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The Scoop on Pap Smears
In this episode, Dr. Evans (Physician, WakeMed OB-GYN) talks about what is a pap smear, what to do with an abnormal pap smear and the screening process.
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Learn more about Joanna Evans, MD
Joanna Evans, MD
Dr. Joanna Perez Evans is an OB/GYN physician with clinical interests in minimally-invasive gynecologic surgery, high-risk obstetrics, family planning and contraception and weight management. She earned her medical degree from the Duke University School of Medicine and completed a residency in obstetrics and gynecology from Magee Women’s Hospital of UPMC in Pittsburgh, PA.Learn more about Joanna Evans, MD
Transcription:
The Scoop on Pap Smears
Deborah Howell (Host): If you're a woman, your gynecologist has probably advised you to get one of these at your next visit, but what is a pap smear screening anyway, and who should be getting one? Let's get this scoop on pap smears with Dr. Joanna Evans, a board certified OB GYN physician with WakeMed, OB GYN. Dr. Evans. So good to have you with us. What is a pap smear?
Joanna Evans, MD: Thank you. It's so good to be here. What's really important for women to understand is that when we say pap smear, we are specifically referring to a screening test that we are collecting and sending to the lab to screen a woman for cervical cancer or the changes that can lead to cervical cancer. One thing that I hear a lot in talking with patients is that they'll tell me, yeah, I went to the emergency room for pelvic pain, or I went to urgent care for some vaginal discharge and they did a pap smear there.
Probably what they did in those settings was a pelvic exam where they were looking at your cervix, maybe testing for infections, but they probably did not actually collect that specimen to screen you for cervical cancer, precancerous changes. And so that pap smeer specimen is something that we would typically collect at an annual visit or an appointment with a gynecologist.
Deborah Howell (Host): Got it. What about Pap history and cytology?
Joanna Evans, MD: So when we say cytology, what that means is basically cells. And so what happens when we collect a pap smear is we use a brush to brush some cells off of your cervix. Those cells then are put into a little container of fluid and they're sent off to the lab where a pathologist looks at them under a microscope. So when they look at that cytology, they are looking to see if those cells look normal. If those cells look mildly abnormal, or if they see any cells that look concerning for a precancer or a cancer of the cervix.
Deborah Howell (Host): And let's talk a little bit about HPV screenings and infection.
Joanna Evans, MD: Yeah. So almost all cervical cancers are caused by infection with the HPV virus. Now HPV is a sexually transmitted infection, but we think about it very differently than we think about any other sexually transmitted infection. The reason why is that most people are gonna have it at some point in their life. No one really knows that they have it, unless it shows up on a pap smear because there's no symptoms. And most of the time that infection is gonna go away on its own over time.
But HPV infection is the big risk factor for developing a pre-cancer or a cancer of the cervix. In around 2012, what happened is that we added routine HPV testing. With a lot of pap smear screening. That's why about 10 years ago, you may remember you used to get that annual pap smear. Every time you went to see your doctor, 10 years ago, we may have told you, you can start just getting the pap every three years or every five years.
The reason is because now in select groups of women, we screen for an HPV infection with that pap smear cytology that we talked about. If that HPV test is negative, the chance of having a precancer or a cancer of the cervix is very low. But if that HPV test is positive, that tells us that we need to look a little bit closer to make sure that there's not a precancer on the cervix that we might need to treat.
Deborah Howell (Host): Sure more information's always better. What about the spectrum of cervical dysplasia detected on pap smeers?
Joanna Evans, MD: Yeah. So cervical dysplasia refers to the HPV related abnormalities that we might see on a pap smear. And so basically, things that we can see on your pap smear, the cells may be completely normal. You may have what's called mild dysplasia, which basically means there's been an HPV infection here. We can tell from looking at the cells that there's been an HPV infection, but those changes are mild. There's nothing that looks like a pre-cancer, there's nothing that is at high risk of turning into a cervical cancer right now.
