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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13 replies

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

    • Doctor-friendly way. Get ‘em trained young and the pattern sticks. Money flows. A life or two might be saved, who knows.

      At age 21 begin screening regardless of sexual activity? Oh? If no sex, no exposure, so why screen, why treat, why waste money? No exposure means negative result.

      No need for “base” screen like mammogram (which I also question how the mashing can damage encapsulated tumors. If aggressive, tumor just got head start. New, 3-D ultrasound should be the cheaper, preferred, smarter, less-risk method of mass screening).

  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.

      • There is buried truth. Any professional who has come out against these tests, citing truths noted above has been buried, along with their facts, by peer review and like pressures out of professional relevance. This has occurred when paps were instituted and has continued to this day whenever a doctor strong with conviction & courage speaks out. Keep us stupid, keep us in line at the door on the yearly date, keep the money flowing, keep asking every question imaginable about sex practices that men aren’t asked, that men aren’t routinely tested for since there’s no pain-tolerable method, keep us & our real advocates, our partners outside, above all keep the status quo.

        And for those others, keep taking pictures of us naked, keep molesting…any doctor in this field woman or man can take advantage of this subjective exam where every part of one’s genitalia is made available to “ensure” we’re healthy. Honestly, we are sexual beings, moreso than men. How many areas “palpated” cause us to involuntarily arouse, engorge, and lubricate? Want me to elaborate? How many women utterly hate these exams not only for the pain, embarrassment (industry word to excuse the whole thing while putting it on backs of women), or feelings of being sexually violated? The rectovaginal exam that palpates both sides of our cervical fornix at the same time (triggers!)(the full feelings), while pressing in via perineum and top of abdomen puts pressure (don’t forget doctor’s thumbs bumping!) on our clitoris (trigger!)(after thorough labial exam), and don’t forget our G-spots (trigger!); while all the while knowing we have four different nerve groups (one which bypasses the spinal cord) all transmit the go signal to our brains. Really now…just take those cleansing deep relaxing breaths. Did I mention the breast exam where our nipples are somehow pinched by those doctors who do the most “thorough” pelvic exams? As for nurses? Those in the room are assistants, not RN’s, and these depend on the doctor for their job. Hardly objective. And unless they have a sexual attraction they don’t pay attention. Say “stop.” Doctors/nurses rarely listen as “…you’re almost done. you want me to finish this so you’ll know if you have cancer or not don’t you? it’s just uncomfortable not painful…your imagination”

        Let’s see how quickly prostate exams would change if men were carefully eyeballed, lubed, prestretched, touched, then penetrated, fingered rectally until they were fully erect and ready to ejaculate; feeling like finger puppets. While laying on a table almost waiting to be mounted.

        I’m not accusing you of being in this group. However, for how women have been treated these things need to be put to light, discussed, and changes made. No “dialog” to further BS women back into the same.

        I am total agreement with dlb2. Finally, after doing extensive research on this matter, I began asking my gynecologist questions. He never knew it, but he was confirming everything dlb2 indicated. There’s no need to rehash statistics; already done. However, my guy further discussed how my genes would’ve given me cancer by now if it were meant to be. Wow! Revealing indeed. So why continued naked exams?

        Routine pelvic exams in asymptomatic women are useless. Nothing can be felt unless the woman is exceptionally skinny and in good shape. No wonder why all the screening is “mandated” to begin “yearly” or even every six months in women 18+. I recognize changes have been made here in age recommendations. However, a young woman going for birth control will be fully, thoroughly screened although this is against ACOG guidelines. In the US, cries for cost containment and improvements for/to patients are ignored in the face of this easy (for the provider), cash cow, and prestigious job. Imagine walking into your clinic seeing a waiting room of women waiting to strip for you. While some will have disease, most won’t and will be there like trained animals one finds at local zoos. Interestingly, husbands who tend to ask a lot of questions are deliberately kept out. The nurses seem to be more rabid in this than the doctors are. This too has changed but not in every clinic. There is NO FULL INFORMED CONSENT. Explanation? Alternatives? Accurate?–Or Not Very? PAIN? Pain Mediation? (beyond the usual “most women report not feeling much discomfort but a couple otc pills should take care of)

        Although a pelvic exam hopes to expose any growths in fact tumors may be present and be totally missed during these subjective exams. My doctor also admitted to this. The fact that actress Fran Drescher had to see 10 different doctors at different clinics/meaning 10x she had to undergo pelvic exams, is disturbing and troubling. Someone close, having uterine fibroids, remarked at doctors (male & a few female) noticing her good looks and their near enthusiasm in getting to the pelvic and following that their near loss of interest. Ultrasounds are much more accurate than hands, they provide data, not thoughts, however she had to request these to stop the parade through her vagina.

        I once had dysplasia. I have the hand-drawn chart picture of my cervix disease progression. Interesting that the disease track went exactly in a half-moon swath where the wooden spatula painfully “harvested” my flesh. Can’t help but wonder if that tool embedded the disease further into my tissues. Same applies to women where the colpo brush is used. And on that note too, although no studies will ever be done to validate this, women have miscarried following pelvic/pap done in pregnancy. The colpo brush manufacturer urges it not be used during pregnancy. Again, no informed consent. Just get up on the table, grin and bear it, smile through the tears and tell each other the doctor wouldn’t lie.

