As Certified Nurse Midwives, your team here at Seasons Midwifery & Birth Center, is proud to offer our clients the full range of Women’s Health Care options. One of these options is routine screening for cervical cancer through pap smear testing. Let’s spend some time here, clearing up some confusion around this important topic.
One of the most common sources of confusion that I encounter among my clients is surrounding the pap smear. Often, folks don’t know why they are done, how they are done or how important they are. Many clients I have counseled believe that anything “done down there” is a pap smear. As a midwife, I enjoy the opportunity to provide education and help my clients understand the process and need for this testing. The bottom line, or take-home message, should be pap smears save lives! At the beginning of the 20th century, cervical cancer was the highest cause of cancer deaths for women and now with screening, it doesn’t even rank in the top 10. Also, even though the new cervical cancer screening guidelines have changed (which is reviewed below), this does not mean that annual well woman exams are not necessary, a pap smear is not the only reason to be seen regularly.
Over 99% of Cervical Cancer is caused by the sexually transmitted Human Papillomavirus (HPV). There are over 100 strains of HPV and most are considered low risk for leading to cervical cancer. Low risk strains are associated with genital warts. The rates and severity of cervical cancer increase with age and are rare in women under 30. With screening, the current rate of cervical cancer in the US has declined to roughly 7 out of 100,000 women.
Cervical Cancer: what, how and why
Unfortunately, there are no outward or noticeable symptoms of cervical cancer until the disease has progressed to a severe level, this is why routine screening is critical. Symptoms of advanced cervical cancer are abnormal vaginal bleeding and discharge, pelvic and abdominal pain and pain with intercourse.
All About the Pap
The Papanicolaou (pap smear) test was introduced to widespread use in the 1950’s and since its introduction, the incidence of cervical cancer deaths in developed nations has dropped up to 70%. The pap smear is the most effective cancer screening test available. During a pap smear, a small sample of cervical cells are taken from the cervical opening. These cells are then sent to a lab for cytology testing; to screen for abnormal cellular growth. Additional testing screens for the presence of HPV. So, there are essentially two tests; the cytology testing or analysis of the cells and the test to assess HPV status. In 2012, new guidelines for the pap smear screening were released and they were a significant change in practice. The change was made with new understanding of the progression of the disease and to decrease the rates of invasive procedures that were not improving outcomes. The guidelines were released by three organizations; The American Society for Colposcopy and Cervical Pathology (ASCCP), The American Cancer Society (ACS) and the American Society of Clinical Pathology (ASCP) .
Begin universal screening of all women at age 21, regardless of onset of sexual activity.
Ages 21-29; cytology screening alone every three years.
Ages 30-64; cytology screening + HPV testing (co-testing) every five years. If co-testing is unavailable, cytology testing alone every three years is acceptable.
Age 65 and older; may stop screening if has a history of either three consecutive negative cytology screens or two consecutive negative HPV tests.
Post hysterectomy: if the cervix is also removed and there is no history of CIN2 or higher within the previous 20 years or cervical cancer ever, then screening is no longer required.
Normal: based on the analysis of the cells there are no abnormal changes suspicious of cancer or pre-cancerous changes.
ASC-US or Atypical Squamous Cells of Undertermined Significance: this is actually an inconclusive result, it means that the cells sampled don’t look normal but they also don’t look abnormal, weird right? It can be a frustrating result to receive. Three quarters of folks with this result will NOT have abnormal cells with further evaluation.
Low-Grade SIL (LSIL) or CIN 1 are mildly abnormal squamous cells that usually resolve on their own.
High-Grade SIL (HSIL), CIN2 or CIN3 are moderate to severely abnormal squamous cells. These cellular changes are strongly linked with a higher risk of becoming cancerous or may mean that there is already underlying cancer. CIN3 may also be called carcinoma in situ, this is an early stage of cancer where tumor cells have not yet invaded surrounding tissue.
HPV results are reported as positive or negative and can be further divided by particular strain of the virus, such as 16 or 18 which are the strains most at risk to develop cervical cancer.
Atypical Glandular Cells (AGC) are abnormal glandular cells, the type found in the endocervical canal.
Adenocarcinoma in Situ (AIS) are pre-invasive cancer cells found in the endocervical canal.
Management of Results
When you receive the results of a pap smear, your Midwife will discuss them with you. In deciding what to do with inconclusive or abnormal results, your choices should be honored and recognized as an integral part of the plan. Additionally, your individual previous health history and current situation should be factored in.
Depending on these factors, the choice may be made to offer follow up testing to gain more information, the first one of these tests is a Colposcopy . This is a relatively simple test that allows your provider to take a closer look at your cervix to determine if there are any cells or areas of cells that look abnormal. If abnormal cells are seen a sample of them, or biopsy, will be collected and sent to a lab for further testing. Based on the results of the biopsy, additional treatments may be recommended. The team here at Seasons Midwifery & Birth Center will help you through any necessary follow up tests.