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!

Pap Smears, Pelvics, and Plenty of Good Advice

Most of us associate Pap smears with the OB/GYN. A light goes off in our head, usually around the same time every year, that says, “You need a Pap.” After you make sure to get a bikini wax and shave your legs (we do it too, but we promise your GYN does not care!), you book your appointment, and off you go. When you get there, you might be surprised when your OB/GYN, or GYN-O, as we know many of you like to call us, conducts nothing more than a pelvic exam, a physical exam, and a good old-fashioned chat. You may be thinking, has she/he developed a case of memory loss and forgotten that I need a Pap? And although we may be super tired from that delivery the night before (yes, we work a lot of nights!), no, we have not lost our minds. Pap smear guidelines have changed a lot over the past 10 years, and most women no longer require yearly Pap smears. Pap smear recommendations change faster than Kim K changes husbands. It’s sort of hard to keep up. And we don’t expect you to. But what we can tell you is that things have loosened up a lot (unlike Kim K’s clothes!). We are less aggressive with what we biopsy and what we remove. We Pap less frequently, and we watch and monitor a lot more. And while we want to see you and hear what’s up in your life, we want to see your cervix a bit less.

For starters, we no longer perform Pap smears on anyone under the age of 21 (regardless of when they started to have sex). While it is a good idea to visit a GYN at about 15 years of age, Pap smears are no longer part of this visit. Data demonstrated that testing such young women did more harm than good (meaning invasive procedures due to abnormal results that would have gone away on their own). Furthermore, after the first Pap smear (if all looks good), we won’t invite your cervix back for another three years. Pap smears can be performed every three years in women between the ages of 21–30 if they are totally negative. And get this: if you are between the ages of 30–65, your Paps are normal, and your HPV (human papillomavirus) test is negative (called co-testing), then we don’t need to see that cervix for five years! If you opt for just the Pap smear, then we need to see you every three years. While we still want to see you and dish on what happened last year, we don’t need to do a Pap smear if the above guidelines are met. Once you start to collect Social Security (age 65), if you have never had any high-grade cervical abnormalities (HGSIL), you can say adios to another Pap smear. The only time the above rules don’t apply (at all) are women who are HIV+ or have severely weakened immune systems. Furthermore, if your Pap smear has been abnormal and your biopsies have come back abnormal, you will be on a totally different plan.

The screening intervals have been spaced out, not because insurance companies are trying to save money (although that is usually the right answer) but because, in reality, most cases of cervical cancer occur in women who were never screened or who were not screened well—not women who were screened by guidelines. If you follow the rules, it’s very rare that you will get burned. Cervical cancer development is slower than the slowest tortoise in a tortoise-and-hare race. It usually takes years and years and years (about 10) for an HPV infection (the most common precursor) to develop into cancer. In many ways, HPV and cervical abnormalities/dysplasia/cancer are the opposite of the chicken and the egg. While both are always seen together, in this case, we know who came first! HPV, specifically subtypes 16 and 18, cause the majority of cervical issues, including cancer. Interestingly, while most of us will contract HPV in our teens/early 20s (about 70% of sexually active college-age women have or have had HPV), most of us will clear it by the time we hit our middle to late 20s and 30s. Most women younger than 21 will clear the HPV infection in eight months. In fact, the majority of HPV infections have said hasta luego two years after they landed on your cervix.

It is when we hit the big 3-0 that things start to change and the HPV infections that are there are more likely to stay there. It is for this reason that HPV co-testing is only done in women older than 30; by this point, if it is still present, we are way more concerned. HPV testing can also be used to sort out if a mildly abnormal (medical term “ASCUS” on the Pap smear report) needs to be investigated further. If the HPV is positive, the situation is way more serious than if the HPV is negative.

Many of us are grade obsessed, number fanatics, and goal oriented. We are not much different when it comes to our health. So here is what those grades mean. Generally speaking, Pap smear reports can be thought of as negative (a.k.a. normal) or abnormal. This may be the one time you want to be negative! The abnormals are like college kids living in New York City after they graduate. That one-bedroom apartment is subdivided in a million different ways to house many and cut costs. Pap smear reports will report on a bunch of things. However, what you are most likely to hear about are the squamous cell abnormalities (these are the main cells that make up the cervix and can become cancerous!). Squamous cell abnormalities can fall into one of the following categories:

  • Atypical squamous cells (ASCs of undetermined significance = ASCUS or ASC. We cannot rule out more serious abnormalities)
  • Low-grade intra-epithelial lesions (LGIL or CIN 1)
  • High-grade intra-epithelial lesions (HGSIL or CIN 2 or CIN 3).

