenocarcinoma in situ, or cancer can stop Pap smears immediately following the removal of the uterus. Those that had a hysterectomy with removal of the cervix and have had a history of CIN 2, CIN3, adenocarcinoma in situ, or cancer must continue with Pap smears. Again, you will need 20 years of screening after the resolution or treatment of the CIN 2+ before you can call it quits.

Last, if you had a hysterectomy and kept your cervix (a.k.a. a supracervical hysterectomy), you can’t bid your Pap smears a fond farewell until you hit 65 (or longer, depending on your history).
And while you might be breaking up for good with your Pap smear, let us be very clear that you are not saying goodbye to your GYN. There are many more topics and tests that are checked at your yearly visit (as well as a good old fashion chat!). Maintaining an ongoing relationship with your GYN is important—remember, you have many reproductive organs other than your cervix!

Can We Call a Cease Fire to Cervical Cancer? The HPV Vaccine

Admission….despite endless years of schooling, training, and then more training, there is a lot that doctors don’t know. We wish we did, because inherently it is in our nature to heal and to fix, but unfortunately, there are many questions in medicine that remain unanswered. Despite our fancy tools (and trust us, there are a lot!), we still lack that crystal ball. And not only can we not diagnose everything, but we also don’t always know why somebody gets a disease. The latter is super frustrating.

How does the woman who eats only organic, exercises daily, and has never smoked get breast cancer? How does the man who has never eaten at McDonalds and spends two hours a day on his treadmill have a heart attack? It simply does not make sense. Therefore, what we do know and what we can stop we want to share or, rather, shout as loud as possible! We want to make sure you know what you can do to decrease your risk, to stay healthy, and to prevent a bad event.

While most cancers are not preventable, for the most part, cervical cancer is. The majority of cervical cancer is caused by a virus (the human papillomavirus, or HPV): not the same virus that causes the common cold or a stomach bug but a virus that can infect the cervix and, if not treated over several years, lead to cervical cancer. Now, just like there are many different types of viruses that can ultimately lead to the same end point (e.g., the common cold), there are different strains of the HPV virus (120 to be exact!). And again, in the same vein as the common cold, some strains are going to knock you on your behind more than others.

So while there are 120 different viruses, about 40 HPV types (medically called genotypes) are sexually transmitted, and 13 have been shown to cause cervical cancer. And to whittle it down even further, about 70% of all cases of cervical cancer are caused by two HPV genotypes, 16 and 18, and 90% of genital warts are caused by HPV genotypes 6 and 11. Therefore, if you can avoid ever being infected with HPV, you will nearly eliminate your chances of getting cervical cancer. Additionally, because regular Pap smears will almost always pick up abnormalities on their way to cervical cancer, if you do get or are infected with HPV and develop cervical abnormalities (a.k.a. abnormal Pap smears), good screening and frequent visits to your gynecologist can ensure a bad thing doesn’t get worse.

But pap smears and the further testing that is required (colposcopy, LEEP, and the cold knife cone) when one is abnormal can be really scary (these procedures can translate into taking off a piece of your cervix). Additionally, it can become a tedious chore (you have to be seen every six months, and who has time for that?). If cervical surgery is required, it can put you at risk for a preterm delivery in the future. By avoiding an infection with HPV, you could avoid a trip on this unhappy merry go round. Although abstinence would do the trick, while we are mothers, we are not ignorant! From teens on up, girls are going to have sex; we do our best to educate and advise, but it’s going to happen. Therefore, the next best thing to do is to prevent the transmission of HPV. This can be done by a vaccination—just as we prevent the measles, the mumps, and polio through a vaccine, we can now prevent the spread of HPV. By vaccinating girls (and boys!), ideally before their first sexual encounter, we can significantly reduce the incidence of cervical cancer, anogenital cancers, oropharyngeal cancer, and cervical warts (now, that’s one heck of a shopping list—not one thing on there we would like to acquire!).

So currently there are two vaccines that have been approved by the FDA to work in preventing HPV infection. One protects against the big four genotypes of HPV (6, 11, 16, 18), while the other only protects against two genotypes of HPV (16 and 18). The latter is only approved for administration in females while the former (four) is approved for administration in females and males. The good news is this: if either is given in the right way—three doses, six months apart in girls (and boys) between the ages of 9–26 years old before they have been sexually active—it works really well. Under these guidelines, it’s nearly 100% effective.

In order to hit all these points, you need to start vaccinating girls (and guys) at a young age. In fact, the target age to start is 11 or 12 years old. If you miss the window and sexual activity starts before you start vaccinating (or you don’t start vaccinating until a later age), it is still worth a shot! While you may have already been infected with HPV, it could be just one strain (let’s say 6). That means that, while the vaccine won’t protect you from 6 or the goodies that come along with it (hello, genital warts), it will protect you from other strains (those that cause cervical cancer). So roll up your sleeve, and start the series, because it is still worth it.

Points worth mentioning…the vaccine can be given to girls as young as 9 and as old as 26; the window is large enough that you shouldn’t miss it. If you are late for a shot (say, you forget to come in 1–2 months after the first dose and roll into your GYN at month three) you are still okay to proceed. Once you start the series, no matter how long it is paused, you can finish it.

The only exception is pregnancy. While there is no definitive data to show that the vaccine is harmful in pregnancy, OB/GYNs recommend waiting to finish the vaccine series until your nine months are up. Breastfeeding women have the all clear to take the vaccine, as the HPV vaccine is inactivated (no live virus).

It’s a small price or “prick” to pay to protect yourself against cervical cancer and genital warts. Neither is pleasant, and we can assure you won’t be missed by anyone. While you still need Pap smears and still need to visit your OB/GYN for checkups, you can check some pretty unpleasant gynecologic conditions off your list if you follow the schedule. Despite the negative hype, vaccines are sort of amazing; we don’t get polio, we don’t get the measles. Now (if done in the way it’s prescribed), we won’t get HPV. This is just another example of how preventative medicine can be effective. So take yourself or your daughter and/or son to the OB/GYN. You don’t want to miss your window, for many women won’t get another chance.