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Updated Guidelines for Paps

  • A. Kenneth Harper MD

The "annual Pap" smear has been recommended for three generations of women to screen for cancer of the cervix. Improved Pap technology and testing for HPV virus has resulted in updated recommendations for Pap screening.

The association of HPV (Human Papilloma Virus) and cervical cancer is critical to the new Pap guidelines. There are two categories of HPV based on the risk of producing cervical cancer: 1) Low risk HPV associated with genital warts but not cervical cancer, and 2) High risk HPV associated with cancer.

HPV is a sexually transmitted disease. The risk of HPV infection can be reduced by receiving the HPV vaccine before the onset of sexual intercourse. The HPV vaccine is given to girls between the ages of 9 and 26 and boys between the ages of 9 and 15 - ideally in the early teen years for both. The first generation Gardasil HPV vaccine offered protection against HPV viruses 16 and 18 (the two most common high risk types associated with cervical cancer) and types 6 and 11 (the two most common low risk types associated with genital warts). A newer version of the Gardasil vaccine was recently approved that will cover 5 addition types of the high-risk HPV types associated with cervical cancer. Vaccination with the new vaccine is projected to protect against 90% of the viruses associated with both cervical cancer and genital warts. Since the vaccine is not 100% protective against HPV (and has no protection against other infections), limiting the number of lifetime sexual partners and using condoms will further reduce the risk of HPV and other sexually transmitted diseases such as Chlamydia, Gonorrhea, syphilis, Herpes, and HIV.

So what are the new recommendations? These recommendations are only for women with no history of abnormal Paps or HIV . Women with HIV or prior abnormal paps require more frequent testing.

  • 1st Pap smear at age 21 - the risk of cervical cancer is extremely low under age 21 and the risk is not reduced by screening under age 21
  • Pap smears every 3 years between ages 30 and 65

OR

  • Pap smear WITH HPV (high risk HPV only) testing every 5 years between ages 30 and 65
  • Pap smears may be discontinued for women after age 65
  • Paps can be discontinued after hysterectomy

The new recommendations are felt to be just as effective and less expensive than annual pap smears in screening for precancerous and cancerous changes on the cervix. The biggest concern of physicians with the new recommendations is that many women equate an "annual Pap" with an "annual exam" and may be less likely to have regular screening exams for other health problems including breast and ovarian cancer. We also worry that teens will be less likely to receive counseling about sexuality, contraception and STD's before they become sexually active if they are not required to have checkups until age 21.

The American Congress of OB/GYN (ACOG) advises that annual wellness exams are still recommended even with a reduced frequency of Pap testing. Also recommended is a counseling visit (with no pelvic exam) by age 15 for all teens unless issues regarding sexuality, contraception and HPV vaccination have been addressed by the child's pediatrician or family physician.

Women's Specialty Care will continue to offer annual Pap smears for those women who prefer to continue annual screening. However, insurance coverage for annual paps may become an issue as the guidelines are adopted more extensively by insurance companies.