Demystifying pap smear and pelvic exam guidelines

Gynecological exams used to be simple: Get an annual Pap smear and pelvic exam.

Current guidelines recommend Pap smears every three or five years depending on a woman’s age, as well as an HPV test after a certain age. And in March 2017, the U.S. Preventive Services Task Force (USPSTF) said there’s not enough evidence to determine whether annual pelvic exams should be routine for women who aren’t pregnant or have symptoms of disease.

But I’ve heard from patients who feel like they’re not getting a full exam if they don’t get a Pap smear and pelvic exam. I try to explain that unless you have certain risk factors or symptoms, you may not need them every year.

It can seem confusing, I know. But remember, these guidelines are not one-size-fits-all, which is why it’s so important to find a healthcare provider you are comfortable with and who can educate you about when to be screened and for what.

Do I need a well-woman exam if I’m not due for a Pap smear?

Annual well-woman exams are about far more than Pap smears. Just because you’re not scheduled for a Pap smear to screen for cervical cancer this year doesn’t mean you should skip seeing your doctor.

First of all, they aren’t the only health screenings we recommend for women at different stages of life. For example, you may be due for a cholesterol screening, mammogram or colonoscopy. Depending on the time of year, this exam also may be a good time to get your annual flu shot.

Well-woman exams provide the perfect opportunity to establish a good relationship with your doctor.

During these visits, you can talk about any health concerns you may have, your potential health risks, your lifestyle habits and your contraceptive options, among other things.

Don’t hold back and don’t be embarrassed. If something seems off with your health, ask. Too many women think some medical symptoms are “normal.” For example, they think incontinence is to be expected after having a baby or as they get older. It’s not. There are ways we can treat it. But first, we need to know it’s a problem.

Under the Affordable Care Act, preventive services offered during a well-woman exam should be covered by your insurance. However, you may discuss concerns with your doctor during a well-woman visit that require additional examination or testing. In those cases, we may recommend you make another appointment to avoid billing becoming complicated, and to have enough time to fully discuss your concerns. I know this can be annoying, but we want to avoid you being “well” and “sick” on the same day!

Young women should have their first well-woman visit starting at about 13. These appointments likely will not include a physical exam, but instead will focus on establishing a doctor-patient relationship and providing education on topics such as body changes, your period, living a healthy lifestyle, contraception and the prevention of sexually transmitted infections.

Usually starting at 21, a physical exam will become an important part of every annual visit. Depending on your age, the physical exam may include a clinical breast exam, abdominal exam, taking vital signs and listening to the heart and lungs. You and your doctor also will discuss whether you need a pelvic exam.

When do I need a pelvic exam?

It’s a common misconception that a pelvic exam and Pap smear are the same thing. They’re not.

Pelvic exams are done to detect illness or abnormalities in a woman’s external genitalia and reproductive organs, including the vagina, cervix, uterus, fallopian tubes and ovaries. Some women find pelvic exams uncomfortable – physically or emotionally – but they only take a few minutes.

There are three parts to the test:

  • External visual exam: Your doctor will look for signs of redness, swelling, lesions or abnormalities on the external genitalia.
  • Internal visual exam: You doctor will insert a speculum, a metal or plastic medical tool, to widen the vagina in order to examine the vagina and cervix.
  • Bimanual exam: Your doctor will place one or two fingers in the vagina and use the other hand to press down on the outside of your body on the area they are feeling to check the size and shape of the uterus and ovaries, as well as feel for masses.

If you’re due for a Pap smear and HPV test, the doctor will collect the cell sample during the pelvic exam.

Pelvic exams traditionally have been recommended for women 21 and older. But in recent years, the accuracy of the exam to detect problems such as ovarian cancer in women who didn’t have symptoms has come under scrutiny. Some medical societies also have noted the exam’s potential downsides, which include false positives that can lead to anxiety and potentially unnecessary and costly additional testing.

The USPSTF said more research needs to be done to definitively recommend for or against routine pelvic exams. In the meantime, it advises women to discuss with their doctors when and how often they need pelvic exams.

We never want to cause harm or put women through unnecessary exams. Analyzing an individual patient’s need for a pelvic exam offers us an opportunity to more actively discuss what’s going on with a woman’s body, including whether they are experiencing symptoms such as:

  • Abdominal pain
  • Bloating
  • Bleeding outside of your normal period
  • Constipation
  • Pelvic pressure or a sensation of a bulge coming outside your vagina
  • Problems during sex, such as pain or dryness
  • Urinary incontinence
  • Vaginal discharge

If symptoms such as these aren’t present, we may recommend that you not need a pelvic exam that year. But other years, we may want to perform one to investigate potential problems.

You don’t need a pelvic exam to be prescribed contraception such as the pill, patch, shot or implant if you are healthy with no abnormal discharge, bleeding or other concerns. We don’t want to put up unnecessary hurdles to getting birth control. However, you may need a pelvic exam if you want a diaphragm or intrauterine device (IUD).

How often should I get a Pap smear and HPV test?

Cervical cancer is nearly always preventable with HPV vaccinations and regular screening.

Unfortunately, nearly 13,000 women in the U.S. will have cervical cancer and more than 4,000 will die of the disease in 2017, according to the American Cancer Society. And the District of Columbia is on the high end of states for cervical cancer rates, with 8.3 per 100,000 women getting cervical cancer. The national average is 6.7 per 100,000.

We use two tests to screen for cervical cancer or cell changes that could turn into cervical cancer:

  • Pap smear: This test looks for precancerous cells on the cervix, which can become cervical cancer if not treated. To perform this test, your doctor will gently scrape cells from the cervix to be examined in a lab.
  • HPV test: This test looks for the human papillomavirus, which can cause cell changes, and is done at the same time as a Pap smear.

HPV is thought to be responsible for more than 90 percent of cervical cancers, which is why we test for it. According to the Centers for Disease Control and Prevention, four out of every five women will have been infected with HPV at some point by the age of 50. Most will never know they have it.

One note: If you’ve had the HPV vaccine, you still need to follow the screening guidelines.

Your age and health determine when you need screening and which tests you should have.

  • Age 21-29: Women should have a Pap smear every three years.
  • Age 30-65: Women should have a Pap smear and HPV test (known as co-testing) every five years. An alternative is to have a Pap smear alone every three years.

Talk to your doctor about the best pelvic exam and cervical cancer screening schedule for you based on your health and family history. Your doctor may recommend more frequent screening if you have certain health indications, such as a history of cervical cancer or a weakened immune system.

Some women no longer need regular screening, such as if you’ve had a hysterectomy in which the cervix also was removed. Women older than 65 who’ve had regular screenings with normal results can stop unless there is:

  • History of cervical cancer.
  • Immunosuppression due to a transplant, human immunodeficiency virus (HIV) or other condition.
  • History of cervical intraepithelial neoplasia (CIN), which is the development of abnormal cells in the cervix.
  • Exposure to diethylstilbestrol (DES) in the womb. DES was a form of estrogen prescribed to some pregnant women for morning sickness until 1971 and is now known to increase the risk of cancer and potential precursors of cancer such as CIN.

The guidelines for pelvic exams and Pap smears may not be as simple as they once were, but their importance has not lessened. Discuss your screening and exam schedule with your doctor at your next well-woman visit.

Director, Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center

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