Do I need an Annual Pap smear? Do I need an annual pelvic exam?
How often do I need to see a Gynecologist?
In my Obstetrics and Gynecology private practice, I am asked daily about the recommendations and new guidelines for Pap smears and annual pelvic and breast exams. Are yearly pap smears really necesarry? The medical information which women obtain from doctors, medical organizations, and the Internet, regarding these issues, seems to be confusing, vague, and contradictory at times. The yearly annual exam including the dreaded pelvic exam and breast exams used to be pushed on women yearly from the time they entered the obgyn office as a teenager. Some recommendations are changing based on age-specific risk benefits, supported by new studies and technologies, and the desire to avoid some of the negative, harmful, impacts of over treating. Recently the American College of Obstetrics and Gynecology (ACOG) issued a Committee Opinion, August 2012, regarding the Well-Woman Visit and also a Practice Bulletin, November 2012, regarding Cervical Cancer Screening and Pap smears. These new recommendations were made after collaboration with the American Cancer Society (ACS), the National Comprehensive Cancer Network, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP). In addition, the U.S. Preventive Services Task Force (USPSTF) has also updated their recommendations.
ACOG recommends that all women continue to have annual visits with the Obstetrician-Gynecologist. ACOG’s Committee Opinion states “The annual health assessment (“annual examination”) is a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems, and establishing the clinician-patient relationship.” ACOG has issued new guidelines regarding when and how often to perform Pap smears, pelvic exams, and Breast exams. These recommendations are age specific and based on individual history. So some women may not have yearly Pelvic exams, pap smears (scraping of the cervix for precancerous cells) or breast exams even though it is still recommended that they see the Obgyn yearly. ACOG’s Committee Opinion states “The decision to perform an internal pelvic examination, breast examination, or both should be made by the physician and the patient after shared communication and decision making.” “The decision to perform any type of pelvic or breast examination should always be made with the consent of the patient.”
The annual examination should include blood pressure, weight, listening to the lungs and heart, examination of the abdomen and lymph nodes. Whether to perform the pelvic exam, Pap smear, and breast exam will be explained further below. There are three parts to the pelvic exam as follows: 1) checking for normal external anatomy (also looking for melanoma’s, warts, skin disorders, etc.) 2) placing the speculum, in order to examine the vagina and cervix and possibly perform a pap smear and 3) the bimanual exam where 1 or 2 fingers are placed in the vagina and the fingers of the other hand are placed on the abdomen so that the uterus, cervix, and ovaries and tubes can be evaluated for abnormalities. At times a pelvic sonogram can replace or augment this third component.
Pap Smear
In the next sections, you will find the new age specific recommendations and new guidelines for Pap smears (scraping of the cervix to look for precancerous cells). You will see that ACOG continues to recommend the Well woman visit to the Obgyn yearly, but is now recommending that the Pap smear be performed only every 3 years for low risk women aged 21 to 29, and every 5 years in conjunction with Human Papilloma Virus (HPV) testing (co-testing), in women aged 30 to 65 who are at low risk. The whole idea of screening at greater intervals with Pap smears is to avoid the harm that too much screening can cause. Screening at closer intervals can lead doctors to perform more unnecessary procedures to the cervix for abnormalities, which most likely would have regressed on their own. You will read more about this in detail below.
This all makes perfect sense, however in reality I have rarely found a patient in my private practice who has consented to having their pap smear performed less than once a year. I have explained the risks of false positives and over treating with yearly Pap smears, and guess what; most patients in private practice with rare exception still want their Pap smears performed yearly. They say, “Your down there so you might as well do it, and insurance covers it”. And quite honestly, I can’t say that I blame them:
For many years now ACOG has recommended Pap smears every 3 years for low risk patients over 30, and there have been few takers. The couple of patients in my private practice, who consented, completely misunderstood and didn’t return for their next annual exam for another 2 or 3 years. It didn’t matter that I had explained multiple times that a Pap smear was just the scraping of the cervix and the rest of the Well Woman exam still needed to be done yearly, including the breast and pelvic exam. Extending screening for low risk women older than 30 to five years, does not seem like it will be well received. The studies certainly bear out ACOG’s recommendations, however patients are leery and weary of studies that one day recommend one thing and several years later change course. A few years ago we were being told that Liquid based Pap smears were better at preventing cervical cancer than the traditional and now we are being told that they are equivalent. Here are some of the concerns that I have heard from patients regarding less testing:
Patients understand that circumstances change and new strains of viruses can emerge and they don’t want to be caught off guard or be the patient who falls through the cracks. Patients know that doctors, nurses, and lab techs are human. If they are only screened every 5 years, then what happens if they are the rare person whose Pap smear is switched or mislabeled by mistake in the office or the lab. And if this happens, then they are only being screened every 10 years in reality. (We, and most doctors, have many safeguards in the office to prevent that from ever happening as does the lab, but humans are human, and I do not know if all doctors have checks and balances to the same degree to prevent this). What if the Pathologist misses the diagnosis and then they are not screened for another 5 years. Again this is unlikely with the safeguards in the labs and computer-screening backup, but these are the thoughts that I hear from patients.