In most cases that mild dysplasia is gonna go away on its own over time, but we do wanna monitor it to make sure that that is what happens. The other thing that we can find on a pap smear is what we would call moderate or severe dysplasia. You might hear that referred to as CIN2 or CIN 3 or sometimes AIS or atypical glandular cells. And that those are changes that are higher risk that are either considered precancerous now, or are high risk to become a precancer or a cancer of the cervix, usually over the next several years. And so it's those high grade moderate or severe changes that are the ones that we really think about treating.
Deborah Howell (Host): Well, thank you for that explanation. Now, how often do we need to get pap smears?
Joanna Evans, MD: That depends on your age and your history. So in general, now we start pap smear screening at age 21. That's a big change from over 10 years ago where women would often start pap smear screening at the point that they started birth control or became sexually active. But now we know that in younger women, if they do get an HPV infection, the chance that it's going to go away on its own is so high, that we don't need to start doing that routine screening until age 21. For women who are 21 to 29, pap smears are generally recommended every three years.
When women turn 30, we start doing routine HPV testing with that pap smear cytology. And if that's all normal, that actually allows us to space those pap smears out to every five years for women who are over 65, if their pap smears have always been normal, they can generally stop doing cervical cancer screening. Now those guidelines will definitely change if you've had abnormal paps in the past, we can certainly we may need to repeat pap smears more frequently to keep an eye on something. But for women whose paps have always been normal, those are the general rules.
Deborah Howell (Host): Let's talk about those exceptions, maybe women who've had partial hysterectomies or total hysterectomies?
Joanna Evans, MD: Yeah. So as a gynecologist there are two types of hysterectomies that I think about in most hysterectomies, we are removing the uterus and the cervix. Sometimes people will have, what's called a super cervical hysterectomy where the uterus is removed and the cervix is left in place. If you've had a hysterectomy and they removed the cervix and you did not have abnormal pap smears prior to having your hysterectomy, you do not need cervical cancer screening anymore. However, if you had a hysterectomy, they took out your uterus, but left your cervix in, then we would continue to screen you, since that organ is still there and you are still at risk for cervical.
Deborah Howell (Host): Okay. Are there any other circumstances where one would need pap screening beyond, 65?
Joanna Evans, MD: Yes. So for women who have had a moderate or severe abnormality in the last 25 years, we wanna make sure that we're continuing pap smears for 25 years after that. So if a woman has a leap procedure or a cone biopsy to treat a severe abnormality of the cervix at age 50 in theory, we would continue to follow pap smears out to age 75.
Deborah Howell (Host): When can people who have not had that circumstance stop getting pap smears?
Joanna Evans, MD: Usually 65, and that's a conversation to have with your doctor to review your history, to make sure that that's a good time for you to stop.
Deborah Howell (Host): Okay. Sounds good. Now let's talk about colposcopy and management of mild versus high grade dysplasia?
Joanna Evans, MD: In most cases, if you have an abnormal pap smear result, come back, your doctor may talk to you about a procedure called a colposcopy, which is the next step in evaluating an abnormal pap smear. Now, sometimes you might have an abnormal pap smear that doesn't need a colposcopy. You're low risk enough for having a precancer of the cervix that we just repeat a pap smear in a year, and the chance of having a precancer before a year is so low that we don't need to do any further investigation. However, for women who have mild changes, detected on a pap smear and have a simultaneous HPV infection, or for women who have moderate or severe looking changes on a pap smear, the next step is a procedure called colposcopy.
That's where you would come into our office. And we would do a procedure where we look at your cervix under a microscope, basically to get a magnified view of the cervix. We usually put a vinegar solution on the cervix that makes any abnormal areas of the cervix detectable to our eye. And that lets us take targeted biopsies of any areas of the cervix that look abnormal. Those biopsies are gonna tell us whether a woman needs treatment for a pre-cancer of the cervix.
Deborah Howell (Host): Got it. And what about excisional biopsy procedure?
