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Changes in Pap Smear Screening Recommendations

Many women have questions about their pap smears and recent changes in screening recommendations.  We have all become accustomed to having a pap smear with our annual exams but new evidence confirms that we are actually "overpapping" women and that, with our improved screening techniques, we can forgo the annual pap. 

Abnormal pap smears are caused by human papilloma virus (or HPV) which is actually a family of over 100 subtypes.  There are a number of high risk subtypes that are responsible for abnormal changes in our cervical cells and genital warts.  These abnormal changes can eventually become cervical cancer if they are persistent and are left untreated.  Certain co-factors make that more likely, such as smoking and a suppressed immune system.

Watching the natural progression/regression of HPV in different populations has allowed newer pap guidelines to be established. The data now show that young women under the age of 21, regardless of years of sexual activity and numbers of partners, will clear the HPV infection on their own without intervention.  Therefore, women do not need a pap until the age of 21. Only 0.1% of cervical cancer has ever been detected in women under the age of 21 and there has been no change in cancer incidence or mortality with screening under the age of 25.  For women in their 20’s, paps every 2 years are sufficient to detect and treat persistent abnormal cells.  For women ages 30-64, they can now have a pap smear combined with an HPV DNA test. This test checks for the high risk HPV subtypes automatically, even if the pap is normal.  If this test is negative, then women can go to every 3 year pap tests because, without a high risk subtype, you will not develop cervical cancer. The HPV DNA test is not indicated in women in their 20’s because this age group tends to have transient HPV infections that do not indicate a heightened risk.

Decreasing pap screening has the benefit of reducing patient anxiety and further interventions and surgeries when the woman’s body was going to clear the infection on its own.  We still recommend yearly breast and pelvic exams despite the changes in pap screening intervals.  And young women between the ages of 9-26 should be offered the Gardasil vaccine which protects against the 4 major HPV subtypes that cause 70% of cervical cancer and 90% of genital warts. 

Resources: SEER database, ACOG practice bulletin, ASCCP consensus guidelines, Moore AJOG 2007, Schiffman NEJM 2005, Naucler NEJM 2007