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Annual gyn visit critical even if Pap smears unnecessary

Pap smear screenings for cervical cancer were introduced in the 1940s, and they have dramatically decreased the number of cases and deaths from this disease. Still, every year more than 12,000 women in the United States find out that they have invasive cervical cancer, and approximately 4,000 die of the disease. Most of the women who are diagnosed with invasive cervical cancer have either not had a Pap smear in five or more years or have never had one.

Pap test
The test itself is simple, quick and painless. The health care practitioner collects a sample of cells from a woman's cervix, which is the end of the uterus that extends into the vagina. The cells are examined under a microscope to detect the presence of abnormal cells. The sensitivity of the smear is extremely good, although not perfect. In most cases, a Pap test does identify minor cellular abnormalities before they have had a chance to become malignant and at a point when the condition is most easily treatable.

There is some controversy about who should have an annual Pap smear and when women should begin and when it's safe to stop. There are some differences in recommendations among various organizations such as the American Cancer Society, the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force (USPSTF), which is cited in the study in question.

The USPSTF suggests beginning screening for cervical cancer within three years of beginning sexual activity or age 21, whichever comes first, and screening at least every three years. The group recommends against routinely screening women older than 65 if they have had a series of normal Paps and do not fall into certain high-risk categories.

Women who have had hysterectomies: Pap or no Pap?
My perspective is that if a woman has had a hysterectomy that includes removal of the cervix because of fibroids, which is the most common reason for the surgery, she probably does not need to have Pap tests. When a woman doesn't have a cervix, doctors scrape cells from the vagina instead. Vaginal cancer is exceedingly rare, and tests of vaginal cells are more likely to result in false positives than they are to detect vaginal cancer.

Many patients, however, ask for Pap smears and feel more secure if their annual visit to their gynecologist includes one, even if technically they may rarely detect any disease. And it's important to emphasize, women who have had hysterectomies because of precancerous or cancerous conditions need to continue to have Pap tests.

Guidelines may not tell the whole story
Almost every gynecologist, myself included, has a story about a patient who has benefited from having a Pap test even though the guidelines may not have considered it to be necessary. A patient of mine, in a monogamous marriage for more than 20 years, who had had several normal Paps, was found to have high-grade cervical cancer in situ. I was skeptical of the accuracy of the test and repeated the Pap three times. When all the tests came back positive, I did a cone biopsy, which confirmed the diagnosis. If I had followed the guidelines, this woman may well have gone on to develop invasive cancer.

Also, other cancers may be picked up by a Pap smear. About a quarter of the cases of endometrial cancer are picked up with Pap tests. And, I had a patient who had a normal pelvic exam, but the cells on her Pap smear were suggestive of ovarian disease. I performed a D and C, which was normal, but a sharp-eyed pathologist was suspicious of the cells on her Pap smear, and it turned out that the patient was shedding cancer cells from her ovaries, which were picked up by her fallopian tubes, passed to the uterus and on to her cervix. Admittedly this was exceedingly rare, but this woman's ovarian cancer would not have been detected at this early stage if she had not had a Pap smear even though she was not at high risk of cervical cancer.

Nearly all gynecologists have these stories, and I believe that's the primary reason why screening recommendations are not always followed consistently.

Annual gyn visit important
Many women equate their annual gyn visit with a Pap smear. If we exclude the Pap test, these women may not make a habit of scheduling an annual visit with a gynecologist. Women who have had hysterectomies still need to see their gynecologist regularly for other screenings, such as ovarian exams if they still have ovaries and breast exams. And young, sexually active women need an annual visit to screen for sexually transmitted diseases even if they have not been sexually active for more than three years.

My advice is to make sure you schedule an annual visit with your gynecologist. It is important for several reasons. If you are not sure you need to have a Pap smear, discuss it with your doctor during your visit and he or she will consider all of your individual health factors and, together, you can decide what is best for you.

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Dr. Minkin is an attending gynecologist at Yale-New Haven Hospital and a clinical professor in obstetrics and gynecology at the Yale School of Medicine. She is a partner of the Gynecology and Infertility Group with offices in New Haven, Guilford and Essex.