Pap Smear

Pap Smear

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In 1928, Dr Papanicolaou discovered that cells in the cervix change in appearance before they become cancerous. The Pap smear, named after the doctor, is used to check for these changes in the cervix (the neck of the womb) at the top of the vagina. It is a screening tool to find early warning signs that cancer might develop in the future. It is not for diagnosing cancer.

The Pap smear is a simple procedure. Cells are collected from the cervix and placed (smeared) onto a slide (Conventional smear) or in a jar (Thin Prep Pap test). The slide or the jar is sent to a laboratory where a pathologist checks the cells. If abnormal changes are found at screening, further tests will be done to see if treatment is needed.

A Pap smear only takes a few minutes. No drugs or anaesthetics are required.

The Pap smear does not check for other problems in the reproductive system. It is not a check for sexually transmitted infections as a routine. However, testing for Chlamydia, Gonorrhea and HPV can be requested on the thin prep Pap test.

How effective is the Pap smear?

Regular Pap smears every two years can help prevent up to 90 per cent of the most common type of cervical cancer.

Like all screening procedures, the Pap smear has limitations. Sometimes it will not detect early cell changes because the smear did not contain enough abnormal cells. Sometimes samples are difficult to interpret due to blood or mucus on the slide. If this occurs, you need to have another Pap smear usually in 3 months time.

How often should I have a Pap smear?

All women over 18 who have ever had sex are advised to have a Pap smear every two years, even if they no longer have sex.

As the most common type of cervical cancer usually takes up to 10 years to develop, there is little advantage in having a Pap smear more frequently than every two years.

More frequent Pap smears may be recommend if your previous smear showed significant cell changes or you experience problems, such as bleeding or pain after sex. If the changes continue, further tests (colposcopy) and treatment may be needed.

What I need to do before going for a Pap test?

The best time to have one is between 10 and 20 days after the first day of your last period. For two days before the test, you should not douche or use vaginal creams, suppositories, foams or vaginal medications (like for a yeast infection). It is also best to not use any vaginal deodorant sprays or powders for two days before your test. And, do not have sexual intercourse within 24 hours of your test. All of these can cause inaccurate test results by washing away or hiding abnormal cells. You should not have a Pap test when you have your period.

How is a Pap test done?

You will be asked to lie down on an exam table and put your feet in holders called stirrups, letting your knees fall to the side. A sheet will cover your legs and stomach. An instrument called a speculum is inserted into the vagina; opening it gently will allow the cervix to be seen and the Pap test can be done. A special stick, brush or swab is used to take a few cells from inside and around the cervix. While painless for most women, a Pap test can cause discomfort for some women.

Pap smear after hysterectomy

If your have had a partial hysterectomy, that is, your cervix was not removed, you will still need to have a Pap smear every two years, even after menopause up till the age of 70.

If you have had a total hysterectomy, that is, your uterus and cervix have been removed; you still need to have a Pap smear every two years, even after menopause up till the age of 70 if any of your Pap smears were abnormal during the last 5 years prior to the hysterectomy.

If you have had a total hysterectomy, that is, your uterus and cervix have been removed; you don’t need to have a Pap smear if your Pap smears were always normal particularly during the last 5 years prior to the hysterectomy.

When should I stop having Pap smears?

If you are 70 years or over and have had two normal Pap smears in the last five years, you do not have to keep having Pap smears, unless you wish to do so.

What is the cause of cervical cancer?

Human Papilloma Virus (HPV), a sexually transmitted infection that in most cases (80%) is cleared by the body’s immune system. The Pap smear may detect the presence of HPV. Some women who have persistent infections may develop abnormalities of the cervix. This is why it is important to have regular Pap smears.

What are the symptoms of cervical cancer?

In the early stages of cervical cancer, there are usually no symptoms. The only way to detect the changes that might become cancer is if you have a Pap smear.

If you have any abnormal vaginal bleeding (such as intermittent bleeding, bleeding after sex or after menopause), abnormal or persistent vaginal discharge (bloody or offensive), or pelvic pain, you need medical attention.

Who is at risk of developing cervical cancer?

All women who have ever had sex at some time in their life are at risk. The risk increases when a woman:

  •   Starts having sex before age 18.
  •   Has many sexual partners.
  •   Has sexual partners who have other sexual partners.
  •   Has or has had Human Papilloma Virus (HPV) or genital warts.
  •   Has or has had a sexually transmitted disease (STD).
  •   Is over the age of 60.
  •   Is smoking

HPV (Human Papilloma Virus)

HPV is a very common virus; four out of five people will have it at some stage of their lives. In some cases, it can increase a woman’s risk of cervical cancer. However, most women with HPV do not develop cervical cancer.

There are over 100 different types of HPV, including some that affect the genitals. Genital HPV is similar to the virus, which causes warts on other parts of the body.

