Postpone Pap Screening, Say New Guidelines
For young women, STDs, not cancer, are the top concern
Elizabeth Stier, a School of Medicine associate professor of obstetrics, gynecology, and women’s health. Photo by Vernon Doucette
Women’s health has grabbed a string of headlines these last weeks.
Coming on the heels of controversial recommendations from a government task force that women at low risk for breast cancer forego routine mammograms until age 50, the American College of Obstetricians and Gynecologists (ACOG) recently released new guidelines for Pap smears, the simple swab test for cervical cancer. These recommend that even sexually active young women postpone their first pap smear until age 21. Unlike the mammography report, which stirred the ire of doctors and confounded patients, the new ACOG recommendations were heartily endorsed by the medical community. Further, instead of the previously recommended annual Pap smear, ACOG advises women in their 20s to have the test every two years. Women over 30 who have had three normal Pap smears in a row are now advised that testing is necessary only once every three years. And women over 65 who have had three consecutive normal Pap smears can stop having them altogether.
BU Today spoke with Elizabeth Stier, a School of Medicine associate professor of obstetrics, gynecology, and women’s health, about the implications of the new guidelines for college-age women and what young women should do to maintain their sexual and reproductive health.
BU Today: Do you agree with the new ACOG guidelines that young women should postpone having Pap smears until age 21 even if they are sexually active?
Stier: We haven’t instituted the change here yet, but increasing the age of screening is a reasonable thing to do. I tell young women, you don’t have to worry about cervical cancer, but you do have to worry about screening for sexually transmitted infection. Young women have a very high rate of HPV, the virus that can cause cervical cancer, and what was happening was that the presence of HPV would mean an abnormal Pap test. But in women under 21, 90 percent of all HPV will clear up after about a year. These young women and adolescents don’t need to be traumatized by getting a speculum exam.
Why have women been urged to get annual Pap tests when abnormal results could be so common, so ambiguous, and most often nonthreatening?
There was no screening at all until the ’50s, when there was minimal screening. In the 1960s we started doing ad hoc screenings, and in the ’70s it became a standard recommendation. But at that time, if you had an abnormal Pap smear you’d have something called a cone biopsy, and if that tested bad you’d have a hysterectomy. In the 1980s colposcopy — a noninvasive way of looking at the cervix — came along, and we could monitor cell change and treat cervical dysplasia (abnormal, potentially precancerous cell growth) with an office surgical procedure called LEEP. Though the cervix healed after LEEP within a few months, studies found that a decade later, women who’d had LEEP were starting to have preterm babies. All this was the result of screening with the Pap test. We know now that most young women will clear HPV. These women rarely get cervical cancer, and we don’t want them to have premature babies. We don’t want to do harm. So when it comes to the Pap test, we’ve come full circle.
Is the Pap test still the best screening tool for cervical cancer?
Yes. For every country that’s adopted screening, mortality from cervical cancer has gone down. It’s not clear, though, that this is from finding very early cancers.
Isn’t the extremely common STD chlamydia also diagnosed by looking at cells from a cervical swab?
It can be. The infection of greatest risk in young women is chlamydia, and everyone should be tested. But it doesn’t have to be a cervical swab; it can be a vaginal swab, which doesn’t involve a speculum, or a urine test. Apparently the urine test is quite accurate.
What women under 21 are at high risk and should get Pap smears?
If a young woman is HIV-infected or if she’s had a kidney transplant and is on immunosuppressive drugs, she should get Pap tests. The very small number of women under 21 who have already been diagnosed with severe dysplasia should also get Pap tests. This is not very common; it’s less that one percent in that age group. And the trouble with diagnosing levels of dysplasia is: the more pathologists, the more opinions.
So if nearly all women under 21 don’t need to worry about cervical cancer, is there any screening for sexual and reproductive health they should be getting routinely?
Anyone, male or female, 20 and under who is sexually active should be tested annually for STDs. This can be done in a pediatrician’s or family doctor’s office with a urine test. College health services are very good at providing birth control and STD counseling. STD screening should always be done as part of primary care. If your doctor doesn’t suggest it, insist on it. Chlamydia, the most common STD, is most often asymptomatic. But in women it can cause pelvic inflammatory disease and infertility, and it’s very treatable with only one dose of antibiotics.
What advice would you like to add for college students?
Use condoms, use condoms, use condoms. I think people make an effort, but they get lazy. And get tested for STDs. It’s very hard to sell preventive medicine to someone who feels great.
Susan Seligson can be reached at sueselig@bu.edu.