Joanna Evans, MD: Excisional biopsies would refer to the treatment that we usually do when we do find a precancer of the cervix. And the types of excisional biopsies that we do are leap procedures, and cold knife, cone procedures. A leap procedure is usually done in your doctor's office. And your doctor would use an electric loop to actually try to remove the abnormal part of the cervix, a cold knife cone biopsy we would normally do in the OR, or operating room. For someone that we're a little bit more worried about, where we would try to remove as much of that cervical tissue as we could. And those biopsies will treat precancerous changes as well as sometimes helping us get a diagnosis and confirm that there's no cancer hiding in the cervix for women where we do find a precancer.
Deborah Howell (Host): And that's always the goal is to find anything that could be hiding that we need to find out about. Right.
Joanna Evans, MD: That's exactly right.
Deborah Howell (Host): Should I see my gynecologist if I'm not due for a pap smear?
Joanna Evans, MD: Yeah. So that's a great question. We love seeing our patients every year for annual exams. I think especially if you're a woman of reproductive age, you're having periods. It's never a bad idea to come and see your gynecologist every year to check in about how your periods are doing. Birth control. We will make sure that you're up to date on your other well, woman screenings like mammogram, colonoscopy, vaccinations. There are some women who see a primary care provider that's very savvy in women's health.
They may even do your pap screening and will address those issues for you. And so if you're seeing your primary care provider for a physical every year and you are getting that well, woman screening, including breast exam, then you don't necessarily have to come see a gynecologist. But we love seeing our patients every year for a well woman visit to check in about how things are going, even if they're not due for a pap smear.
Deborah Howell (Host): I can tell you do enjoy it. And Dr. Evans, we really appreciate all your good work and it's been so great to have you on today. Thanks so much for your.
Joanna Evans, MD: Thank you. I've had a great time talking with you.
Deborah Howell (Host): That's Dr. Joanna Evans, a board certified OB GYN physician with WakeMed, OB GYN. I'm Deborah Howell with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Thanks for checking out this episode. To find a WakeMed OB GYN location near you or to schedule an appointment, please visit. wakemed.org. And if you found this podcast helpful, please share it on your social channels, that'll help us out a lot and be sure to check out the entire podcast library for topics of interest to you. Thanks for listening and have a great day.
The Scoop on Pap Smears
Deborah Howell (Host): If you're a woman, your gynecologist has probably advised you to get one of these at your next visit, but what is a pap smear screening anyway, and who should be getting one? Let's get this scoop on pap smears with Dr. Joanna Evans, a board certified OB GYN physician with WakeMed, OB GYN. Dr. Evans. So good to have you with us. What is a pap smear?
Joanna Evans, MD: Thank you. It's so good to be here. What's really important for women to understand is that when we say pap smear, we are specifically referring to a screening test that we are collecting and sending to the lab to screen a woman for cervical cancer or the changes that can lead to cervical cancer. One thing that I hear a lot in talking with patients is that they'll tell me, yeah, I went to the emergency room for pelvic pain, or I went to urgent care for some vaginal discharge and they did a pap smear there.
Probably what they did in those settings was a pelvic exam where they were looking at your cervix, maybe testing for infections, but they probably did not actually collect that specimen to screen you for cervical cancer, precancerous changes. And so that pap smeer specimen is something that we would typically collect at an annual visit or an appointment with a gynecologist.
Deborah Howell (Host): Got it. What about Pap history and cytology?
Joanna Evans, MD: So when we say cytology, what that means is basically cells. And so what happens when we collect a pap smear is we use a brush to brush some cells off of your cervix. Those cells then are put into a little container of fluid and they're sent off to the lab where a pathologist looks at them under a microscope. So when they look at that cytology, they are looking to see if those cells look normal. If those cells look mildly abnormal, or if they see any cells that look concerning for a precancer or a cancer of the cervix.
Deborah Howell (Host): And let's talk a little bit about HPV screenings and infection.