I have seen many women in my 24 years in practice with a cervix so difficult to reach or access that I have had to get on my knees or place them on an electric table with a deep tilt to get to the cervix. I wonder if certain other less experienced doctors and nurse practitioners are able to appropriately access the cervix in these similar situations, making cervical screening less accurate. Or what about the patient who is treated for precancerous cells at a young age but forgets or just never was informed enough to be able to tell her new doctors about this, and is placed in the low risk 5 year screening group.
So with all of this said, I do believe in the ACOG recommendations for the average patient. However I have developed a screening method called Intelligent Conservative Alternative Testing (ICAT). The ICAT protocol is for the patient who does not agree to Pap smears and HPV testing every 5 years but wants alternative screening yearly or every 2 years. The HPV test would still be done every 5 years, but yearly or biannual Pap smears would still be done. However testing would be done within the context of understanding that if we had followed ACOG guidelines that we wouldn’t have the information from the Pap smear available to us until the next 5-year screen. So an abnormal result would be interpreted within this context and close observation used versus treatment in some of these situations and the most extreme results treated. This would help to lessen the false positives and fears of overtreatment vs. under treatment. Each case would be individualized, and as an example, the patient who had completed childbearing or had no interest in future pregnancy would be treated more aggressively, if the patient requested. And patients who desired future pregnancy would be treated very conservatively with observation or tissue sparing procedures.
One of the new recommendations that I agree with completely is not performing Pap smears on young women until age 21. So if I haven’t lost you by now, read below to find the age specific ACOG recommendations for Pap smears, Pelvic exams, and Breast Exams.
Women and girls Younger than 21 – Annual Exams
ACOG recommends that the first visit to the Obgyn for the asymptomatic patient should take place between the ages of 13 to 15, and subsequent yearly visits after this. The first visit is a time when the doctor-patient relationship can be established and discuss any issues that the patient and parent may have related to physical development, the menstrual cycle, body image, and other physical and emotional issues related to adolescence and development. Also the HPV vaccine, contraception if needed, and the understanding and prevention of STD’s, can be discussed if desired by the patient and parent. Obviously many girls will not need this type of discussion by an Obgyn during the above age range. Parents must make this decision.
A pelvic exam is not recommended in an asymptomatic patient who is younger than 21 years and has no complaints. However an external exam can be done if desired to evaluate for normal anatomy or abnormalities. Again, this is patient and parent choice. For symptomatic patients with complaints of pelvic pain, menstrual problems, or vaginal discharge or infection, an internal pelvic exam may be necessary, if approved by the patient and parent (for those younger than 18years). But most times a pelvic exam is just not necessary and can be avoided in this age group.
The CDC recommends that all sexually active girls in this age range be screened for the STD, Chlamydia annually. If this is requested then Nucleic acid amplification testing for Chlamydia and gonorrhea can now be performed on urine samples or by self-collected swabs, where the patient places a cotton tip applicator in the vagina in privacy. These self-collected tests can also be used to test for vaginal yeast, trichomonas, and bacterial vaginosis infections.
The Pap smear (scraping of the cervix for precancerous cells) is not recommended in patients younger than 21 years old regardless of whether they are sexually active or not. Cervical cancer has been found to occur in 1 to 2 girls per year out of a million (1,000,000) girls aged 15 to 19. Studies have found that Pap smear screening did not reduce this tiny risk any further. Many sexually active girls in this age group will acquire the Human Papilloma Virus (HPV) on the cervix. HPV is the virus responsible for causing precancerous cells. However the body’s immune system will usually clear this virus within about 8 months. If Pap smears were performed in this age group as they were in the past, then many women would receive unnecessary procedures for treatment, since the abnormal cells being treated would most likely have resolved spontaneously. LEEP procedures, which are avoided, are known to possibly cause a small increased risk of premature labor in future pregnancies.