I think that telling girls that they should not have a PAP until they are 21 is the worst medical advice I have ever heard. I have HPV and found out through a PAP when I had just turned 20. They did a biopsy and found that I had severe dysplasia all over my cervix and it was spreading. Severe dysplasia is one step before cancer. Women my age normally don’t have this. But, guess what? I did.
I had to get a laser cone biopsy done to get the all the infected cells out before they progressed and spread into cervical cancer. Had I waited until I was 21, the cells would have spread and progressed. My HPV has yet to “clear up” in a year, which these medical experts from the article claim it will. If I had waited, I may not have my cervix right now.
These experts are giving bad advice. Just because going to a doctor can be scary and invasive, does not mean that you still should not go. If you are mature enough to have sex, then you are mature enough to handle a doctor visit.
An unfair cycle
The ACOG may reccognize that a LEEP procedure can cause later damage, especially during pregnancy and childbirth, but it does not mean that screening can be postponed. LEEP is a woman’s choice, but I feel that a woman should be aware of her condition and the options that are available.
HPV is the most common STD. One in four women will have it in point in their life and it has a strong link to cervical cancer. These are what the commercials are telling us and why young females are getting the Gardisil shots. The Gardisil shots only protect women from the most high risk strains, but what about the less risky? Do we just ignore it because it has a high probability of going away when females are young? No, that’s not how society should work. It is well known that ignorance is not bliss. The truth isn’t always attractive, but it should be told.
If young women are contracting strains of HPV and not getting pap smears, then they may spread the virus – high and low risk strains. Predictably, there would be a larger number of women going into their first pap smears at age 21 and finding out that they have HPV. Those 21 year olds, who didn’t know they had it, may have had sexual contact with any number of men. Despite men having annual STD check-ups, there isn’t a very good test for HPV in men yet. Those men who are cleared and think they do not have any STDs may have sex with more women. Inuitively, it is an never-ending cycle.
Pap smears may not end the cycle, but they definitely put a kink in it. Perhaps a woman has a pap smear and realizes she has HPV. The woman has different options. She can keep it to herself and continue the cycle until the virus disappears (assuming it does). She may be able to trace exactly who she contracted it from and inform that person. She can make a decision to refrain from sexual contact until it goes away. She can opt for a LEEP procedure. Any combination of these options results in a more effective outcome, especially when applied to millions of women.
A more informed population is able to make smarter decisions.
so much effort and time is put in to convince girls and boys to get checked and still many are careless. by saying things like, “don’t need to get checked until youre 21″ is simply going to reverse this progress that was being made. If there are people who are careless or scared today even though they have been told many times that screening saves lives, what do you think will happen when they begin reading these types of articles? Will they be able to understand that this is a generalization? they might not. The reality is the more you get tested, the better. Why skip a year? why not take control? We need to encourage and encourage! We need to keep telling people to get checked if we want to make progress, if we want to help others.
The slight discomfort of the test is worth it. GET CHECKED!
Informed consent is missing from cervical screening
The sad thing is the damage these doctors have done by being dishonest with women in the first place, instead of giving us ALL of the facts and accurate statistics, we got scare campaigns and half truths.
The last poster is an example of a woman who has been misled by doctors. I’m sure a Dr has never told her cervical cancer is uncommon, some would say, rare.
1000 women need regular smears for 35 years to save ONE woman from cervical cancer – Dr Angela Raffle, UK cervical screening expert, research published in the BMJ in 2003.
Instead doctors have made out this cancer was/is a major threat in the developed world, NOT TRUE.
You are more likely to be harmed by pap smears and false positives/over-treatment than be saved by a smear – MUCH more likely.
Dr Richard DeMay, American pathologist tells us 0.65% of women benefit from smears (with no screening at all only 1% of women would get this cancer)
99.35% derive no benefit from smears (incl the 0.35% who may be disadvantaged after false negatives)
Now the hidden shame – this test is unreliable. The rareness of the cancer is one thing, but this testing exposes huge numbers of healthy women to the ordeal of colposcopy and usually some form of biopsy after false positives. (the test is wrong)
These unnecessary procedures can risk your reproductive and general health. Cone biopsy and LEEP carry the most risk – infertility, miscarriages, problems during pregnancy, pre-term labour/premature babies & psychological issues.
The risks go way up if you over-screen or screen inappropriately – if you’ve never been sexually active, you are most unlikely to benefit from smears and if you have them, you expose yourself to risk. Women in lifetime mutually monogamous relationships – same thing, no benefit, high risk.
Women under 25, some say 30 – screening does not affect the tiny death rate from this cancer, but these women produce very high numbers of false positives and receive over-treatment.
