For most women, the Pap smear is a routine part of the annual well-woman exam performed by our OB-GYN specialists in Queens and Long Island.
What Is a Pap Smear?
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 where cells collected from the cervix are sent to the lab to be examined under a microscope.
- An HPV test to determine whether DNA from the human papillomavirus (HPV) is present in the sample submitted.
Pap Results Are Often Inaccurate
The Pap smear is a pretty crude screening test with many false positives (abnormal results in normal women) and 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.
Why Is the HPV Test Included?
Testing for HPV is used to help triage abnormal Paps. The human papillomavirus causes virtually all cases of cervical cancer and pre-cancer. 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.
What Does a Positive HPV Test Mean?
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; most women with a positive HPV test will eventually have a negative test result. 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.
Can HPV Be Prevented?
Gardasil is an HPV vaccination that helps prevent precancerous and cancerous lesions caused by the 9 HPV strains contained in the vaccine. While the original version was FDA-approved in 2006 for preteens and young adults up to age 26, a new version called Gardasil 9 was approved in 2018 for women and men age 27 to 45.
What Is a Colposcopy and Why Is It Done?
Follow-up of an abnormal Pap usually requires colposcopy, an office procedure that 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) into the vagina to make it easier to see the cervix.
- Swabbing the cervix with vinegar to make it easier to see abnormal cells. Precancerous and cancerous lesions turn white or exhibit other changes when swabbed with vinegar.
- Examining the cervix with a special lighted magnification instrument called a colposcope, which looks similar to binoculars.
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.
What If the Colposcopy Results Are Normal?
We often find that women with mildly abnormal Pap results have a cervix that looks totally normal at colposcopy; typically we ask these patients to return in 4 to 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 at colposcopy, but the biopsy results are normal.
What Happens If Colposcopy Results Are Abnormal?
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 (Dysplasia)
What Is the Treatment for Precancerous Cells of the Cervix?
When pre-cancerous conditions of the cervix require treatment, a minor procedure can either remove or destroy the area in question. In the past, abnormal areas of the cervix were treated with one of the following treatments:
- Cryotherapy: a wand with a frozen tip freezes the abnormal area.
- Laser ablation: a special handpiece is used to vaporize the abnormal area.
Today, treatment for pre-cancerous conditions of the cervix usually consists of a loop electrical excision procedure (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 to 10 minutes to perform, with patients going home shortly after the procedure. Recovery is not painful and patients can generally return to work the next day.
How Effective Is LEEP?
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 that 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.
Follow-up Care Is Essential
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.
May We Help You?
Would you like to find out more about our treatments and services? Are you looking for a second opinion on a diagnosis or treatment recommendation you received at another practice? The experienced team at The Woman’s Health Pavilion is happy to help. Just let us know how and when you’d like to hear from us.