As far as breast exams. Breast cancer is extremely rare and almost non-existent before the age of 20. Therefore breast exams are not recommended for girls younger than 20 years.
Based on the above guidelines each family needs to make their own decisions regarding how to proceed in this age group. ACOG makes very general recommendations for large groups of girls and women throughout the country. They are trying to set a safety net below the most “at risk” patients. These recommendations obviously won’t fit all families’ and patients’ situations. I obviously recommend and encourage complete involvement of the mothers in the adolescent age group, and to be present for any discussion or possible exam if desired. Of course a nurse is always present if a physical exam is done. There are times that a private conversation with a teenager will elicit information that had not been shared with her mother. But this type of conversation would be the choice of the mother if the patient were under 18 years. In the end parents must decide what type of discussion if any should be had with their daughter. As the father of 3 daughters, I am very cognizant of this and look for holistic approaches for parents and daughters.
In our office, patients who are not sexually active rarely receive pelvic exams nor is it ordinarily necessary. Of course if a patient wants to be checked for normal anatomy then this can be done. Patients in this age group with abnormal menstrual bleeding can usually be managed just by taking a history. If it is necessary to check the pelvic anatomy then usually a non-invasive pelvic sonogram, where the probe is placed on the abdomen, can be performed in the office.
So the bottom line is that breast exams are not done in this age group and pelvic exams can usually be avoided in this age group. ACOG recommends yearly visits Beginning about 15 or if sexually active before. This recommendation as well needs to be customized to fit the situation. Sexually active girls should be seen yearly. All other girls should be seen yearly or at least know how to access care as needed.
Women 21 years old to 29 years – Annual Exams
ACOG recommends yearly Obgyn visits, annual exams in this age group, at which time a history is taken and physical exam is done and medical and preventive issues addressed. Annual pelvic exams are recommended. However ACOG makes it clear in their Committee Opinion that under certain circumstances, the patient and obgyn may defer the pelvic exam. And of course a patient should never have a pelvic exam unless they have consented. A patient who is virginal may decide not to have a Pelvic exam or Pap smear at age 21. I would explain to her that 99% of cervical cancers are related to the HPV virus and that only 1% are not. Also, a pelvic sonogram may be substituted for the bimanual portion of the pelvic exam.
It is now recommended that a woman’s first Pap smear (scraping of the cervix for precancerous cells), be performed at age 21 years regardless of whether a woman is sexually active or not. Previously ACOG guidelines had recommended Pap smears every 2 years in this age group. They have now changed their recommendation to a Pap smear every 3 years. Human Papilloma Virus (HPV) testing, which is recommended along with the Pap smear at 30 years and older, is not recommended in this age group. So yearly or annual Pap smears are not recommended in this age group. ACOG is trying to find the most ideal screening interval for Pap smears, where cervical cancer is prevented but the least amount of harm is done by over screening and finding too many false positives. By stretching out the Pap smear screening interval from 1 year to 3 years a “Modeling study” has predicted that at least 200 less colposcopy procedures would be performed on 1,000 screened women over a 10 year period. But the amount of future cancer would only be slightly higher. Colposcopy is a procedure done when a Pap smear is abnormal, and where the obgyn looks at the cervix under a microscope like instrument and performs biopsies of any suspicious areas. If the biopsies indicate abnormalities then a LEEP procedure may be done which removes a larger piece of the cervix. It is felt that LEEP procedures may impact future pregnancy in some women by weakening the cervix and causing premature labor. In this age group most of the abnormalities on a Pap smear, including HPV and precancerous cells would just regress spontaneously. ACOG does recommend in this age group that women with HIV, women who are immunocompromised and women who have been diagnosed and treated for certain precancerous cells of the cervix, have Pap smears at closer intervals.
Breast cancer is uncommon between ages 20 to 29. ACOG and other groups recommend that low risk women in this age group, have breast exams every 1 to 3 years.
