The Pap Education

Are women demanding unnecessary tests?

By Megy Karydes

A cancer that starts the day after a negative Papanicolaou (Pap) test, under the new guidelines, may have three years to develop before the next Pap test detects it.

An annual Pap test for a healthy, sexually active woman used to be the norm as a preventive measure against cervical cancer. But in 2009, The American College of Obstetricians and Gynecologists (The College) began urging less frequent screenings and came down firm in 2012 in its recommendation that most women should be screened for cervical cancer no more often than once every three to five years.

A more alarming report recently released by the Centers for Disease Control and Prevention (CDC) indicates that about 60 percent of women who have had total hysterectomies are still being tested for cervical cancer, despite no longer having cervixes, and tests still continue in light of the fact that routine screening for cervical cancer by Pap testing is no longer recommended by The College for women who have undergone a total hysterectomy (the removal of the uterus including the cervix) or for adequately screened women over the age of 65. Its guidelines align with the American Cancer Society’s, which also recommends that women who have had a total hysterectomy not receive Pap and HPV tests unless the hysterectomy was done as a treatment for cervical precancer or cancer.

So why are annual Pap tests still so common? Many physicians insist that women are demanding them at their annual visits. Patients say they are relying on their doctor’s recommendations. Is it confusion or lack of dialogue that’s at the heart of the matter?

“Many women don’t feel they’ve had a proper gynecological exam without a Pap test, even if they’ve had a full hysterectomy and don’t need one,” says Dr. Lauren Streicher, assistant clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine and author of The Essential Guide to Hysterectomy.

“Also, after a lifetime of being told you need to have one annually, it’s sometimes hard for a patient to understand why suddenly she only needs to have it done every three to five years. Many women still request a Pap even when they have been educated about the new guidelines. If it makes them feel less anxious, I’m happy to do it. Peace of mind is worth a lot,” Streicher says.

Naomi Czerwinskyj, 30, of Chicago, says she never asked her doctor whether the Pap was needed annually because, until recently, it was always done. “I suppose I always assumed that since my doctor offered it every year, it was a normal procedure, and so I never asked,” she says.

This year, though, her doctor told her that an annual Pap test wasn’t necessary as long as the previous test was normal. “I was not told by my doctor explicitly that the new recommendation applied to women with no history of cervical cancer in their family or abnormal test results,” Czerwinskyj says. “The concept was confusing to me because I don’t think she explained it well. I understood from her that as long as the previous Pap was normal, they didn’t need to test. Of course, afterwards I questioned the validity of that.”

For some patients who have other medical problems, trying to remember when your last Pap test was done can be confusing in and of itself if it’s not done annually.

Niles resident, Toni Vlahoulis, 45, had a partial hysterectomy early in 2011. She can’t recall whether she had a Pap test or not since then or whether her doctor advised her to continue to have them annually or less frequently. “It’s not that I feel she’s doing a poor job, but I have more to worry about in terms of my health than just a Pap,” says Vlahoulis. “I trust that if I need one, she’ll do it. And if I don’t, she won’t.”

“Despite much information on Pap smear testing, surprisingly, many women do not know why Pap smears are done,” says Camilla Bicknell, a women’s health nurse practitioner in Colorado and co-author of the Pregnancy Power Workbook. In addition, she says, to women believing they needed to have one done every year, many thought it was somehow tied to getting contraception or hormone replacement. “This was oftentimes reinforced by medical practices that passed on the adage, ‘You’ve got to get your Pap, or you can’t get your pills’,” Bicknell says.

Bicknell recognizes that confusion can be a serious problem on both the physician and patient sides, which is why she recommends that each have an open-communication policy.

“Rather than asking one’s provider to have a Pap smear done when it isn’t recommended, a woman should ask, ‘Do you have information about the newest Pap testing guidelines?’ or, ‘Since I don’t need a Pap smear this year, can we use that time to talk about other preventive services I may need?’ This discussion offers many more benefits, as it opens the door for contraception options, cholesterol levels, cardiac risk, bone health, breast health, colon health, domestic abuse [and other issues],” Bicknell says.

Another reason physicians prefer to continue to use Pap tests is that their patients may not always be forthcoming about how many sexual partners they’ve had. Even if the patient has been monogamous, it’s possible her partner hasn’t been.

According to Dr. Aarathi Cholkeri-Singh, an OB/GYN in a private practice in Naperville and Schaumberg, member of the AAGL (formerly known as the American Association of Gynecologic Laparoscopists), associate director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital and clinical assistant professor of obstetrics and gynecology at University of Illinois at Chicago, from a physician’s perspective, some women’s sexual history may warrant cancer screening outside the guideline recommendations for Pap smear testing.

“Either the woman is with other sexual partners, or she finds out that her partner was with other women,” says Cholkeri-Singh. “Typically, women do not use any form of contraception after a hysterectomy performed at any age or over the age of 65 due to the unlikelihood of a pregnancy. Therefore the spread of HPV is possible without the use of condoms, which may put these women at risk for precancerous lesions. Based on the guidelines, however, these women should not be screened.

“Ultimately, physicians treat individuals based not only on statistics, but on patients’ risks factors. Although the risk of cancer in this subset of women is very low, it is not zero percent. Every woman in our practices has a story, and as physicians, we want to reassure positive healthy outcomes.”

Dr. Suzanne Trupin, clinical professor of obstetrics and gynecology at the University of Illinois College of Medicine at Urbana-Champaign and CEO of Women’s Health Practice in Champaign consider Pap tests to be an incredibly effective and relatively low cost and minimally invasive way of preventing cervical cancer. “Physicians do not want to risk a relapse into the high rates of cervical cancer seen worldwide by any real, or apparent, lack of vigilance,” notes Trupin.

Futhermore, a Pap smear examination is a simple, quick and usually well-tolerated exam and test for women to undergo. This, notes Cholkeri-Singh, in combination with medical insurance companies still covering Pap tests despite the patients’ histories, allows physicians and patients to easily have the test performed on an annual basis.

“Therefore, cost and inconvenience to the patient is minimal,” Cholkeri-Singh adds. “These women are at low risk for a positive test result, but the reassurance of a negative test or the possibility of early detection and prevention is highly [valued] by the woman and physician.”

While it may be true that many patients feel added security knowing a seemingly easy, low-cost test exists to detect cervical cancer early, some patients rely heavily on their doctor’s recommendations, too. The message of not needing an annual Pap test if your history doesn’t warrant it is beginning to reach the perception of Chicagoland women and their physicians.

Monica Nagel, 43, of Glenview was accustomed to having her test annually until last year when her primary care doctor advised that she could return in two years. Cherilyn Easterwood, 39, of Chicago, has hers done every three years, per her gynecologist’s recommendation and has been since 2005.

As all of the physicians remind their patients, the recommendations are just that: recommendations. Each patient is different, and if a test seems like a good option under individual circumstances, they will do the test. However, as more patients and physicians learn of the recommendations, it may be a matter of time until the once-annually recommended test becomes less routine for women.