Joanna Evans, MD: Yeah. So almost all cervical cancers are caused by infection with the HPV virus. Now HPV is a sexually transmitted infection, but we think about it very differently than we think about any other sexually transmitted infection. The reason why is that most people are gonna have it at some point in their life. No one really knows that they have it, unless it shows up on a pap smear because there's no symptoms. And most of the time that infection is gonna go away on its own over time.
But HPV infection is the big risk factor for developing a pre-cancer or a cancer of the cervix. In around 2012, what happened is that we added routine HPV testing. With a lot of pap smear screening. That's why about 10 years ago, you may remember you used to get that annual pap smear. Every time you went to see your doctor, 10 years ago, we may have told you, you can start just getting the pap every three years or every five years.
The reason is because now in select groups of women, we screen for an HPV infection with that pap smear cytology that we talked about. If that HPV test is negative, the chance of having a precancer or a cancer of the cervix is very low. But if that HPV test is positive, that tells us that we need to look a little bit closer to make sure that there's not a precancer on the cervix that we might need to treat.
Deborah Howell (Host): Sure more information's always better. What about the spectrum of cervical dysplasia detected on pap smeers?
Joanna Evans, MD: Yeah. So cervical dysplasia refers to the HPV related abnormalities that we might see on a pap smear. And so basically, things that we can see on your pap smear, the cells may be completely normal. You may have what's called mild dysplasia, which basically means there's been an HPV infection here. We can tell from looking at the cells that there's been an HPV infection, but those changes are mild. There's nothing that looks like a pre-cancer, there's nothing that is at high risk of turning into a cervical cancer right now.
In most cases that mild dysplasia is gonna go away on its own over time, but we do wanna monitor it to make sure that that is what happens. The other thing that we can find on a pap smear is what we would call moderate or severe dysplasia. You might hear that referred to as CIN2 or CIN 3 or sometimes AIS or atypical glandular cells. And that those are changes that are higher risk that are either considered precancerous now, or are high risk to become a precancer or a cancer of the cervix, usually over the next several years. And so it's those high grade moderate or severe changes that are the ones that we really think about treating.
Deborah Howell (Host): Well, thank you for that explanation. Now, how often do we need to get pap smears?
Joanna Evans, MD: That depends on your age and your history. So in general, now we start pap smear screening at age 21. That's a big change from over 10 years ago where women would often start pap smear screening at the point that they started birth control or became sexually active. But now we know that in younger women, if they do get an HPV infection, the chance that it's going to go away on its own is so high, that we don't need to start doing that routine screening until age 21. For women who are 21 to 29, pap smears are generally recommended every three years.
When women turn 30, we start doing routine HPV testing with that pap smear cytology. And if that's all normal, that actually allows us to space those pap smears out to every five years for women who are over 65, if their pap smears have always been normal, they can generally stop doing cervical cancer screening. Now those guidelines will definitely change if you've had abnormal paps in the past, we can certainly we may need to repeat pap smears more frequently to keep an eye on something. But for women whose paps have always been normal, those are the general rules.
Deborah Howell (Host): Let's talk about those exceptions, maybe women who've had partial hysterectomies or total hysterectomies?
Joanna Evans, MD: Yeah. So as a gynecologist there are two types of hysterectomies that I think about in most hysterectomies, we are removing the uterus and the cervix. Sometimes people will have, what's called a super cervical hysterectomy where the uterus is removed and the cervix is left in place. If you've had a hysterectomy and they removed the cervix and you did not have abnormal pap smears prior to having your hysterectomy, you do not need cervical cancer screening anymore. However, if you had a hysterectomy, they took out your uterus, but left your cervix in, then we would continue to screen you, since that organ is still there and you are still at risk for cervical.
Deborah Howell (Host): Okay. Are there any other circumstances where one would need pap screening beyond, 65?
