Pap Smear Primer

[Guest guest]

Pap Smear Primer: Answers to Common Questions and Concerns Alice Chang, M.D. Harvard Medical School August 30, 2001

Moderator:Welcome to today's chat! Our topic is Pap Smear Primer: Answers to Common Questions and Concerns. Our guest is Alice Chang, M.D.

Alice Chang, M.D., is an instructor in medicine at Harvard Medical School, and on the faculty of the Department of General Medicine at Brigham and Women's Hospital. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine, and patient education.

Please join me in welcoming Dr. Chang.

You may submit your questions at any time. Please be patient; this is a live event. All questions are submitted to the Moderator, and read to the doctor one at a time. There may be a slight delay as she dictates her answer to the transcriptionist, who then types Dr. Chang's answer into the chat room.

Please remember that Dr. Chang cannot diagnose your individual problem during a chat. Keep your questions general enough that the doctor is able to address them.

Question:Are Pap smear tests necessary if someone has had a hysterectomy?

Dr. Chang:Even after a hysterectomy, there can be some microscopic cells from the cervix left behind. If for some reason microscopic cancer cells were left behind or come back in this area, the Pap smear can detect the earliest sign of cancer recurrence.

This is an important test to continue having if your uterus and cervix were removed because of cancer. If you had the hysterectomy for a reason other than cancer, many physicians feel you may be able to stop routine screenings, or at least decrease the frequency of testing. You should discuss your specific medical history with your physician and decide if and when you both feel comfortable not having pap smears done anymore.

You will probably be advised to continue having yearly exams — ncluding a pelvic exam — to feel for any abnormalities of the ovaries (if they were not taken out with the surgery).

Question:I am 51 years old, should I keep having a pap smear yearly?

Dr. Chang:Many women ask if and when they can stop having Pap smears. It is important to realize that women between the ages of 50-70 account for many cases of cervical cancer. Usually, they have not had Pap smears in the years before their diagnosis. For this reason, it is still advised to continue having Pap smears until somewhere between the ages of 60 to 70, depending on whom you ask.

This is assuming that your recent Pap smears were normal, and you do not have a high risk for cervical cancer. The best thing to do is to talk to your physician and decide together when you can quit having Pap smears. Your physician may still recommend a pelvic exam of the uterus and ovaries with your yearly exam.

Question:Can birth-control pills affect cervical changes that would result in abnormal findings?

Dr. Chang:Birth-control pills do not cause changes in cervical cells that you would see on a Pap smear. But, there is some evidence that taking birth-control pills may increase your risk of having cervical cancer. This may not be related directly to the pill, but instead may reflect increased sexual activity in women who are using birth control.

Question:Do bacterial infections change the Pap smear result?

Dr. Chang:Sometimes you will see a Pap smear result that notices a yeast infection or Gardnerella, which is a bacteria. Having inflammation from infection can affect the way cervical cells appear on the slide. As a result, the cervical cells may be reported as being abnormal, but this does not necessarily mean that you have cancer. Sometimes your physician will have the bacteria treated, and then do a retest Pap smear. Your Pap smear result still can be normal, even when bacteria or yeast are seen. In that case, you do not need to have the test repeated.

When bacteria or yeast are seen on a Pap smear, you don't have to have treatment for these findings if you are not having symptoms of vaginal discharge or itching. It is normal to have some yeast or bacteria in the healthy vaginal environment.

Question:Why is it normal to have some yeast or bacteria in the healthy vaginal area? What is PV? I may have the wrong initials, but there might be an infection or disease with a similar name.

Dr. Chang:We all have yeast or bacteria living on our skin. The same goes for the vaginal area. It is not a problem until they grow in larger numbers and cause symptoms. In fact, having different kinds of yeast and bacteria help to keep growth under control. That's why some women are prone to yeast infections after getting antibiotics. When the bacteria are killed, the yeast can grow temporarily out of control.

You are referring to HPV -- Human Papilloma Virus. This is a virus you can catch from sexual contact. It is associated with the development of cervical cancer. You can also have Pap smear results that comment on HPV infection. If there are abnormalities associated with this virus, you will probably be encouraged to have more frequent Pap smears.

If there are signs of pre-cancer or early cancer, especially when HPV infection is seen or tested, your doctor will refer you to a gynecologist for colposcopy. In a colposcopy, your gynecologist uses a small scope with a lens on the end to look for microscopic changes on your cervix. A biopsy of any abnormalities can be taken. This can be done in the office and feels like a longer pelvic exam.

Question:I have genital warts; should I have a Pap smear?

