Pap Smear Recommendations
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Christina Chu, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: January 7, 2004
Within the past 2 years, the American Cancer Society issued new recommendations for cervical cancer screening. These recommendations were reviewed and endorsed by the Society of Gynecologic Oncologists and the Gynecologic Cancer Foundation as well. The newer guidelines represent some important changes from the past recommendations, particularly in regards to how frequently a woman needs to be tested. Women should keep in mind that having a pelvic examination is not the same thing as having a Pap test to screen for cervical cancer. A pelvic examination where a physician evaluates the pelvic organs (such as the vulva, vagina, cervix, uterus and ovaries) is part of routine health care for women and is recommended on a yearly basis. Cervical cancer screening may be performed before a pelvic examination at the same office visit, but is not the same thing.
When should I start getting tested for cervical cancer?
Women are advised to begin Pap testing either three years after the onset of vaginal intercourse, or at the age of 21, whichever comes first. It is important to note that Pap testing is only one part of comprehensive gynecologic care. Any adolescent who is currently sexually active or contemplating sexual activity should seek gynecologic care and be provided appropriate preventative health care, contraception counseling, as well as screening and treatment for sexually transmitted disease.
How often do I need to be tested for cervical cancer?
After the initiation of cervical cancer screening, women should continue to undergo testing with either a conventional Pap smear every year, or a liquid-based Pap test (such as Thin Prep) every 2 years. At or after the age of 30, women who have had 3 consecutive normal tests may then have screening extended to once every 2 to 3 years. An important exception to this recommendation is for women who are at higher risk of cervical cancer-such as women exposed to DES in utero, or those who are HIV positive or immunocompromised for another reason.
Some laboratories may offer human papilloma virus (HPV) DNA testing that may be done at the same time as a Pap test. Currently, HPV testing is only indicated in cases when the Pap test shows "atypical cells of undetermined significance" or ASCUS. In this case, when additional testing shows the presence of high risk HPV, patients should undergo colposcopy for further evaluation. Patients with the diagnosis of ASCUS who test negative for high risk HPV may be followed with another Pap test in approximately 6 months.
Is there a time when I can stop getting tested for cervical cancer?
Under the new guidelines, women may decide to stop getting Pap tests when they have met all the following criteria:
- age 70 or older
- three consecutive normal Pap tests in the last 10 years
- no abnormal Pap tests in the last 10 years
- no history of in utero exposure to DES, or immunocompromise (including HIV positivity).
Every patient should discuss the decision to stop getting routine screening for cervical cancer with their physician to evaluate the risk and benefits of testing. Women who are at increased risk for cervical cancer (in utero exposure to DES, or immunocompromised status) should continue screening as long as they are in reasonably good health. Until more studies are done, women who have tested positive for HPV should also continue screening at the discretion of their physician. The new recommendations state that women with life-threatening illnesses may forego testing for cervical cancer.
Do I need to be tested for cervical cancer if I have had a hysterectomy?
If the entire cervix has been removed, and if the hysterectomy was performed for benign reasons, routine Pap testing of the vagina is not necessary. It is important for physicians and patients to review pathology reports and medical history to make certain that the entire cervix was removed and that the hysterectomy was performed for benign reasons. The presence of CIN2 or 3 (moderate or severe dysplasia) is NOT considered to be a benign reason for surgery.
For those women who have had a hysterectomy, the following still require Pap testing:
- any woman who has had a subtotal (or supracervical) hysterectomy
- hysterectomy was performed for gynecologic cancer
- hysterectomy was performed with the presence of CIN 2 or 3
- it is not possible to confirm the absence of CIN 2 or 3 prior to hysterectomy
- women exposed to DES in utero.