Archive for HPV
A recent announcement from the FDA came as no surprise to those of us following the changing guidelines for PAP smears. The FDA has approved the use of HPV high risk DNA detection as a sole screening tool for women!
Over the past decade or more, much research into the role of HPV has been performed. This has yielded the information that the majority of cervical cancers arise from the activity of the Human Papilloma Virus on the cervix. Prolonged inflammation from an active HPV infection causes changes on the cervix which can lead to cancer.
Most likely your recent PAP smears have included a test for high risk HPV DNA activity. This is a virus that is acquired through sexual activity, and most of us have been exposed to this virus at some time of our lives. The vast majority of us suppress the virus and it lies dormant, never causing a problem. A smaller percentage of us however, do not suppress the virus efficiently enough, and it becomes active from time to time.
Enough activity over enough time from the high risk strains of HPV can place us at risk for cervical cancer.
A PAP smear takes a superficial scraping of cells from the cervix and looks for abnormal looking cells. An HPV test indicates whether the virus is active at the time of the PAP smear.
A positive HPV test and a normal PAP smear would indicate active virus but no inflammation of the cervix. This sort of result indicates the necessity for regular yearly screening, looking for inflammation from prolonged HPV activity.
A negative HPV test and normal PAP smear indicates no activity and no abnormal cell. This normal result often means a PAP and HPV can be done every 3, or even 5 years. The process from HPV activation to a cancer is felt to be slow, often years. Therefor, most gynecologic professional societies feel this is a safe interval.
A positive HPV and an abnormal PAP smear indicates the virus is active and causing damage to the cervix. In most women, this abnormality will correct itself as the immune system activates to suppress the virus. In some cases however, the immune system cannot suppress the virus and it goes on to cause pre-cancer and the cancer cells of the cervix.
Detection of high risk DNA activity is the factor that often drives decision making on the screening interval for PAP smears. So it makes sense that a test using only this modality will become available and recommended.
This gives women and their providers an option for screening. It is important to realize however, that a recommendation from the professional gynecologic societies has not been evident yet.
The PAP smear still has a place in women’s screening. It can detect uterine problems that a HPV DNA test would not pick up. Whichever screening test you set your heart on for this year, remember that a pelvic exam is still recommended yearly. Not undergoing a PAP smear does not mean you do not need a yearly exam!
How many of us dread that yearly obligation of the screening PAP smear?
Most of us get accustomed to this exam over the years, but still may unconsciously avoid the exam by increasing the interval year to year. Good news! According to the USPSTF, we may very well not need to get this test yearly!
The USPSTF, United States Preventative Services Task Force, has issued new guidelines for women and PAP smear screening. When the PAP test is coupled with an HPV test, the sensitivity for screening for cervical cancer is increased.
The HPV virus is a sexually transmitted virus of which certain strains can cause cervical cancer. It is felt by experts that most sexually active women have already been exposed to this virus. The importance comes in identifying those women who have persistent activity of one of the high risk strains, as this can lead to cellular changes and sometimes to cancer. The majority of women will suppress the virus through their immune system, and not develop permanent or significant cellular changes on the cervix.
Cervical cancer usually develops relatively slowly, and experts have been attempting to identify a safe interval for screening. Long enough to give us a break from this yearly screening, but not so long as to miss an early sign of an abnormality. It is also been shown that many abnormalities resolve on their own before any intervention is required; usually due to a healthy immune system.
These new screening guidelines include:
- Women aged 21-65 can undergo PAP smears every 3 years provided they have normal results. For women over 30, this interval can be extended to 5 years if coupled with the HPV test.
- Women under 21 do not need to get a PAP smear. This is due to healthy immune systems in young women and probability that any abnormality will resolve in its own.
- Women over 65 can stop getting PAP smears if they have had 3 normal PAP smears in recent years, and are not at high risk for cervical cancer. These risks would include being immuno-compromised, having a history of cervical cancer or a high grade precancerous lesion.
- Women who have had a hysterectomy do not need to undergo PAP tests unless their hysterectomy was do to cervical or a high grade precancerous lesion.
The above is the guidelines of the USPSTF, and they are NOT in agreement with the American Academy of Obstetricians and Gynecologists (ACOG); The American Medical Association(AMA); American Cancer Society (ACS); American Academy of Family Physicians (AAFP) and the American College of Preventative Medicine (ACPM) as well as other organizations.
- The above organizations all agree with beginning PAP smears at age 18 or within 6 months of onset of sexual activity
- Thin Prep PAP smears every 1-2 yrs until 30, at which point every 3 years with an HPV test unless an abnormal reading occurs at which point resume yearly screening.
- Option for discontinuing screening age 65-70 if no risk factors of cervical cancer exists and no abnormal PAP readings in prior 10 yrs.
This represents quite a difference for the USPSTF recommendations and you may be wondering what you should do.
It is important to discuss this with your medical provider as they have your medical history and results of past PAP tests. They can discuss your risk factors and help you come to a decision regarding what interval is safe for you. Regardless of how often you and your provider decide you should be screened, it is still essential that you get a yearly general exam. This should include a breast exam, skin exam and review of risk factors for other medical problems based on your history, family history, and your lifestyle and habits.
Let me know your thoughts and comments about these new guidelines. It is curious that the guidelines of the USPSTF should differ so from the many medical societies. I would love to know you thoughts on this subject!
Many of you may feel that you no longer need PAP smears if you have gone through menopause, or you are over 50 years of age. It is important to review your PAP history with your provider because you still may be at risk for an HPV related problem.
This may come as a surprise for many, especially if you have been in a monogamous relationship or been abstinent from sexual activity. You may still be at risk as HPV can resurface after years or even decades of dormancy, due to menopause and the effect on the immune system.
Menopause is considered a time of immuno-suppression because of the fluctuating hormone levels. Many illnesses can be more active during this period because of this immuno-suppression. HPV is acquired from sexual activity, either a new partner or from a prior partner. It may have lain dormant for many years, however it can cause cervical abnormalities if it become active again. If you stop having PAP smears, these abnormalities may not be discovered until a cancer has formed.
The current recommendations are for women over 30 to have the HPV test done every 3 years, to ensure there is no persistent activity of the HPV virus on the cervix resulting in dysplasia or cancer. You may not need a yearly PAP smear, but you should have a yearly exam including pelvic and breast exam. These recommendations include menopausal and post menopausal women, often into the mid to late 70′s.
Our life spans are getting longer, and the quality of our older years are improving. Continuing to screen for life altering and ending illnesses can help us stay healthy as we age. I welcome your comments and thoughts regarding this topic!
Bruce and I discuss the new cervical cancer screening guidelines. In this discussion we will explain the organization – USPSTF – that issues guidelines and discuss the mission it receives from the Department of Health and Human Services. We review the new guidelines, interject our own non-academic opinions, and give you plenty of information to discuss with your health care provider.
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