Pap Smears Pelvic Examinations Well Woman Examinations. When should you have them performed???

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1 Pap Smears Pelvic Examinations Well Woman Examinations. When should you have them performed??? Arlene Evans-DeBeverly, PA-C Copyright 2012 There are always ongoing changes in gynecology, including the recommended frequency for well woman examinations, pelvic examinations and Pap smears. Many different organizations have published new guidelines in the past 5-10 in an effort to bring you the very latest health-wise information. Through time these various guidelines coalesce into recommendations that become the standard. It is easy for us to embrace these guidelines but we do need to keep up to date. For many decades we were taught that women should have a Pap smear every year and we became accustomed to having a Pap smear every year. Now, things have changed. This is because the accuracy of the Pap smear has improved with regard to assessing the cells for abnormal changes, such as precancer and cancer. Currently we can test for various components, including the presence of infections when the Pap smear specimen is studied. This is especially true with regard to the fact that we are now screening for the human papilloma virus, known to cause cervical pre-cancer and cancer that can be detected on your Pap smear specimen. If you are not a carrier of the virus, it is extraordinarily unlikely that you will ever develop cervical pre-cancer or cancer. So what are the current guidelines (Remember these are not mandates)? Let s look at the tests first. Pelvic exam vs. Pap smear Many women do not understand that there is a distinct difference between a pelvic examination and a Pap smear. You can have one, the other or both. Let s begin by distinguishing these two events. A pelvic examination consists of two components. The first component is comprised in the examination of the external female genitalia, also commonly known as down there. It allows us to look for any irritation, growths, or changes in your tissue. The second component of the examination is divided into three additional components; we will refer to these as A, B and C.

2 A. The speculum examination, during which an instrument, call a speculum, is introduced into the vagina. This allows visualization of the vaginal tissue and cervical tissue, looking for any unusual discharge, new growths irritation, or changes that might be considered potentially abnormal or a change from the way you examined previously. B. The bimanual examination that allows for the examination of the pelvis to check for tenderness, uterine and ovarian size as well as to evaluate changes that may have occurred in the pelvis. During this examination one or two fingers are inserted in the vagina until they touch the cervix. We can gently move the cervix to determine if there is tenderness. We can then proceed to actually feel the uterine outline and, in some cases, the size of the ovaries as well as determine if other pelvic masses may be present. During this examination, we can also assess the bladder for tenderness. C. Finally, the examination may include what is referred to as the rectovaginal examination. During this examination, examination consists of a finger in the vagina and one in the rectum allowing more complete evaluation of the pelvis and to rule out any changes on the back side of the uterus and ovaries. In addition, we are able to determine the adequacy of the rectal sphincter and to rule out growths, such as polyps, in the lower portion of the rectum. The Pap smear You may have all of the above performed and still not have a Pap smear collected. The Papanicolaou test, commonly referred to as a Pap smear, is a specimen of cells collected from the outer surface of the uterine cervix and from the endocervical canal, the short canal that leads from the cervix into the uterine cavity. Pap smears have been refined to identify cervical precancer, not uterine cancer. Dr Papanicolaou first reported that abnormal cells could be diagnosed by means of a vaginal smear in 1928, but the importance of his work was not recognized until The American College of Obstetrics and Gynecology has published the guidelines that I have cited below. They strongly recommend visits and encourage shared decision making between the practitioner and the patient. An important part of this decision making process will have to do with sexual history including whether or not there is a history of abnormal gynecologic findings, including abnormal Pap smears. Guidelines for Well-Woman Gynecologic Visits Annual well-woman gynecologic health assessments can promote prevention, identify disease risk and existing medical problems, and establish clinician patient relationships, according to new expert-opinion

3 based guidelines from the American College of Obstetricians and Gynecologists (ACOG). Major recommendations include: The first gynecologic visit should occur between age 13 and 15 and should emphasize education (e.g., body image, weight management, immunizations). Pelvic examination is not a prerequisite to testing for sexually transmitted diseases or to initiating oral contraceptives in healthy, asymptomatic women. Annual examination of the external genitalia should be performed in all women; complete pelvic examination is recommended for all women aged 21. Despite lack of evidence about the value of internal examinations, decisions about performing such examinations should be made jointly by clinician and patient "after shared communication and decision making." Annual pelvic examination is not necessarily required in healthy, asymptomatic women who have undergone total hysterectomy and bilateral salpingo oophorectomy for benign indications and who have no histories of genital tract neoplasia, or in women who, because of age or health status, would choose not to act should abnormalities be discovered. Clinical breast examination is recommended, although clear evidence of benefits or harms is lacking. Comment: Many clinicians have feared that extending Pap smear intervals to or beyond 2 to 3 would result in missed opportunities for preventive care. The ACOG committee addresses this concern by explaining the benefits of annual visits beyond cervical cancer screening. The Affordable Care Act mandates insurance coverage of yearly well-woman visits, thereby supporting the insured women's access to these services. Many women believe the terms "Pap smear" and "pelvic exam" are one and the same; they are two different procedures. For shared decision making to be meaningful, we must continue educating women that the need for a Pap smear is not the only reason to seek well-woman care. As a personal comment, I do not agree with the no Pap smears until the age of 21. I believe determination of whether or not a Pap smear should be performed should be based on sexual history. Certainly, if a young woman became sexually active at 15 or 16 of age, we have already passed 5-6, during which time a sexually-transmitted infection, such as human papilloma virus, could have been causing changes to occur the cervical tissue, leading to a pre-cancer, either a low grade or high grade lesion. In addition, Pap smears are not 100% perfect. They can miss infections, such as human papilloma virus and they can miss pre-cancer cells, either mild or severe, that have developed.