        Why do doctors pap at first pre natal and post natal? When cervix is total flux and cells are haywire and likely to show as abnormal? To satisfy insurance co’s & lawyers that cc wasn’t there at beginning of pregnancy & didn’t suddenly sprout at delivery. No medical value. Just pain, anxiety for patient, and selfish gratification for the penny pinchers.

        Incidentally, my dysplasia was cured via cryosurgery. Something else I was rushed into immediately after the second pap and colpo as if my very life depended upon freezing away cells that would take another four yrs at minimum to turn to disease. Why I ask? Everything I read points to a classic used car lot “bait and switch” gimmick, used to “save my life.” The doctor might as well added I’ll have a surprise during & after the cryo too. Why inform me? Why not inform me? That I can answer. Like if I were truthfully informed re the pap/pelvic; I’d stay the **** away from the office, seeking appropriate treatments until no other alternative to being hacked existed. If I were fully informed, these conservative treatments, one which works being offered by a DC in Chicago which causes HPV lesions to scab off & go away-permanently w/o having my cervix amputated via LEEP would come to the forefront. Hey, once again I could trust my doctor.

        We shed cells everywhere. My present gynecologist, after admitting I had zero chance of cc, as that is a young woman’s disease etc, and further me being 30yrs outside dysplasia, monogamous relationship, age 50+, now says I’m at terrible risk and the cancer can suddenly come up from within, on its own, a different type of cancer. Something I’ve read the pap cannot diagnose. The same cancer this doctor already he admitted he can’t detect via a pelvic/pap. Yet he plays dumb to the available, accurate urine test by Trovagene, to the UDO urine HPV test which is more accurate than pap, or to the Delphi Screener, which above all things I could use at home!!! I call those my willingness to comply.

        Compared to a pap that creates false positives/false negatives/rejections and further anxiety plus overtreatment & waste of money and what I described above. And, as you by now know, I don’t appreciate the sudden pressure to shed my clothes yet again. Additionally, if I may skip to this, he had no interest in helping me regain age-related lost sexuality; saying all that was normal. While he wants to again probe me internally, he isn’t interested in blood work to explain my hormones. [would his impotence be acceptable, with a smile, to himself?].

        My doctor should be looking at me as a whole picture, not just as holes. A pap/pelvic exam, the urine test/Delphi/UDO test are not complete w/o bloodwork & familial history. I should have full informed consent, not chosen anecdotes that the heroic sacrifice he or she makes by stuffing their hands into me will save my life. If they are reluctant to prescribe pain meds, they should be equally reluctant to invade my body by other means. My enjoyment of life, my sexual health, goes right along with living, and involves more work than a “quick, easy, and painless” pelvic/pap.

        Get it? Which doctor are you?

      • No offense intended, but that’s doctor speak. That person makes sense, changes are needed, you post no arguments to that post whatsoever…

        But then you say “…we’re obliged to follow guidelines because they usually include best practice with current knowledge.” I’m literally doing a double take and I want to be sick at this thinking. If this were pain medicine or something involving your own body you thought was wrong, there’s no way you’d jump to lock step into that parade. You, as a doctor, took the oath. Remember? You are obliged at nothing that potentially harms us patients. That is something included in your ridiculous pay grade and what you’re educated to do.

        Earn your money. Grow a spine. Treat your patients with respect they deserve. Stop blaming the hospital, the establishment for terrible policies when YOU make up the thinking that drives that establishment. But those guidelines do bring in a good patient load, and money. So what’s really the best practice here with current thinking–not best knowledge. That today comes out of those countries abandoning the techniques equal to yestercenturies physically bleeding the patient for different illnesses. Yet, the more I research this subject, the more I come across doctors making asinine statements validating, clinging onto the past.

        Thank you for this site. I hope many more women get to read these comments; so long as you choose to publish them as written.

    • These are new recommendations for when to do a pelvic exam –> July 24 2012: Pelvic Exams: New Guidelines for Asymptomatic Women: http://www.medscape.com/viewarticle/768021?src=mpnews&spon=16

  3. And that so-called “vaccine?” Another empty promise. No safety. No or questionable protection at 70% efficacy on very few virus compared to the slew out there. So, gotta continue pap/pelvic; make sure your body parts work well while you don’t know if my body parts are behaving doing at all!! ACOG discusses sexual arousal in providers is normal and must be suppressed. Oops, already hit that one.

    More doctors recommend against the vaccine, mine included. $300 for three injections. No lifetime protection. And, why, again, um, are we to get this poking?

    • Edit: So, gotta continue pap/pelvic. Doctor says to patient “…make sure your body parts work well.” Patient replies “While I don’t know if during the exam your body parts are behaving properly…” Doctor’s face turned red.

      This is taken from an actual dialog between doctor & patient in the UK. The patient was 19, the doctor recently out of med school was covering for the main provider who was on vacation. Despite the medical reason why the patient presented, which didn’t involve her vagina, this young buck’s only purpose (he thought) for seeing her was to talk her into the stirrups.

Trackbacks

  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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