Pap smear: fast facts

Most women today know what a Pap smear is or have had one or even a few. Dr Sumayya Ebrahim educates us on this procedure.

What is a Pap smear?

It’s a screening test for the early detection and screening of cervical cancer. It’s named after a Greek doctor, Dr Papanicolou, who first published his work on this in 1928.

The cervix is the part of the female reproductive organs that is also typically called the mouth of the uterus.

Cervical cancer is the most common gynaecological cancer seen in women in SA under the age of 40. The tragedy is that this cancer is completely preventable with regular screening. 

The value of a Pap smear is that it can detect changes in the cervix at an early stage of abnormality. This can be monitored and treated effectively, preventing the cancer from forming.

How is a Pap smear done?

Usually done by a nurse, doctor or gynaecologist who has a good idea of female anatomy, the cervix needs to be visualised and a little scraping is taken from there with a brush or wooden device. 

The cells are then placed either onto a glass slide (and fixed with a spray) or the brush is placed into a liquid medium (called liquid-based cytology). This is sent to the laboratory to be analysed under the microscope by a pathologist.

The accuracy of this test is reliant on:

• Good visibility of the cervix.
• Adequate pressure on the device by the sampling person.
• The sample must include cells taken from the outer and inner cervix.
• The cells must be visible to the pathologist. Too many blood or white cells may make reading the smear difficult.

How often should I have a Pap smear?

Different countries have different policies depending on the magnitude of their problem of cervical cancer and financial resources. 

The reality is that many screening programmes are limited by lack of adequate funding. This situation is especially true in SA. Here, we have a unique situation of two vastly different co-existing health sectors: 

• Private healthcare funded by medical aids and people who earn enough to afford this (any test is available to those who can afford it).

• Public healthcare where Pap smear availability is restricted by budgets and not available to all who need it. 

This latter situation is called an under-resourced setting, and the former, a high-resourced setting. 

Latest guidelines

The guidelines from The South African HPV Advisory Board, published in The South African Journal of Gynaecological Oncology, in 2017, recommend:

FIRST PAP SMEAR: age 25 or earlier at the time of a positive HIV test.

LAST PAP SMEAR: Low-resource setting: age 55 

High-resource setting: age 65 

This can only be done if the latest smear is normal. In the event of being HIV positive, Pap smears should never be stopped.

PAP SMEAR INTERVALS: If there is associated HPV screening which is negative.

Low-resource setting: Every five to 10 years.

High-resource setting: Every three to five years.

Please be aware that these are guidelines only. Your doctor may offer you something different depending on your unique circumstances.

What is HPV and how is this linked to Pap smears?

Human papilloma virus, or HPV, is a virus that is associated with the formation of cervical cancer. Research shows that this virus is present in about 70% of all cervical cancers. There are about 150 different strains of this virus but only a handful of them (typically type 16 and 18) are linked to cervical cancer. These are called high-risk subtypes.

HPV is mainly sexually transmitted (that is, skin to skin sexual contact, including vaginal, anal, or oral sex). It can also be passed on from a mother to her baby during pregnancy, labour or delivery.

HPV can remain silent with no outward signs and symptoms. You may not know you have it until you are tested positive for it or a smear picks up HPV-related abnormal cells.

An HPV test (looking for the viral DNA) can be performed at the same time as a Pap smear, if liquid-based cytology is used or if a dry swab is taken from the cervix and/or vagina. 

Routine testing for HPV with a smear is generally not recommended under 30 years of age. It’s extremely common in this age group and often the infections clear by themselves within a year or two.

What if I test positive for HPV?

Testing positive for high-risk HPV means that you can develop abnormal cells on the cervix so you will need to plan your monitoring tests and any necessary treatments with the help of your caregiver.

What if I have a normal pap smear and high-risk HPV positive?

This means that you have a higher risk of having abnormal cells in future and that you should have a smear at least once a year.

What if I have an abnormal pap smear and high-risk HPV positive?

Depending on the severity and grade of the abnormality, you will either be advised to have further testing or to have treatment. 

Further testing could be advised in the case of mild, moderate and severe abnormalities where the full extent of the problem is unclear. This would be a colposcopy and a biopsy (involves looking at the cervix with the aid of a special microscope and applying special stains to show up abnormal areas that can be biopsied).

If after a biopsy, the abnormality is mild you could be advised to just monitor the situation with regular smears until the problem clears.

If the abnormality is moderate to severe, treatment will be offered. Treatment can be in the form of surgical removal of the abnormal area or even laser treatment to destroy the abnormal cells.

If I have had a hysterectomy, do I still need a Pap smear?

A Pap smear is a screening test for cervical cancer. So, no cervix means a low to nil chance of getting cervical cancer. Since most types of hysterectomies involve removing the cervix as well, a frequent Pap smear is no longer necessary. 

Exceptions would be if the cervix was still left behind; if the hysterectomy was performed for precancerous cells on the cervix; or in the event of an HIV positive diagnosis. 

In these instances, Pap smears (called vaginal vault smears now) are done more frequently according to the advice of your gynaecologist.

References: 

1. http://www.sajgo.co.za/index.php/sajgo/article/viewFile/253/pdf_4

MEET OUR EXPERT  – Dr Sumayya Ebrahim

Dr Sumayya Ebrahim is a gynaecologist in private practice in Gauteng. She is also a blogger. Check out her blog Vaginations by Dr E on www.vaginations.co.za