The CDC recommends that all sexually active women 25 years or younger have yearly STD screening for Chlamydia. As described in the Younger than 21 section above, if this is requested then Nucleic acid amplification testing for Chlamydia and gonorrhea can now be performed on urine samples or by self collected swabs, where the patient places a cotton tip applicator in the vagina in privacy. These self-collected tests can also be used to test for vaginal yeast, trichomonas, and bacterial vaginosis infections. If a pelvic exam is being done then the gynecologist can easily do this testing by swabbing the cervix and vagina.
Women 30 to 65years – Annual Exams
ACOG recommends an annual yearly visit with the Obgyn for all women in this age range. At this time a history is taken and a physical exam is done, and medical and preventive issues discussed.
A yearly pelvic exam is recommended in this age group, but some women may decide to defer this based on their circumstances and wishes. ACOG guidlines recommend that a Pap smear and Human Papilloma Virus (HPV) testing (co-testing) be done every 5 years for low risk patients in this age group. If HPV testing is not done then the Pap smear is recommended every 3 years. So annual or yearly pap smears are not recommended in this age group unless a woman certain risk factors. As described in the paragraphs above, the recommendations for Pap smear frequency has spaced out to decrease the false positives and the performance of possibly harmful and unneeded procedures. More frequently performed Pap smears lead to increased detection of abnormalities, many of which would spontaneously regress if not treated. In this situation more colposcopies and LEEP procedures of the cervix are performed. LEEP procedures may, in a minority of instances, weaken the cervix and increase the risk of premature labor. High-risk patients should have Pap smears performed more frequently.
Breast exams are recommended to be performed every 1 to 3 years until age 39 and then yearly after age 40 years.
Screening for STD’s like Chlamydia or gonorrhea are recommended in high-risk patients and can be performed by the gynecologist at the time of the pelvic exam or by the patient with a self collected swab or urine sample, if a pelvic exam is not being performed.
In summary, it is recommended that low risk women in this age range should see the Obgyn yearly. Most low risk women will elect to have breast exams and pelvic exams yearly, but they should be offered options regarding this. Pap smears and HPV testing are recommended every 5 years for low risk women. STD testing is recommended yearly for high-risk women.
After Age 65 years – Annual Exams
As with other ages, the annual Ob/Gyn exam is recommended every year. A pelvic exam is recommended yearly. A breast exam is also recommended yearly.
ACOG recommends that Pap smear and HPV screening be discontinued in women after 65 years, who have evidence of “adequate negative prior screening results”. This refers to women who have had 3 negative consecutive Pap smears during the previous 10 years; or 2 consecutive negative tests with the Pap smear and HPV testing, done 5 years apart, during the previous 10 years. In these women it is recommended that no further cervical screening be done. The rationale for this is stated in the ACOG Committee Opinion as follows: “Modeling studies suggest that in women screened with cytology every 3 years until age 65 years, continued screening every 3 years until age 90 years in 1,000 women would prevent approximately 1.6 cancer cases and 0.5 cancer deaths.” It is felt that this low cancer risk is not significant enough to offset the many procedures that would need to be performed in order to find these cancers. Even low risk women older than 65 with a new sexual partner are not recommended to continue Pap smears.
Pelvic exams can be stopped altogether if a patient reaches an age or acquires other health conditions which would cause her not to intervene if something abnormal were found.
Women who have had a hysterectomy – Annual Exams
In women who have had a Total Hysterectomy (removal of the uterus and cervix), ACOG recommends that Pap smears be discontinued if the patient has never had precancerous cells of the cervix or vagina consisting of moderate dysplasia or worse. So these patients would never have another Pap smear. With the cervix being gone then the vagina would be the area of concern. The rationale is that vaginal cancer is so rare and that the testing would create many false positives and unnecessary procedures, not worth the potential negligible yield.
In women who have had a hysterectomy but still have their ovaries, a Pelvic exam to check the ovaries with a bimanual exam and also an exam of the outside genitalia are still indicated. If the ovaries have also been removed for benign conditions then the internal and bimanual exam could be deferred and only an exam of the external genitalia performed.
Please see the age specific recommendations for other components of the annual exam.
This article, Do I need an Annual Pap smear, Do I need a yearly Pap smear, is an original article written by Dr Keith Reisler. Dr Reisler has been a Board Certified ObGyn Specialist for 24 years. He sees patients for all aspects of gynecologic and obstetric care and second opinions in Plano, Dallas, Frisco, Allen, Carrollton, Richardson, Colony, Wylie, Prosper, Mckinney, Celina and the surrounding areas.