What’s happened to paps?

A new cervical screening program has replaced pap smears; it’s now every five years (instead of two) and a there’s new option available for those who can’t tolerate the examination.

It is with some trepidation that I re-enter the minefield of cervical screening blogs.

The subject has previously caused some fiery debate in this forum. At the risk of sounding overcautious, I want to be very clear up front: this article is intended to be informational only, as an aid to those who choose to participate in the new and (mostly) improved National Cervical Screening Program. I say mostly because, whilst patient outcomes are likely to be better, the implementation process has been a lot for us poor GP’s to get our heads around. Right, now that’s sorted…

What is the new test?

For a pap smear (the old test) cells were collected from the woman’s cervix and smeared onto a glass slide to be examined under a microscope by a pathologist, who looked for any pre-cancerous cell changes. We now know however that Human Papillomavirus (HPV) is the culprit that causes these changes in the first place, so since December 2017 the new screening test is an automated test for HPV DNA, with samples being suspended in liquid and run through a machine. This is backed up by an examination of the cervical cells by a pathologist only if HPV is detected in the sample or the woman has symptoms.

Does that mean no more speculum examinations?

Well, no. You will still need to see your GP or health worker for a speculum examination so that they can examine your cervix for any abnormalities and collect a sample of cells from it with a small brush. If a woman over 30 strongly objects to having speculum exams and/or has declined screening for some years, or if a speculum exam is deemed inappropriate, there is now the option of a self-collected vaginal sample. It’s not as accurate as a sample collected by a clinician but far preferable to not being screened at all, so ask your GP if you’d like more information.

When should I have one?

As detailed on the Department of Health’s (DOH’s) webpage, the new program consists of “a five yearly human papillomavirus (HPV) test for people aged 25 to 74. People will be due for the first Cervical Screening Test two years after their last Pap test. The changes include:

• • the Pap test will be replaced with the more accurate Cervical Screening Test

• • the time between tests will change from two to five years

• • the age at which screening starts will increase from 18 years to 25 years

• • people aged 70 to 74 years will be invited to have an exit test.”

How come it’s only every five years? Surely that’s not as safe as every two years?

HPV causes cervical cancer, so it makes sense that if there is no HPV present in the cervix there won’t be any cell changes either, and it’s unlikely that any new cell abnormalities will arise in the near future. Essentially the test detects the causative agent (HPV) at an earlier stage than cellular changes were detected by paps, so in the absence of any HPV the screening interval can be safely extended. Extensive research and expert recommendations have gone into formulating the program which, according to the DOH, is expected to protect up to 30% more women.

What happens if my HPV test is positive?

If HPV is present the sample will then be examined by a pathologist for cellular abnormalities; what happens after that depends on what type of HPV and cellular changes are present. The highest-risk HPV types for cervical cancer are 16 and 18. If you have 16 or 18 you will be referred for a colposcopy, which is a special speculum examination done by a gynaecologist; they will then be able to advise whether further treatment is needed. If the HPV detected in your sample is not type 16 or 18 the recommendation is likely to be to repeat the test in 12 months, with a strong chance that the infection will have been cleared by your immune system by that time.

I had the HPV vaccinations, so why do I need screening?

The Gardasil vaccine is given to kids in Year 7 and protects against HPV infections when they later become sexually active. A newer version of the vaccine now protects against nine HPV types, but even this will not protect against all the HPV’s that can cause cervical cancer. Your chance of getting cervical cancer is dramatically reduced by vaccination but it’s not zero (up to 90% of cervical cancers are prevented by Gardasil 9) so cervical screening is still recommended. Quitting smoking also significantly reduces your risk of cervical cancer, by the way.

What about the under 25’s?

Pap tests used to start when you were 18 or over and had been sexually active for two years. Now when I tell young women that screening doesn’t start until age 25 many of them are concerned that they will be more at risk of developing cancer before then. Extensive research (as quoted from the Cancer Institute NSW) has demonstrated however that:

• • Cervical cancer is rare in women aged under 25.

• • When young people do have a HPV infection, it is usually transient – meaning their immune system will clear it up and the infection won’t cause harm.

• • Most young women are protected against the main cancer-causing types of HPV through the HPV vaccine, and if they haven’t had it themselves, ‘herd immunity’ provides some level of protection.

• After more than 25 years of screening women under 25, the data shows there is little benefit to screening, and it can actually cause some harm. Treatment for minor cell changes can cause pain, bleeding and risk of infection, plus a small risk of causing problems for future pregnancies. The vast majority of cell changes in young women clear up naturally, without ever needing treatment.

What if I have symptoms?

It is VERY important to understand the difference between screening tests and tests used to investigate symptoms (diagnostic tests). If you have unusual symptoms such as pain, weird bleeding patterns, bleeding after sex or bloody discharges you should always see your GP for examination and investigation, which may include a diagnostic cervical test even if you are under 25.

The information provided in this article is provided for information purposes only. You should seek assistance from a health care professional when interpreting these materials and applying them to your individual circumstances. If you have any concerns about your health, consult your general practitioner. Information provided in this article does not imply endorsement of third-party services or products and cannot provide you with health and medical advice.