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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!

Cervical Mucus: A Marker for Ovulation and a Must for Pregnancy?

For many of us, there is nothing more off-putting than the thought of tracking your cervical mucus day after day, month after month. It’s not easy knowing what you are looking at, why you are staring at your underwear, how long this exercise needs to go on, and what you will do with this information.

Egg white versus watery, creamy versus sticky. Are we baking a cake or making a baby? While in many ways, it’s sort of a little bit of both, tracking your cervical mucus is not a prerequisite for detecting ovulation or having a baby. The changes that occur over the course of those approximately 26 to 36 days can provide helpful hints on both if and when you are ovulating. However, while it is important and does serve as a reservoir for sperm, it is much lower on the fertility pecking order.

The cervix is the lower part of the uterus (a.k.a. the womb); it is the conduit between the uterus and the vagina. When not pregnant, the cervix measures about 2 to 3 cm. During pregnancy and particularly as its end is near, the cervix begins to shorten, thin out, and ultimately dilate. Think of the cervical mucus as the pond at the base of this conduit. It serves as a reservoir for sperm by providing it with nutrients and safety for several days (up to five, to be exact!). While the majority of sperm is in the tubes minutes after ejaculation, the pond holds on to the stragglers. Over the course of about three to five days, sperm is released into the uterus and the tubes, hoping to meet its mate and make an embryo.

Much like the variability in the uterine lining during the approximately one-month-long menstrual cycle, the cervix and its mucus also go through a host of changes. After bleeding has stopped, the cervical mucus is usually scant, cloudy, and sticky. This lasts for about 3–5 days. What comes next is the stuff that you are taught to look for.

In the three to four days leading up to and after ovulation, the mucus changes to clear, stretchy, and fairly abundant. Following ovulation, the cervix becomes somewhat quiet, and cervical discharge remains scant. The “stage hands” behind the curtain setting the scene for the changes observed in cervical mucus are estrogen and progesterone production. Altering levels of estrogen and progesterone results in major modifications in mucus content and production.

If the cervix falls short on producing and maintaining its reservoir (a.k.a. mucus), problems can arise. However, while cervical factor infertility used to be considered a serious and real problem, today the cervix and cervical mucus production are hardly ever the cause of infertility (only about 3% of infertility cases are due to the cervix). Because of this, tests to evaluate the cervix/mucus are no longer needed.

Traditionally, a postcoital test (nicknamed the PCT) was performed to seek out cervical dysfunction. Now, picture this: fertility doctors used to obtain a sample of cervical mucus before ovulation and after intercourse and check it out under the microscope. They were looking for the presence (or absence) of moving sperm. Although this is sometimes used in couples that cannot have a formal sperm check, it is otherwise one for the ages. The subjectivity, poor reproducibility, and very inconvenient aspect of it have eighty-sixed the PCT in the land of fertility medicine.

In cases where the cervix has been previously cut, burned, or frozen, a narrowing of the cervical canal can arise (medically called cervical stenosis). Cervical stenosis can make procedures that require access to the uterus difficult (picture trying to pass something through a really narrow hole—it doesn’t fit!). Therefore, prior to undergoing any fertility treatment, a cervical dilation (that is, a widening of the cervix) may be required. This allows your doctor to then put sperm or embryos back into the uterus.

However, while the narrowing can make infertility procedures somewhat more challenging, the width is not what’s causing the entire problem. Cervices that have been exposed to trauma like surgery can have difficulty producing mucus. No mucus equals not much of a place for the sperm to hang out (cue IUI or IVF).

While the cervix may not be playing the feature role in the fertility play, it does serve as an important role. In addition to providing a respite to sperm, it also helps maintain a pregnancy to term. When a cervix shortens or dilates before time’s up, it can lead to a snowball of negative events: preterm labor and preterm delivery, to name a few. Bottom line, it’s not only a reservoir but also a roadblock. Until that nine-month mark has passed, it should not let anything out that front door!

Think about your cervix and cervical mucus but don’t drive yourself nuts. Yes it is a way to confirm ovulation but no it’s not the only way. While we are advocates of knowing your body and being aware of what’s going on with your cycle, obsessing over what’s going on won’t change what’s coming out. We have ways to get the sperm to meet the egg even if the cervix isn’t cooperating!