4 Let s look at the history of Pap smears, human papilloma virus (HPV) and cervical cancer. The FDA approved the first HPV test in The HPV test with Pap did not become the standard of care for women over 30 of age until In the 1930s, cervical cancer was the most deadly women's cancer in America. It killed more women each year than breast or lung cancer. In the past 80 there has been a decrease in the death rate from cervical cancer due to Pap smears and HPV testing. Today, death from cervical cancer is relatively rare in the U.S. In 2009, about 4,000 American women died of cancer of the cervix. Reviewing the medical history of these women revealed that the overwhelming majority had never had cervical cancer screening, and most that did, were screened more than 10 before diagnosis. The U.S. Preventive Services Task Force (USPSTF) is releasing new guidelines on cervical cancer screenings. The USPSTF is reportedly an independent panel of non-federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists). The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements." The USPSTF hopes that their guidelines will clarify some of the confusion between the healthcare providers and their patients. The new guidelines advise women to reduce the number of tests they receive throughout their lives, hoping to ensure that women receive the benefits of testing while minimizing the risks (and the cost) of diagnosing cervical abnormalities. They too, recommend that women under 21 of age not be tested. Again, I personally take exception to that guideline. Their rationale is as follows: Many sexually active women under 21 will develop a HPV infection which can lead to pre-cancerous lesions. If we are performing Pap smears before a woman is 21 of age and we find a precancerous lesion, they state that the provider will want to treat the disease. However, most of us offer the patient the option of treatment or monitoring the lesion. I have

5 seen it quoted, many times that almost all of the lesions will revert to normal. In fact, 60-70% of those lesions will revert to normal, without treatment. However, that leaves 30-40% of the lesions that can progress. They also state, that these lesions can be easily treated many later: They do not usually mention that some lesions have progressed to the point of requiring surgical intervention, including hysterectomy, to treat the lesion; or may result in a cervical cancer death. The task force has also recommended that women over 21 undergo a Pap test screening every three, instead of annually. This is because HPV can take more than a decade to progress to a cervical high-grade lesion or cancer. Here is a summary of the guidelines from various organizations: All women should start screening at age 21. No longer is screening recommended three after starting vaginal intercourse. Women aged 21 to 29 should get a Pap test (conventional or liquid-based) every three. The statement specifically recommends against annual Pap testing. The former guideline called for a conventional Pap test every year, or a liquid-based Pap test every two, for this age group. For women 30 and over, Pap tests should be done every three. The guidelines recommend against annual or more frequent Pap testing for this age group. Combining the Pap test with HPV testing every three to five is the preferred strategy for women aged 30 and older. Screening is not recommended for women 65 or older who have had three or more normal Pap tests in a row and no abnormal Pap test results in the past 10, or who have had two or more negative HPV tests in the past 10. Women who have a normal Pap result and a positive HPV test result should repeat both tests or receive a gene test called genotyping that determines if they have HPV 16 and 18. These types of HPVs are known to cause 70% of cervical cancers. There is no immediate need for a colposcopy. (HPV 16 and 18 are the most common causes of cervical dysplasia and cervical cancer.) Women with a mildly abnormal Pap result (called ASC-US) and a negative HPV test result should follow up with either HPV testing plus a Pap test, or HPV testing alone, at intervals of three or longer. Women who have been vaccinated against HPV should begin cervical cancer screening at the same age as unvaccinated women, i.e. at age 21.

6 TABLE 1: Summary of guidelines from various organizations Age: Less than Over 65 Pap Test No No more than every 3 Every 3 which may be extended to 5 if HPV test is used in conjunction with Pap Test. No, if three or more normal Pap tests in a row and no abnormal Pap test results in the past 10, or have had two or more negative HPV tests in the past 10. HPV Test No Yes Yes No TABLE 2: Screening Methods for Cervical Cancer. Joint Recommendations of the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology Population Recommended Screening Method Comment Less than 21 old No screening old Cytology alone every old Human papillomavirus and cytology co-testing (preferred) every 5 Cytology alone (acceptable) every 3 Over 65 old No screening is necessary after adequate negative prior screening results Women who underwent total hysterectomy No screening is necessary Screening by HPV testing alone is not recommended Women with a history of CIN 2, CIN 3 or adenocarcinoma in situ should continue routine agebased screening for at least 20 Applies to women without a cervix and without a history of CIN 2, CIN 3, adenocarcinoma in situ, or cancer in the past 20 Women vaccinated Follow age-specific recommendations against HPV (same as unvaccinated women Abbreviation CIN indicates cervical intraepithelial neoplasia; HPV, human papillomavirus Modified from Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer Clin 2012;62: Remember, these are guidelines, not mandates. In gynecology, we are called upon to address some of the worst case scenarios. For that reason, there are many practitioners who will be utilizing the guidelines as guidelines but tailoring the most effective care for the individual woman based on her medical history, her sexual history and her peace of mind.