Joanna Evans, MD: Yes. So for women who have had a moderate or severe abnormality in the last 25 years, we wanna make sure that we're continuing pap smears for 25 years after that. So if a woman has a leap procedure or a cone biopsy to treat a severe abnormality of the cervix at age 50 in theory, we would continue to follow pap smears out to age 75.
Deborah Howell (Host): When can people who have not had that circumstance stop getting pap smears?
Joanna Evans, MD: Usually 65, and that's a conversation to have with your doctor to review your history, to make sure that that's a good time for you to stop.
Deborah Howell (Host): Okay. Sounds good. Now let's talk about colposcopy and management of mild versus high grade dysplasia?
Joanna Evans, MD: In most cases, if you have an abnormal pap smear result, come back, your doctor may talk to you about a procedure called a colposcopy, which is the next step in evaluating an abnormal pap smear. Now, sometimes you might have an abnormal pap smear that doesn't need a colposcopy. You're low risk enough for having a precancer of the cervix that we just repeat a pap smear in a year, and the chance of having a precancer before a year is so low that we don't need to do any further investigation. However, for women who have mild changes, detected on a pap smear and have a simultaneous HPV infection, or for women who have moderate or severe looking changes on a pap smear, the next step is a procedure called colposcopy.
That's where you would come into our office. And we would do a procedure where we look at your cervix under a microscope, basically to get a magnified view of the cervix. We usually put a vinegar solution on the cervix that makes any abnormal areas of the cervix detectable to our eye. And that lets us take targeted biopsies of any areas of the cervix that look abnormal. Those biopsies are gonna tell us whether a woman needs treatment for a pre-cancer of the cervix.
Deborah Howell (Host): Got it. And what about excisional biopsy procedure?
Joanna Evans, MD: Excisional biopsies would refer to the treatment that we usually do when we do find a precancer of the cervix. And the types of excisional biopsies that we do are leap procedures, and cold knife, cone procedures. A leap procedure is usually done in your doctor's office. And your doctor would use an electric loop to actually try to remove the abnormal part of the cervix, a cold knife cone biopsy we would normally do in the OR, or operating room. For someone that we're a little bit more worried about, where we would try to remove as much of that cervical tissue as we could. And those biopsies will treat precancerous changes as well as sometimes helping us get a diagnosis and confirm that there's no cancer hiding in the cervix for women where we do find a precancer.
Deborah Howell (Host): And that's always the goal is to find anything that could be hiding that we need to find out about. Right.
Joanna Evans, MD: That's exactly right.
Deborah Howell (Host): Should I see my gynecologist if I'm not due for a pap smear?
Joanna Evans, MD: Yeah. So that's a great question. We love seeing our patients every year for annual exams. I think especially if you're a woman of reproductive age, you're having periods. It's never a bad idea to come and see your gynecologist every year to check in about how your periods are doing. Birth control. We will make sure that you're up to date on your other well, woman screenings like mammogram, colonoscopy, vaccinations. There are some women who see a primary care provider that's very savvy in women's health.
They may even do your pap screening and will address those issues for you. And so if you're seeing your primary care provider for a physical every year and you are getting that well, woman screening, including breast exam, then you don't necessarily have to come see a gynecologist. But we love seeing our patients every year for a well woman visit to check in about how things are going, even if they're not due for a pap smear.
Deborah Howell (Host): I can tell you do enjoy it. And Dr. Evans, we really appreciate all your good work and it's been so great to have you on today. Thanks so much for your.
Joanna Evans, MD: Thank you. I've had a great time talking with you.
Deborah Howell (Host): That's Dr. Joanna Evans, a board certified OB GYN physician with WakeMed, OB GYN. I'm Deborah Howell with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Thanks for checking out this episode. To find a WakeMed OB GYN location near you or to schedule an appointment, please visit. wakemed.org. And if you found this podcast helpful, please share it on your social channels, that'll help us out a lot and be sure to check out the entire podcast library for topics of interest to you. Thanks for listening and have a great day.