- ATHENS OFFICE MED4WOMAN ATHENS
- VOLOS OFFICE MED4WOMAN VOLOS
Obstetrician-Gynecologist
PhD, University of Athens Medical School
Obstetrician-gynecologist Panagiotis Polyzos practices at the Institute of Life, the IVF Unit of IASO Maternity Hospital.
The Pap test (Pap smear) is a routine examination, that all women should undergo from the start of their sexual life and then at regular intervals, depending on age. It is one of the routine and screening tests for cervical cancer (just as mammography is for breast cancer) that are currently performed to detect potentially pathological or abnormal cells on the cervix. At the same time, it serves as the first line of detection for the HPV virus which is now becoming an epidemic, since the majority of sexually active people will come into contact with it at some point in their lives.
In addition to identifying any pathological or abnormal cells on the cervix and within the endocervical canal, the Pap test can also detect mild cervicitis, vaginitis, or possible fungal infections. However, what has dominated medical interest in recent years—and remains a significant scientific concern for both physicians and patients—is the HPV virus.
The HPV (Human Papillomavirus), which is usually detected (in women) through a Pap test because it causes no clinical symptoms, is a sexually transmitted virus passed from a sexual partner to the woman, usually without the man having any symptoms. There is no medication that eliminates the virus itself. What we must emphasize is that in most women, about 9 out of 10, the immune system clears it on its own within one to two years. From that point on, treatments, whether simple monitoring, loop diathermy or cauterization, address the lesions the virus causes and not the virus itself. The vaccine is not a treatment: it prevents infection with the types it covers. In a smaller proportion of women the infection persists or recurs, for example with immunosuppression or smoking, and these cases need close monitoring.
So, if screening shows high-risk (oncogenic) HPV, especially types 16 or 18, or abnormal cells, the next step is usually what we call colposcopy. Colposcopy is a gynecological examination that takes a little longer and is more detailed. During it, the gynecologist uses a special microscope—called a colposcope—to examine the cervix more closely. Through a specific process, the doctor can observe the lesions caused by the virus on the cervix and within the endocervical canal in greater detail. In the particular area where the so-called columnar epithelium transitions into squamous epithelium—known as the transformation zone—certain changes or lesions caused by the virus may occur. Based on the size, type, and grade of these lesions, a decision will be made regarding whether treatment is necessary. If the lesions are suggestive of possible dysplasia—either low-grade (CIN I) or high-grade (CIN II, CIN III) —or are categorized as LG-SIL or HG-SIL, treatment options may include loop electrosurgical excision (LEEP), cone biopsy (conization), simple cauterization, or biopsy.
At this point it should be stressed that several types of genital warts are also caused by HPV, and although there is no cure for the virus itself, there is a way to treat these warts. Treatment may be medication or may involve diathermy and cauterization. Again, the same forms of energy are used, such as laser, loop, etc. Beyond that, because there is a direct link between specific HPV types (16, 18) and cervical cancer, always after very long periods of time, HPV is a factor that predisposes to cervical cancer under certain conditions.
Regular Pap tests help prevent cervical cancer. Cells of the cervix can change without any symptoms or pain. Even minor cell changes can progress to cancer if they are not treated.
Moreover, the Pap test can provide useful information regarding hormonal function and can help monitor the administration and effects of hormonal treatments. Finally, it enables the detection of inflammation of the vagina or the cervix (vaginitis, cervicitis), as well as the identification of their underlying causes, such as bacteria, fungi, trichomonads, viruses, and other infectious agents.
The doctor performing the Pap test gently scrapes cells from the cervix using a small spatula and a brush. The cells are spread on a glass slide, which is then sent to the laboratory for microscopic examination.
You will most likely be asked to have Pap tests more often (every 3-6 months). In addition, through certain specialized DNA tests, so-called viral typing, we can identify the specific types that carry a higher predisposition and a stronger association with possible development of cervical cancer, usually after 10 to 20 years or more. Another thing we should know about HPV is that it is sexually transmitted.
However, it can also be transmitted through skin-to-skin contact of the genitals and the genital area, so under certain conditions condoms may not be enough, because the infection may be in the area around the genitals. Even so, they are the most important and the only form of protection we have against this virus. What we must always remember is that HPV is now extremely common: as mentioned above, most sexually active people will become infected at some point, usually temporarily. More and more sexually active people have now been infected; in men it usually causes no symptoms, which makes it easier to transmit, and unfortunately it remains in the body without causing any symptoms.
Smoking is also considered a contributing factor to the development of cervical cancer and represents an additional risk factor that predisposes individuals to this condition.
In recent years, one of the most important areas of research has been the development of a vaccine designed to prevent infection with the HPV virus, since HPV is one of the primary risk factors for cervical cancer.
