PAP test: More is not better!

The recommendations for cervical cancer screening appears to be changing rapidly in the last decade. This will cause more confusion among physicians and patients as well. It is important to stay aware of the latest research and findings.

When in comes to PAP tests, more is not better. This can be clearly observed if we compare two countries: USA and Netherland. American women undergo 3 to 4 times as many Pap tests as their Dutch counterparts. Despite the vastly different screening rates, the overall mortality data suggest no substantially different trends between the 2 countries. This suggests that more frequent screening for cancer of the cervix using PAP testing is not necessarily more beneficial.

So what make physicians do more than a patient needs? Most physicians will follow guidelines. With more research and evidence guidelines change and some physicians takes longer to catch up than others. Some physicians are resistant to change: “We have always done it this way and it always worked”. Others believe screening more often would not harm, a belief contradicted by evidence. Frequent PAP testing can result in more anxiety and unnecessary interventions, additional cost to the patient and system.

On the other hand, all patients I diagnosed with cervical cancer had not had a PAP test for the last 7 years or more. I have yet to see a patient with cancer of the cervix who had recent normal PAP tests. So less can be dangerous.

Here is the latest, all you need to know in a nutshell:

Begin screening at age 21 regardless of sexual activity.

Younger than 21? There is no need for PAP or HPV testing regardless of sexual history. Cervical cancer is rare and HPV is very common in this age group.

Between 21 & 29? PAP is needed every 3 years. HPV testing is not needed.

Between 30 & 65? You need both PAP and HPV testing every 5 years (preferred) or PAP alone every 3 years (acceptable).

Older than 65? No need for PAP testing if you never had cervical dysplasia (precancerous cells) in the past 20 years.

Older than 65 with new sexual partner? No need for PAP testing

Following a total hysterectomy (surgery to remove uterus and cervix)? No need for PAP testing

Following a partial hysterectomy  (surgery to remove uterus and retain the cervix)? Follow the same recommendations as if you did not have a hysterectomy.

Following the HPV vaccine? Follow the same recommendations as if you did not receive the vaccine.

It is worth noting that the above guidelines are for general screening and do not address high-risk populations as patients with a history of cervical cancer, exposure in utero to diethylstilbestrol, or those who are immunocompromised (example: patients with HIV/AIDS or organ transplant).

The above concerns performing a PAP test. Every woman will still need an annual pelvic examination (some call it ‘vaginal exam’, ‘speculum exam’, ‘bimanual exam’, and the misnomer ‘PAP test’) wether a PAP test is being obtained or not. Such exam is essential to assess the vulva, vagina, cervix, uterus, tubes and ovaries for any masses or abnormalities.

You might be interested in reading:
HPV: Can a sexually transmitted virus cause cancer?
HPV vaccine for womyn over 25 and for men too

Categories: Health

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8 replies

  1. A very usefull information presented in a reader-friendly way.
    Thanks Dr. Hasan

  2. I have to disagree – routine pelvic exams are not recommended in the UK, Australia and in many other countries, they are of poor clinical value in asymptomatic women and expose women to risk, even unnecessary surgery. I’d never permit one…your Dr Carolyn Westhoff is trying to raise awareness in the States, she believes this exam partly explains your high hysterectomy rates, 1 in 3 women by age 60 – 600,000 every year – so much for lifelong surveillance and interference on the symptom-free female body! There is also no evidence to support routine breast exams, but they lead to excess biopsies, they’re not recommended either in many countries.

    Also, you might be interested to know the Netherlands is about to move with the evidence yet again and introduce a new program, 5 hrHPV primary triage tests offered at ages 30, 35, 40, 50 and 60 and ONLY the roughly 5% who test positive will be offered a 5 yearly pap test….they are the only woman who have a small chance of benefiting…the vast majority of women will be HPV negative and not at risk from cervix cancer, they don’t need pap tests, biopsies or anything else and will simply be offered the HPV program or they can test themselves using the reliable Delphi Screener. (also in use in Singapore, Italy and elsewhere) Those negative and confidently monogamous or no longer sexually active can forget all further testing. This program will greatly reduce pap testing, biopsies, laser treatments on not-at-risk woman (most of us) and is more likely to prevent these rare cancers by identifying the small group of HPV positive women. This will not only spare most women the unpleasant and risky burden of unreliable pap testing and false positives, but will better protect their health from potentially damaging excess biopsies and over-treatment which can cause reproductive, general and psych health problems. (cervical incompetence, premature babies, miscarriage, high risk pregnancy, the need for c-sections & cervical cerclage, cervical stenosis, infertility, etc)
    The Dutch have been able to focus their program on what’s best for women and the best use of scarce health resources and have continued to move with the evidence. Sadly, in many countries political and vested interests control and benefit from these programs and defensive medicine also encourages excess.
    As a low risk woman my risk of cc is near zero, the risks were too high for me and I have always declined testing. I would never consider a pap test anyway without first establishing my HPV status with the Delphi Screener, there is absolutely no point having a pap test if you’re HPV negative and most women are HPV negative….combining HPV and pap testing is unnecessary and unhelpful – the HPV test should stand alone as the primary screening test.

    This testing did not need to cause very high levels of distress, fear and harm, there were always better ways of dealing with this rare cancer, now there is absolutely no excuse…
    Sadly, no country in the world has shown a benefit pap testing those under 30, but all have evidence of harm, young women produce the most false positives. Also, HPV primary testing is also not recommended as 40% would test positive when most are transient and harmless infections that will clear by age 30. Those countries who don’t test young women have the same number of very rare cases in those under 30 as countries who do…sadly, testing just results in lots of harm – the same cases occur whether you screen or not. The Dutch and Finns are simply advised to see a doctor with persistent and unusual symptoms.
    The Finns also follow the evidence and avoid harmful excess – they have the lowest rates of cc in the world and send far fewer women for colposcopy/biopsy, they offer 6-7 pap tests, 5 yearly from 30 to 55 or 60.
    Change in many countries will only occur when women start refusing the excess and demand smarter testing and reliable self-test options like the Delphi Screener and Tampap. The truth has been buried for decades and there has never been any respect for our legal right – informed consent – that must change.

    • I agree with most of what you wrote, and you raise very important points. Thank you for reading and responding elaborately.

      However, I don’t believe there is a “buried” truth. It takes decades of research to reach the best practice and the guidelines for HPV and PAP testing have undergone many changes recently. I do anticipate that more changes will come that would reflect what you have mentioned above. It makes sense. However, until then we are obliged to follow guidelines because they usually include the best practice using our current knowledge.

    • These are new recommendations for when to do a pelvic exam –> July 24 2012: Pelvic Exams: New Guidelines for Asymptomatic Women:


  1. HPV: Can a sexually transmitted virus cause cancer? « Dr. Hasan Abdessamad
  2. HPV: Can a sexually transmitted virus cause cancer? « Dr. Hasan Abdessamad
  3. HPV vaccine for womyn over 25 and for men too « Dr. Hasan Abdessamad
  4. HPV in Lebanon: Silent disease empowered by silent society « Dr. Hasan Abdessamad

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