Health Articles:

You May Not Need a Pap This Year

By Dr. Shahrzad Z. Orona

New Guidelines for Female Annual Exams: A Look at the Pap Test and HPV

The Pap (Papanicolaou) test was introduced over five decades ago and has since become perhaps the most successful screening test in history. The Pap is a screening test that takes cells from the cervix to look for abnormal changes. It has led to a 75% reduction in the incidence of cervical cancer in the United States .

The human papillomavirus (HPV) has been shown to be the cause of this preventable cancer. HPV is a skin cell virus and is the most common sexually transmitted infection. There are more than 100 types of HPV. The types that infect genital skin do not generally infect skin cells on other parts of the body. HPV is transmitted by skin-to-skin contact; this can occur even when condoms are used. The HPV types that infect genital skin are grouped into low-risk and high-risk types, according to their association with cervical cancer. The most common types that infect genital skin (and that thus increase the risk of cervical cancer) are the high-risk types. Most people will have HPV at some point, but cancer is rare. People can be infected with more than one type of HPV at the same time. The virus generally causes no visible change and is usually cleared by the immune system.

Some people with certain low-risk HPV types will develop skin growths called condylomas or genital warts. Genital warts are not at risk for becoming cancer cells.

The guidelines for getting tested for cervical cancer are as follows (with some of these being new):

• Young women should get screened at age 21 or three years after the onset of vaginal intercourse, and should then get yearly Pap tests until age 30.
• If normal, follow up yearly for annual exam and Pap.
• If abnormal in anyway follow up with HPV testing, follow-up Pap, and possibly colposcopy (microscope that looks at cervix).
• Women over age 70 who have had three satisfactory, negative Pap tests in the preceding 10 years no longer need testing -- American Cancer Society recommendation ( ACS )—although the American College of Obstetricians and Gynecologists (ACOG) has not set an age limit due to lack of sufficient data and leaves this up to the patient and practitioner. Please note these patient still do require annual exams; however, the Pap test does not need to be included.
• Women who have had a total hysterectomy for benign disease should not be tested for HPV, because they no longer have a cervix and therefore do not require screening for cervical cancer
• Women 30 and older, should have a Pap and be tested for HPV.
• If both test are normal, a Pap test does not need to be performed for 3 years. Again keeping in mind that the annual exam still needs to be performed yearly.
• If abnormal cytology and/or HPV, follow-up and colposcopy will be recommended.

The FDA approved the test specifically for women 30 and older because in younger women high-risk HPV is extremely common but is usually cleared by the immune system.

The purpose of adding an HPV test to screening is to determine whether a woman has the objective risk factor (i.e. HPV) for cervical cancer and to allow for targeted screening. Combined screening will find disease missed by the Pap test alone and create opportunity for closer surveillance of women at risk (as determined by a positive test for high-risk HPV). It will, thus, allow a safe reduction in screening frequency in women who are negative for high-risk, HPV, as they have a very low risk of cervical cancer.

The combination of the negative Pap test result and a negative HPV DNA test is considered to have a negative predictive value of greater than 99%. This means that we can safely assure those women who have double-negative results (normal Pap and no HPV present) that they have virtually no risk of cancer or precancer on their cervix now or for the next three years.