About three thousand women a year in the United Kingdom are diagnosed with this type of cancer. There are more than 100 types of HPV. The second phase of these studies, in May 2005, showed the first signs that, most likely, an HPV vaccine could, under certain conditions, reduce HPV infection. The study known as FUTURE II released its first results in October 2005. This 3rd phase of the study included more than 12,000 women aged 16–26 years and demonstrated the following:
The women participating in the study did not have HPV at the start and were divided into two groups.
The first group received the vaccine called GARDASIL and the second received a placebo, that is, a substance with no relation to the drug. These 2 groups of 12,000 women were followed for the next 2 years, while leading a normal sex life, to see whether they would develop the virus or any other form of dysplasia or any other precancerous condition of the cervix. The vaccinated group showed no such finding, while of the 5,258 who had received the placebo injection, 21 developed some form of pathology over the following two years, a rate of 0.4%. The results also showed protection against types 6, 11, 16 and 18, which the vaccine covers. A second vaccine, Cervarix, which was released later, was also tested in parallel. Today the nine-valent vaccine, which covers nine types of the virus, is mainly used. This particular study included 18,000 women and is called the PATRICIA study (PAPILLOMA TRIAL TO PREVENT CERVICAL CANCER IN YOUNG ADULTS).
Current guidelines have changed from the old “once a year for everyone” rule. As a guide:
Vaccination with the HPV vaccine does not exempt you from the Pap test.
The sample takes a few seconds and does not hurt. You may feel pressure or mild discomfort. A little spotting the same day is harmless. Today the preferred option is often the ThinPrep liquid-based test, which also allows an HPV test from the same sample.
An abnormal Pap test does not mean cancer. It means something was found early, when it is easy to treat. That is the purpose of the test: to prevent cervical cancer.
The Pap test examines under the microscope whether the cells of the cervix have changed. The HPV test looks for the DNA of the high-risk types of the virus that can cause these changes, such as types 16 and 18. After 30 the two tests are combined, because together they give the most reliable picture. For the virus itself and genital warts see the related guide.
The Pap test is also safe during pregnancy. Taking a sample from the surface of the cervix does not affect the fetus and does not cause miscarriage. If you have not had a recent test, your doctor may schedule it at your first prenatal visit. A little spotting after the sample is common, because the cervix has more blood vessels during pregnancy.
After childbirth, it is best to wait about 6 to 8 weeks for the cervix to recover. During breastfeeding, low estrogen levels can make the sample harder to read.
In menopause the situation is similar. The epithelium thins and the transformation zone moves up into the cervical canal. That is why the result sometimes comes back “atrophic” or ASCUS without any real lesion. A short course of local estrogen before the repeat test often clarifies the picture. Screening does not stop at menopause: it continues at least until age 65.
The Pap test is a screening test, meaning it is designed for women without symptoms. If you have symptoms, do not wait for your next scheduled appointment, even if your last result was normal:
Most of these have a benign cause, such as an ectropion, a chlamydia infection or a polyp. They still need a clinical examination, because a negative Pap test does not rule out every condition of the cervix.
If the cervix was also removed for a benign reason and there is no history of precancerous lesions, it is usually not needed. If the cervix was preserved, or the surgery was done for a precancerous lesion or cancer, screening continues. An annual gynecological checkup remains essential.
International guidelines recommend starting at 21 and repeating every 3 years when results are normal. In Greece it is often done every year, as part of the annual gynecological checkup. After 30, combining it with an HPV DNA test allows less frequent screening when results are negative. Your doctor will set your schedule.
Ten to twenty days after the first day of your period. For 48 hours beforehand, avoid intercourse, vaginal suppositories, creams and douching.
It does not mean cancer. Most of the time it shows inflammation or mild changes that resolve on their own. Depending on the finding, the next step is a repeat test, an HPV test or colposcopy.
From 21 to 29, every 3 years. From 30 to 65, a Pap test with an HPV test every 5 years or a Pap test every 3 years, as long as results are normal. More often if your doctor recommends it.
No. The sample takes a few seconds. You may feel pressure or mild discomfort, and rarely a little spotting the same day.
Preferably not, because blood can affect the sample. The ideal window is 10 to 20 days after your period starts.
That atypical cells of undetermined significance were found. Usually an HPV test or a repeat Pap test in a few months follows, and colposcopy if needed.
The cost depends on whether it is a conventional or liquid-based test and whether it is combined with an HPV test. Ask the office when you schedule your appointment.
Not reliably. It may show signs of inflammation or trichomonas, but it does not replace specific tests for chlamydia, gonorrhea or other sexually transmitted infections. If you want this kind of testing, ask for it separately at the same appointment, from a vaginal sample or a urine sample.
There is no established routine HPV test for men without symptoms. Your partner needs an examination only if he has warts or other lesions in the genital area. A positive result does not necessarily mean a recent infection, since the virus can stay silent for years.
A single test may miss a small lesion. That is why its value lies in repeating it at regular intervals and in combining it with an HPV test after 30, which significantly increases the sensitivity of screening.