HPV infection is very common and in most people it clears up naturally in about 8-14 months.

What does HPV have to do with cervical cancer?

In a small number of women, the HPV stays in the cells of the cervix. When the infection is not cleared, there is an increased risk of developing abnormalities. In very rare cases, these abnormalities of the cervix can progress to cancer.

When cervical cancer develops, HPV is found in almost all cases. However, it is important to remember that most women who have HPV clear the virus naturally and DO NOT go on to develop cervical cancer. Having regular Pap smears is the best way to ensure that any changes are monitored and managed to protect your health.

If you have early cell changes due to HPV, there is a strong likelihood that these changes will clear up naturally in 8 to 14 months. Because of this, and the fact that cancer of the cervix takes around 10 years to develop, it is recommended to have another Pap smear in 12 months time.

How did I get HPV?

Genital HPV is spread through genital skin contact during sexual activity. As viruses are microscopic, HPV can pass through tiny breaks in the skin. HPV is not spread in blood or other body fluids. While condoms are barrier to many sexually transmitted infections, they offer limited protection against HPV, as they do not cover all of the genital skin.

Genital HPV is so common that it could be considered a normal part of being a sexually active person. Most people will have HPV at some time in their lives and never know it. You may become aware of HPV if you have an abnormal Pap smear result, or if genital warts appear. Because the virus can be hidden in a person’s cells for months or years, having a diagnosis of HPV does not necessarily mean that you or your partner has been unfaithful. For most people it is probably impossible to determine when and from whom HPV was contracted.

Can HPV be cured or treated?

There is no cure or treatment for HPV. It will, in most cases, be cleared up by your immune system. However, the effects of the virus, such as any warts that appear, or changes to the cells of the cervix, can be treated.

Should I have a special test for HPV?

There is a HPV test available, which can identify strains of HPV. This is not a test for cancer. HPV tests are available in Australia, however, because most HPV infections usually resolve naturally, and there is no cure, there is little reason to have an HPV test routinely.

It is recommend that HPV testing be used for women who have been treated for a high grade abnormality. The HPV test is done to make sure the virus has gone from your body.

While a Pap smear cannot identify which type of HPV is present, regular Pap smears will make sure any changes that occur are identified early and managed effectively.

What about a vaccine for HPV?

Persistent infection with high risk HPV types is associated with the development of cervical cancer. Infection with high risk HPV types is also implicated in the development of other cancers, including the vulva, vagina, anus and penis.

Of the high risk HPV types, type 16 and 18 account for some 70% of cervical cancers. Low risk HPV types cause genital warts. HPV infection is common with an estimated 70% of sexually active women becoming infected.

Vaccination to prevent infection with high risk HPV types has the potential to reduce the incidence of precursor lesions and cervical cancer.

Two products for vaccinations are available in Australia, Gardasil and Cervarix.

Recommendations

  • The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recommend the vaccination of females aged 9–26 years against HPV. However, all sexually active women can receive the HPV vaccine.
  • Women with a history of previous HPV infection, abnormal cervical cytology or genital warts will most likely benefit from protection against disease caused by the other HPV vaccine genotypes with which they have not been infected.
  • The vaccine may be less effective in women who have been exposed to HPV before vaccination than in women with no prior HPV exposure at the time of vaccination.
  • The vaccine is a preventive tool and is not a substitute for cancer screening. Both vaccines protect against future acquisition of HPV genotypes that account for approximately 70% of HPV-related cervical cancer worldwide and screening should be continued to cover the remaining high risk types.

Vaccination is Not Treatment

The HPV vaccine is not therapeutic and is not intended to treat patients with cervical cytologic abnormalities or genital warts.

Patients with these conditions should undergo further tests (colposcopy) and treatment as needed.

It is important to note that many early cytologic abnormalities can be detected and managed conservatively given the significant rate of regression. This is especially true in adolescents and young women.

Vaccination of Pregnant and Lactating Women

Gardasil and Cervarix have been classified as pregnancy category B2. The vaccine is not recommended for use in pregnancy. There is no evidence to suggest that administration of Gardasil or Cervarix adversely affects fertility, pregnancy or infant outcomes.

Women who become pregnant during the course of vaccination should defer the subsequent doses until the completion of pregnancy, regardless of timing. Vaccination should resume at the appropriate dose interval. There is no need to recommence the complete vaccination program. For example, women who have received one or two doses should receive the second and/or third dose at the completion of the pregnancy.

Vaccination of Women Older Than 26 Years

Although the peak incidence of genital HPV infection is within the first five years after commencement of sexual activity, new HPV infections do occur throughout a woman’s life, particularly in the context of new sexual partners and changing sexual behaviour. 

Vaccination of Males

Gardasil is approved for use in males aged 9 to 15 years.

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