As you walk up the stairs, the abnormalities become more significant. You are climbing closer and closer to cancer. It is for this reason that the interventions become more and more serious; you may go from an office-based biopsy (medically termed colposcopy) to a procedure where we cut out a portion of the cervix (LEEP or cold knife cone). While Pap smears have the ability to tell you even more than we listed above (such as cellular changes suggestive of an infection, the presence of endometrial cells and glandular cells), these are much less likely. We have backed off big time with the screening, not because we want to see more badness, but because we want to prevent badness. Excisional cervical procedures increase the risk of preterm labor/preterm delivery. The cervix is there, at the end of the uterus, to keep things closed until it’s go time. If there is only a sliver of cervix left, it is going to have a hard time doing its job. By avoiding unnecessary procedures in young women who will most likely clear the HPV infection and the cervical cell abnormalities, we avoid future fertility issues.

Breaking news: if you are young enough (we are not!) to have received the HPV vaccine, that does not mean you don’t need Pap smears or cervical screening. HPV vaccine is like a really good insurance policy. However, it doesn’t mean that you can’t be caught in a bad flood or have a house fire. You still need cervical screening and should follow the same age-appropriate guidelines.

The yearly trip to the OB/GYN is usually met with the same feeling we have when going to the dentist. Yes, you have to do it but are always a little afraid to hear what they have to say. Most of the time, it’s good. You get the all clear and don’t need to worry until the next year. Even if you don’t need that Pap smear, you do need to go to the doctor. While we don’t clean teeth, we don’t check your vision, and we don’t check your hearing, we do make sure that your female organs are A-ok. Make sure when you do get a Pap smear you write down the results and keep it with your most treasured items (Grandma’s earrings, Mom’s ring, your first lock of hair). That way you will not only know what’s up, but also if you move or move away from your OB/GYN, you will know what happened in the past. You don’t need to understand the grades or know when Kim gets divorced and remarried (that is, the Pap smear guidelines change), but you should be the master of your own medical records. It will cut down on a lot of unnecessary testing.

Our Yearly Date: We Name the Place, You Name the Time

When your Google calendar and iPhone reminder flash GYN appointment, time to get a bikini wax, you probably think to yourself, Ugh, maybe I can come up with an excuse to cancel. And after a couple times of “I have a cold. I have a work event,” and simply, “I totally forgot,” you finally force yourself to come in and see us. The annual GYN exam is sort of like jury duty. You can run, but you can’t hide. At some point, your GYN needs will catch up with you, and you will have to sit in our “chair.” And while we are certainly not asking you to judge anything, we are asking you to recap your past year(s) and think about your future. Am I ready to have a baby? Should I be on contraception? Do I need a Pap smear, STD screening, or a breast exam? We want to break it all down and make sure that you are doing the best things for your body.

First things first. Your trip to the GYN should be yearly (at the least). Although acute issues (UTI, vaginal discharge, vaginal itching, abnormal vaginal bleeding) may require an immediate trip, the routine stuff doesn’t need to be dealt with more than yearly. And while this yearly meeting may no longer include a Pap smear, it should most certainly include a discussion on previous Pap smears and future Pap smear screening. The recommendations have been modified, and women in their 20s and 30s without a history of abnormal Pap smears may no longer need yearly cervical checks. However, that doesn’t mean you don’t need to check in with your OB/GYN. Despite the common misconception, we GYNs do a whole lot more than Pap smears!

This annual aloha should first and foremost include a lot of talking. We will discuss eating habits, exercise, sleep patterns, work-life balance, stressors, medications (both prescription and supplements), and relationships. Have your parents, siblings, or grandparents acquired new diseases? Have there been new genetic findings in the family? Additionally, it is super important to address all things sex: sexual health, sexual orientation, and sexual activity (nothing is off limits with your GYN!). We also need to address drinking, smoking, and partying behaviors. While we are totally down with you having a good time, we want to make sure that you are safe. Lastly, no visit to the GYN would be complete without a period pow-wow. What’s going on with your period? What’s the cadence of the bleeding? Are you spotting, and are you having crazy cramps? Abnormalities in your period can shed a lot of light on what’s going on with your ovaries and uterus.

When it comes the exam part, it’s important to have your blood pressure checked and your height and weight measured every year. We also recommend a yearly breast and pelvic exam. For those who are sexually active, STD screening is a good idea (age and risk factors are used to determine whom to screen, for what disease, and how frequently). In women with a strong family history or a personal history of a particular condition, we may consider checking certain blood levels such as cholesterol and lipids (fat). If other symptoms arise—problems hearing, seeing, or headaches—we will address them with the appropriate tests. In many ways, the visit is a debrief, a review of what went well and what didn’t go so well the year before. Together, we can plan on how to attack your next year head on.

Without trust, you won’t be comfortable bearing it all—which is big-time important in making sure you stay healthy. Like all good partnerships, your relationship with your GYN of choice needs to be built on trust. Unlike the jury you may be called to sit on, we are totally not judging you (for what you do/did or if you waxed/shaved!). We want to take the evidence you present us with and make sure you are not doing your body or your brain any harm. Some actions can stay on your permanent record, no matter how good your lawyer is. Let us make sure your record stays clean!