Look at the risk factors and your risk profile and if you want to have smears, make it an informed decision.
Finland has a responsible and honest program – they offer screening 5 yearly from 30 – 5 to 7 tests in total. They have the lowest rates of cervical cancer in the world and send the fewest women for biopsies. Still it’s an unreliable test so even their program sends somewhere between 30%-55% of women for colposcopy at some point in their lifetime.
Annual and biannual smears amount to over-screening and cause high rates of false positives for little additional benefit.
Annual screening sends 95% of women at some point for colposcopy (and usually biopsy) Two yearly – 77%
Three yearly – 65%
Less is much more with screening.
You can get an abnormal pap smear for HPV infections, inflammation, hormonal changes (pregnancy), perfectly normal changes that occur in your teens & early 20′s and around menopause, trauma (childbirth) – around 95% of all referrals are unnecessary. Almost all of these things do not need medical treatment, the immune system sorts them out over time.
If you value your health and reproductive health, take the time to do your own reading, don’t rely on doctors.
Dr Joel Sherman’s medical privacy blog is an exception, an ethical Dr who believes women should be giving informed consent for pap smears. His site under women’s privacy issues has all the references mentioned above…the DeMay & Raffle articles.
It’s time we protected ourselves from this harmful and dishonest program. Too many women are being harmed and without informed consent.
Paps don't help women under 30, but carry risk...
It puzzles me that governments and doctors keep pushing for women under 30 to have pap tests and scold those who choose not to screen for whatever reason.
The evidence does not support the recommendation, young women don’t benefit from pap tests and risk their health.
So, why are they still pushing pap tests on women under 30, which risks their health for NO benefit?
Take a look at “Cervical Cancer Screening”, a pull-out guide for doctors that appeared in Australian Doctor in 2006 – written by Assoc Prof Margaret Davy, Director of Gyn-oncology, Royal Adelaide Hospital and Dr Lesley Shorne.
“No country has reported any decline in the incidence of or mortality from cervical cancer in women under 30, irrespective of screening. Many countries do not perform screening in women under 30″.
We know from UK research by Angela Raffle, screening expert and from Finland that young women produce very high rates of false positives and are then either asked to watch and wait & re-test in 12 months which causes enormous worry or they’re referred for colposcopy and usually some form of biopsy. Some of these women will be left with damage that can lead to infertility, cervical stenosis (retention of menstrual fluid, infections that require procedures and/or surgery) cervical incompetence – miscarriage, high risk pregnancy requiring cervical cerclage, premature babies, psych issues, more c-sections – LEEP and cone biopsies carry the most risk)
1 in 3 pap tests will be “abnormal” in the under 25 age group, but cervical cancer in this group is VERY rare. (and it’s rare in all age groups) 1 in 14 for older women – almost all abnormal paps are false positives, the cancer is rare, HPV & abnormal paps are common.
So, screening women under 30 doesn’t change the tiny death rate, but causes great worry and/or harm.
What is going on? What motivates those who give women bad and incorrect advice?
Sadly, there is an acceptance in women’s cancer screening to suppress risk info, to inflate the benefits of testing, to exaggerate the risk of the cancer and to downplay all the risks of testing – that is paternalistic and unacceptable.
Older women have a remote chance of benefiting so every woman should examine her risk profile before she agrees to testing. No woman needs more than 5 yearly testing from age 30 to 50, 55 or 60. This is the Finnish program – they have the lowest rates of cc in the world and produce the smallest number of false positives and refer the fewest women, still high at 35%-55% lifetime risk of referral, but better than 78% of Australian women and 95% of US women. Testing causes high over-detection and over-treatment to help less than 1% of women – 0.65% in the States, 0.45% in Australia….and all with no informed consent.
The facts are available – Dr Joel Sherman’s medical privacy blog under womens’ privacy issues has lots of real information – in the side bar, see articles by R DeMay and A Raffle.
The American well-woman exam is not evidence based either and is more likely to risk your health. These exams are not recommended at all in symptom-free women in the UK and Australia. (aside from the pap test, which is voluntary and requires your informed consent)
Pap tests and mammograms can never be “required” for anything – the US practice of denying women the Pill or HRT until they submit to unnecessary and potentially harmful gyn exams and/or pap tests is unethical and a violation of the Patient Bill of Rights – a blood pressure test and your medical history is all that’s required for the Pill…challenge any Dr who demands or attempts to coerce you into cancer screening or routine gyn exams and report him/her, if necessary.
Google recent US news feature: “Women who need birth control get unneeded pelvic exams”.