PAP Smear Recommendations

By Frederick R. Jelovsek, M.D

How often is a PAP smear necessary? Different doctors and organizations have different answers. A 1996 conference as recently reported in: Braly, P.S., The NIH consensus conference on cervical cancer: Implications for practice. Primary Care Update for Ob/Gyns 1997 (4):179-183, gave some consensus guidelines.

PAP smears should be started when sexual activity starts or at age 18, whichever is earlier. Three annual PAP smears should performed and after that, smears can be less than annually if a patient is low risk. Few women qualify as low risk, meaning no more than two lifetime sexual partners and a partner with no more than two lifetime partners. Thus many women should continue to have a yearly PAP smear and after age 65, all women should have an annual exam.

Other risk factors for cervical cancer include smoking, lower socioeconomic status, age, having had multiple pregnancies, immunosuppression, and sexually transmitted diseases - especially human papilloma virus (HPV) which is found in 100% of cervical cancers. Certain strains of HPV, types HPV-16, -18, -31, and -45, are high risk and account for 80% of cervical cancer. In spite of this knowledge, there is still no consensus about screening patients who have abnormal PAP smears for these HPV virus types. Studies are ongoing to see if this additional screening in addition to the PAP smear is cost-justified. Most investigators believe that it not only takes years for the progression from HPV infection to malignancy but that it is apparent that the infection alone is not sufficient for the development of cervical cancer. Other cofactors are needed in addition to HPV. Tobacco carcinogenic and mutagenic substances, compromised immune status, dietary deficiencies, radiation exposure and coexisting viral and bacterial infections are thought to somehow enhance a malignant transformation.

It is estimated that as many as 5-20% of persons 15-49 years old are infected with HPV. Vaccines against HPV are currently being developed but they are not going to be available in the near future. If you have ever had abnormal PAP smears or had venereal warts (HPV infection, condyloma accuminata), you should be sure to get an annual PAP smear for the rest of your life.
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