It used to be so simple—go for an annual Pap.
For generations of women, the Pap was a yearly ritual, something of a cultural icon. Invented by Dr. Georgios Papanicolaou, his namesake test has caused cervical cancer rates to plummet in the U.S. and other nations where it’s widely used. It’s no exaggeration to say the Pap is one of the greatest public health triumphs in history.
Pap smears involve taking a sample of cells from the inner and outer portions of the cervix. The smear part is when the cells are affixed to a glass slide, shipped to a lab, and examined closely under a microscope by a specialist trained to look for any cells that look abnormal. More recently we’ve referred to the Pap test: instead of being smeared on a slide, these days it’s more likely that the cells collected for a Pap are placed in a vial and suspended in a solution as they’re whisked away to the lab.
The Introduction of the HPV Test
In 2003, the first big shift in cervical cancer screening came as an HPV test came on the market. Where the Pap looks for wonky cells that are a red flag for potential cancer or pre-cancer, an HPV test detects the genetic material of high-risk types of HPV, the virus that causes virtually all cases of cervical cancer. Determining whether or not a woman has HPV gave providers another tool to use with a Pap to figure out which women might be at greatest risk for cervical cancer. This is especially true for women age 30 and older, for whom the HPV/Pap co-test became the preferred approach for cervical cancer screening in 2012. (HPV infections in women younger than 30 usually clear away pretty fast, whereas in women over 30 they still aren’t usually dangerous but tend to stick around a bit longer.)
In April 2014, the FDA approved the first HPV test to be used as primary screening. In other words, it allows providers to screen a woman with only this HPV test, not as part of a buddy system with a Pap done at the same time. In 2018, the US Preventive Services Task Force (USPSTF) added HPV primary screening to its list of recommendations for cervical cancer screening for women 30 and older.
Room for Choice
For younger women, the Pap is still the recommended option. For women aged 21-29, USPSTF recommends screening with a Pap test every 3 years. Once a woman turns 30, there are three possible recommended options:
- Pap test alone every three years
- Co-testing with a Pap and an HPV test every five years
- HPV testing along every five years
Why the longer time between screenings when an HPV test is used? Because if a woman tests negative for certain high-risk HPV types, he has a very low risk of developing cervical pre-cancers over the next five years. And there are some potential harms with testing too often: the more tests we do, the more we tend to refer to follow-up diagnostic procedures, needless biopsies, and so on.
There’s still a role for the Pap even with HPV primary; recent guidance calls for women who are positive for a high-risk HPV type apart from HPV16/18 to have a Pap (those who are found to have HPV16/18 are referred to a colposcopy, where the healthcare provider examines the cervix with a special microscope and takes small samples from any areas that look suspicious).
Patients, providers, women’s health advocates alike all have questions about the best approach to screening in this brave new age. Let’s simmer this all down to some more digestible chunks and see if it makes sense:
- The most important thing for women is to get screened, period! Don’t worry so much about which test or combination of tests your healthcare provider might use—make sure you start the conversation.
- Talk to your healthcare provider, ask them what’s right for you.
- Express any concerns. Remember the medical team is in your corner.
- If your (or someone in your family) is age 26 or younger ask about an HPV vaccine.
- Watch our HPV and cervical cancer videos.