Postpone Pap Screening, Say New Guidelines
For young women, STDs, not cancer, are the top concern
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.
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