Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Which women are at increased risk for having an abnormal Pap smear?
According to the American Cancer Society's most recent guidelines, all women should begin cervical cancer testing (screening) at age 21. Women aged 21 to 29, should have a Pap test every 3 years. HPV testing should not be used for screening in this age group (although it may be used as a part of follow-up for an abnormal Pap test).
Beginning at age 30, the preferred way to screen is with a Pap test combined with an HPV test every 5 years. This is called co-testing and should continue until age 65.
Another reasonable option for women 30 to 65 is to get tested every 3 years with just the Pap test.
Women who are at high risk of cervical cancer because of a suppressed immune system (for example from HIV infection, organ transplant, or long term steroid use) or because they were exposed to DES in utero may need to be screened more often. They should follow the recommendations of their healthcare team.
Women over 65 years of age who have had regular screening in the previous 10 years should stop cervical cancer screening as long as they haven't had any serious pre-cancers (like CIN2 or CIN3) found in the last 20 years (CIN stands for cervical intraepithelial neoplasia and is discussed in the section about cervical biopsies, in “How are cervical cancers and pre-cancers diagnosed”). Women with a history of CIN2 or CIN3 should continue to have testing for at least 20 years after the abnormality was found.
Women who have had a total hysterectomy (removal of the uterus and cervix) should stop screening (such as Pap tests and HPV tests), unless the hysterectomy was done as a treatment for cervical pre-cancer (or cancer). Women who have had a hysterectomy without removal of the cervix (called a supra-cervical hysterectomy) should continue cervical cancer screening according to the guidelines above.
Women of any age should NOT be screened every year by any screening method.
Women who have been vaccinated against HPV should still follow these guidelines.
Similarly, the United States Preventive Task Force recommendations apply to women who have a cervix, regardless of sexual history. These recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).
The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years
A number of risk factors have been identified for the development of cervical cancer and precancerous changes in the cervix.
HPV: The principal risk factor is infection with the genital wart virus, also called the human papillomavirus (HPV), although most women with HPV infection do not get cervical cancer. (See below for details). Almost
all cervical cancers are related to HPV infection. Some women are more likely to have abnormal Pap smears than other women.
Smoking: One common risk factor for premalignant and malignant changes in the cervix is smoking. Although smoking is associated with many different cancers, many women do not realize that smoking is strongly linked to cervical cancer. Smoking increased the risk of cervical cancer about two to four fold.
Weakened immune system:Women whose immune systems are weakened or have become weakened by medications (for example, those taken after an organ transplant) also have a higher risk of precancerous changes in the cervix.
Medications: Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at increased risk.
Other risk factors: Other risk factors for precancerous changes in the cervix and an abnormal Pap testing include having multiple sexual partners and becoming sexually active at a young age.
How is a Pap smear done?
A woman should have a Pap smear when she is not menstruating. The best time for screening is between 10 and 20 days after the first day of her menstrual period. For about two days before testing, a woman should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician). These agents may wash away or hide any abnormal cervical cells.
A Pap smear can be done in a doctor's office, a clinic, or a hospital by either a physician or other specially trained health care professional, such as a physician assistant, a nurse practitioner, or a nurse midwife.
With the woman positioned on her back, the clinician will often first examine the outside of the patient's genital and rectal areas, including the urethra (the opening where urine leaves the body), to assure that they look normal.
A speculum is then inserted into the vaginal area (the birth canal). (A speculum is an instrument that allows the vagina and the cervix to be viewed and examined.)
A cotton swab is sometimes used to clear away mucus that might interfere with an optimal sample.
A small brush called a cervical brush is then inserted into the opening of the cervix (the cervical os) and twirled around to collect a sample of cells. Because this sample comes from inside the cervix, is called the endocervical sample ("endo" meaning inside).
A second sample is also collected as part of the Pap smear and is called the ectocervical sample ("ecto" meaning outside).
These cells are collected from a scraping of the area surrounding, but not entering, the cervical os.
Both the endocervical and the ectocervical samples are gently smeared on a glass slide and a fixative (a preservative) is used to prepare the cells on the slide for laboratory evaluation.
A bimanual (both hands) pelvic exam usually follows the collection of the two samples for the Pap smear. The bimanual examination involves the physician or health care practitioner inserting two fingers of one hand inside the vaginal canal while feeling the ovaries and uterus with the other hand on top of the abdomen (belly).
The results of the Pap smear are usually available within one to two weeks. At the end of Pap smear testing, each woman should ask how she should expect to be informed about the results of her Pap smear. If a woman has not learned of her results after a month, she should contact her health care practitioner's office.