Dr. Chang:Genital warts develop from HPV infections of skin cells. For the reasons that we just discussed, people with HPV infection are at a higher risk for cervical cancer. You should especially make sure that you have at least yearly Pap smears because you are at higher risk.

Question:If someone has had several positive Pap smears, and after subsequent tests everything was fine, does that person have an increased risk to get cancer later?

Dr. Chang:You can be told you have an abnormal Pap smear without having signs of cancer. It would be important for you to know what the positive Pap smear result was.

There is something called ASCUS, Atypical Squamous Cells of Unknown Significance. It means that some cells looked funny but were not precancer or early cancer. To make sure that the cells are actually normal, a repeat test may be advised. If you had ASCUS, you are not necessarily at higher risk for cancer.

But if you had precancerous changes on your previous Pap smears, you would be at higher risk for cervical cancer. It is possible for precancerous changes to go away on their own on subsequent Pap smears. Therefore, just based on what you told me, there is no way to be certain about your risk for cervical cancer without specifically asking your doctor.

Question:Should the Thin Prep test be used for annual exams like my doctor recommends?

Dr. Chang:The Thin Prep is the newest Pap-smear test. It probably picks up more abnormal cells than the standard Pap-smear test. But we are not sure that it actually diagnoses more real cases of early cancer. For this reason, it is not necessary for you to have the Thin Prep rather than the standard Pap smear. But, it is OK if your physician prefers you to have these tests.

Question:Can the HPV lie dormant for, say, 20 years and then all of a sudden become active?

Dr. Chang:The way HPV hides in our cells is to insert itself into our DNA. It can lie dormant for years and then become active much later on. On the other hand, your body may clear the infection after just a few years.

Question:I had a Pap smear and did not know I was pregnant. Will this affect my baby?

Dr. Chang:Having a Pap smear while you are pregnant won't affect your baby. In fact, when you first visit an obstetrician you will have a Pap smear test if you haven't had one recently. It is important to know, early in your pregnancy, if you have early signs of cervical cancer.

If there are any abnormalities, your doctor can advise you on the best treatment strategies for you during your pregnancy. Precancerous changes can be treated while continuing your pregnancy. If you have cervical cancer, a decision would have to be made based on the stage of cancer and risk for it to spread on whether you should continue the pregnancy.

This does not happen very often. It is good early in your pregnancy to know that everything is normal.

Question:At what age should you get your first Pap smear?

Dr. Chang:The first Pap and pelvic examination should be done in the first year of sexual intercourse, or the age of 18, which ever comes first. For the first three years, most physicians recommend having yearly Pap smears done. If they are all normal, you can have a discussion with your physician about whether you can have them less frequently.

If you are not at high risk for cervical cancer, you may be able to wait two or three years before having repeated Pap smears. There are no studies showing that more frequent Pap smears (more than every three years) are better at detecting or curing cervical cancer.

Because HPV (a viral infection associated with cervical cancer) can be passed sexually, it is advised that Pap smear be done within a year of any new sexual partner.

Question:Should a Pap smear be painful?

Dr. Chang:No, a Pap smear should not be painful. Of course, most women will tell you it is the least favorite part of the exam because of how it feels when the speculum is put into place. Here are some tips on what to expect:

You may feel a slight pressure when the speculum is inserted into the vagina. Next, the speculum is opened just enough to separate the vaginal walls enough to view the cervix. The vagina is a muscular wall, much as any muscle. When the speculum is inserted slowly, you should feel no pain. If your muscles are tight, or not relaxed, you may feel discomfort. Simply ask your doctor to stop and explain what you are feeling.

Always mention if you are having pain, since this exam should not be painful. If you are having an exam because you think you may have an infection, you may experience discomfort from inflamed vaginal walls.

To make a routine exam more comfortable, try to time the test for the first week after your period. The cervix can be more sensitive right before your period.

If this is your first Pap smear and you have not been sexually active, you may find that using tampons during your period for a few months before your exam may make you more comfortable. In extreme cases, women have severe spasm of the vaginal walls that require the use of muscle relaxants in order to do the exam.

Sorry if I made this sound scarier than it really is! Most young women are pleasantly surprised when it is not as bad as they thought it would be.

Moderator:Well, our time is up. We had a lot of great questions; I wish we had time to get to them all.

Thank you, Dr. Chang, for taking time out of your busy schedule to join us today to talk about this important topic.

If you joined us late, a transcript of this chat will be available soon. For those interested in more information on pap smears, the transcript will include links to additional resources.

Join us again this Wednesday, September 5th, at 1:00 p.m. Eastern Time. Our topic will be: Do You Know What Your Toddler Knows?

Additional Resources:

Pap Test Pelvic Exam Women's Health

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