The Pap smear is a screening test for cervical cancer. Nowadays, most women having a Pap test done are actually getting two different tests: A traditional Pap, in which cells collected from the cervix are sent to the lab to be examined under a microscope, and also an HPV test, which determines whether DNA from the HPV virus is present in the sample submitted.
The Pap smear is a pretty crude screening test, with many false positives (abnormal results in normal women) and also many false negatives (normal results in women with cervical disease). As such, many of the women who are asked to return for evaluation of an abnormal Pap test are found to be perfectly OK. Sometimes these false positive Paps can be explained by a recent vaginal infection, or trauma to the cervix due to douching, tampons, or intercourse; sometimes the false positives just represent an inherent limitation of the test.
Testing for HPV is used to help triage abnormal Paps. The Human Papillomavirus causes virtually all cases of cervical cancer and pre-cancer, and DNA from the virus can be found in the cervical and vaginal secretions of almost all women with these conditions. Thus, an abnormal Pap with a positive HPV test is more likely to represent a true disease process than an abnormal Pap with a negative HPV test.
HPV is a very common virus: About one quarter of women going through college will be exposed to HPV during their college years. In most cases, your body will effectively fight the HPV virus, and the expected result for most women with a positive HPV test is that their test will eventually turn negative. It is impossible to prove that the HPV is completely cleared in such cases—and not just present in a low-level dormant state—but having many consecutive negative tests over several years suggests that the virus may actually be cleared from your system altogether. Many women will have at least one positive HPV test at some point in their lives; a smaller number will be persistently positive; among those persistently positive, a few will require treatment for precancerous conditions.
HPV is a very common virus. About one quarter of women going through college will be exposed to HPV during their college years.
Since we introduced HPV testing in our practice in 2005, we have had conversations with patients about positive HPV results virtually every day—that’s how common the virus is. Interestingly, we have yet to see a case of invasive cervical cancer among the thousands of patients in our practice who undergo screening at recommended intervals. The few cases of cervical cancer we do see all seem to fit the same pattern: A patient new to our practice, who is discovered to have cervical cancer after not seeing a gynecologist for many years. Cervical cancer is largely a disease of neglect, and is largely preventable by routine periodic screening with Pap and HPV testing.
Follow-up of an abnormal Pap usually requires colposcopy, an office procedure which allows us to examine the cervix closely for signs of disease. Colposcopy is performed by inserting a speculum (the same instrument we use to collect the Pap smear), swabbing the cervix with vinegar, and examining the cervix with a special pair of binoculars. Because precancerous and cancerous lesions turn white or exhibit other changes when swabbed with vinegar, lesions can be seen using colposcopy. If an abnormal-appearing area is seen, a biopsy may be done; this feels like a pinch in a place you’ve never been pinched. Biopsies are sent to the laboratory to be examined under a microscope.
We often find that women with mildly abnormal Pap results have a cervix which looks total normal at colposcopy; typically we ask such women to return after 4-6 months to repeat their testing so that we can be sure that they’re OK. The same protocol applies if an abnormal-looking area is seen, but the biopsy results are normal.
If the biopsy demonstrates an abnormality, treatment will depend on the severity of the problem. Normal cervical cells do not turn cancerous overnight: Cells on the cervix appear to go through a long pre-cancerous phase called cervical intraepithelial neoplasia (CIN), or dysplasia. It takes several years for cells to go from normal, to low-grade dysplasia (CIN 1), to high-grade dysplasia (CIN 2 and 3), and then to cancer. Whereas high-grade dysplasia almost always requires treatment, many cases of low-grade dysplasia will resolve without treatment, particularly in younger women. Thus, many women with low-grade dysplasia can be closely followed—as long as they are reliable with follow-up.
Cervical Intraepithelial Neoplasia, or Dysplasia
When pre-cancerous conditions of the cervix require treatment, a minor procedure can either remove or destroy the area in question. Treatments such as cryotherapy and laser ablation of the cervix have historically been popular: These procedures employ either a wand with a frozen tip (in the case of cryotherapy) or a special handpiece (in the case of laser ablation) to destroy the abnormal area by freezing or vaporization, respectively. Nowadays, treatment for pre-cancerous conditions of the cervix usually consists of a loop electrical excision procedure, or LEEP. In this procedure, an electrified wire loop is used to shave the face of the cervix where the abnormal cells reside. This outpatient procedure takes just 5-10 minutes to perform, with patients going home shortly after the procedure. Recovery is not painful, and women can generally return to work the next day. The LEEP procedure is more likely to permanently cure dysplasia than either cryotherapy or laser ablation; an added advantage of the LEEP procedure is that it produces a specimen which can be examined by a pathologist, leaving no doubt regarding the extent of disease. Since cryotherapy and laser ablation destroy the area, no specimen can be examined.
The LEEP Procedure. A wire loop is used to excise an abnormal area on the cervix. A ball electrode is then used to control bleeding.
While persistent HPV infection is not unusual, dysplasia is generally curable. Women with abnormal Pap results, positive HPV tests, or known cervical dysplasia must be followed closely, no matter what. If you have been diagnosed with these conditions, your care cannot take a back seat to your work schedule, your budget, or your health insurance coverage. If you have had a lapse in your care, we will welcome you back with no judgment: Our primary concern is to be sure you are safe. New patients who would like to discuss their past results and treatment should try to obtain copies of their past Pap, HPV, and pathology results for us to review.
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