The Abnormal Pap Smear

December 14, 2007

News of an abnormal pap smear is the most frequent reason for a call back from a gynecologist's office. This report is always difficult to hear over a telephone, and many GYN doctors prefer to give the details face to face, only increasing the anxiety between the time of the phone call and the scheduled conference. Although it's true the dreaded "abnormal pap" can run the gamut from mere harmless inflammation of the cervix (mouth of the womb) all the way to cancer, often it's of the harmless variety.

We gynecologist's are victims of our own technology in that the screens we use to search for disease aren't very specific and result in a lot of false bad news. Ironically, when it happens to you, that's the good news. For further evaluation can clear the patient and she leaves the office with more expense but with a clear sense of well-being.

There's also the false good news, a report that is re-assuringly normal, resulting in the patient going her way for another six months to a year with advancing disease. Luckily, this advance is very slow. Which brings us to the real beauty of the pap smear:

  • Even though it is sometimes wrong, if a woman actually has a pre-cancerous condition, sooner or later the pap will definitely pick it up.

Which further brings us to the only reasonable rule of pap smears: If your paps are normal, keep getting them on schedule; and if one is abnormal, seek further evaluation so that if there really is something there, a typically slow-growing disease can be eliminated quickly and easily, maintaining the anatomy and full reproductive potential.

So why do we settle for this game of sometimes right, sometimes wrong for a screen that's so important?

Because it's so inexpensive. And of all the money spent on healthcare, it's best to save the big expense for the tests prompted by the small percentage of those whose screens come back abnormal.  People smarter than me do the arithmetic and healthcare is cheaper this way without increasing the number of adverse outcomes. (That's what the conventional wisdome is, anyway.)

So you had an abnormal Pap. What's next?

 

Colposcopy

 

Currently a secondary procedure is carried out in the laboratory on all abnormal Paps. It is a culture for Human Papilloma Virus (HPV). This culture will determine if you are harboring this virus and, if so, which one it is. There are many types of HPV: some that can lead to cancer, some that can cause warts, and some that do both. This additional testing is usually done and its report ready by the time the Pap comes back to your doctor or nurse practitioner, meaning the additional HPV testing results are part of the Pap report.

The real test to judge the merits of a Pap smear result is an office procedure called colposcopy. Some doctors only do this if the Pap report includes a positive result for the bad HPV. Some doctors do the colposcopy for any abnormal Pap, even if the culture for HPV is negative. This may be overkill. Those against such overkill can only condemn it for financial reasons, which is why insurance companies try to make the indication for colposcopy only for high-risk HPV detected on culture from an abnormal Pap specimen. Those for this overkill claim that more information is always better than less information and colposcopy has essentially no risk. Also supporting an aggressive rationale for colposcopy is that colposcopy is THE test that you can rely on, not the Pap, which is just a screen.

So why not just do a colposcopy on everyone and by-pass all of this foolishness of an inexact screen? Because that test is expensive--about ten to twenty times more. It makes more sense to save that one for the times that the cheaper pap comes back unusual (as stated avove).

A pap smear is nothing more than a gentle scraping at the cervix during a GYN exam, sometimes resulting in some mild cramping and spotting. A colposcope, although nothing more than a microscope on a stick, evaluates the entire pap smear area stereoscopically, easily guiding the specialist to the areas that caused an abnormal pap--areas that are biopsied with tiny clippings--again, perhaps some mild cramping. These clippings, however, are not the scattered loose cells strewn over a slide as in a pap. Instead they are actual "chunks" (microscopic, of course) of the tissue the way it sits in the cervix. This yields a result of certainty that will be either no cause for concern or a need for treatment.

Some doctors merely repeat a Pap when it comes back abnormal.  I myself move straight to colposcopy, because if a repeat Pap comes back normal, which one do you believe? Certainly I can't argue with those who merely repeat a Pap when the "abnormality" is just inflammation, as in a yeast infection or bacterial vaginosis, or cell repair, as in the changes that happen after such a mild infection; but I'm paranoid and I think that such inflammatory debris can sometimes hide underlying disease on the slide.  With the newer Paps (see below) which actually culture out the types of HPV virus as to whether they're the ones that cause pre-cancerous changes (dysplasia) or merely benign warty changes, some doctors decide on whether to be conservative or aggressive based on these results.

 

Treatment

 

Most of the treatments involve simply eliminating the abnormal tissue. Freezing it (cryosurgery), the old stand-by, is inexpensive compared to laser, which is the newer technique. Both have the same success rate, but freezing requires no anesthetic, is ten times cheaper, and is done right in the office. You drive home.

The laser is done with an anesthetic, usually in a surgicenter as an outpatient. It vaporizes the tissue, sealing off bleeding at the same time.  It's advantage is that it can also be used to eliminate vaginal warts, an additional problem from a batch of mixed virus that can also cause abnormal pap smears. Also, the laser doesn't result in the inconvenient discharge cryo causes.

The newest technique is LEEP, or an electrified loop excision that is the best of both laser and cryo--office procedure, cheap, and no general anesthesia. Under a local anesthetic, a small hot wire loop sweeps under the abnormal area superficially, scooping it out and eliminating it. You still drive home. The only limitation to a LEEP is that the edges of the specimen are fried, leading a pathologist to be uncertain as to whether the entire lesion was included in that removed if it's too conservative an excision. Seeing a lesion at the burned margin will lead a gynecologist to believe that there may be some abnormal tissue on the edge of what was left.

Cone biopsy is reserved for those cases in which the lesion, on colposcopy, goes up out of site up the birth canal. It's impossible to tell if the unseen lesion may be worse than what's visible. Removal of a donut-shaped end of the cervix is best studied under a microscope after having been removed surgically.  Recover from a cone biopsy involves more nagging bleeding than after a LEEP or laser, but the real danger is that the integrity of the cervix to hold in a future pregnancy may have been compromised, putting one at risk for preterm delivery.

Hysterectomy (removal of the uterus (womb), cervix included) can be used to treat dysplasia when there are additional considerations.  This is a drastic therapy, of course, and shouldn't be considered in anyone not finished her childbearing.  Additional reasonable conditions for this "final" treatment include:

  • Abnormal bleeding warranting hysterectomy in a woman finished childbearing
  • History of recurrent dysplasia--that is, treatment failures with previous more conservative approaches (laser, LEEP, cryo), in a woman finished childbearing
  • Endometriosis, in a woman finished childbearing
  • Pelvic pain warranting hysterectomy, in a woman finished childbearing
  • Other malignancy or pre-malignancy changes in the uterus or ovaries

Speaking of treatment failure, just how many times can a young woman (who wants to preserve childbearing) undergo conservative treatment for dysplasia?

Good question.  It all depends on how well the cervix heals after destruction of that portion holding the abnormal cells.  Remember what the cervix does...  It allows sperm in, which isn't unduly compromised by these treatments, but it also is strong enough to hold in the entire pregnancy until it's an appropriate time for labor.  When that structural strength is weakened, premature dilation can happen, resulting in a premature baby.

 

Generally, the cervix is fairly forgiving of laser, even several times.  Cryo, too.  Each individual cervix, however, can have its "breaking point," only to haunt a pregnancy in the future.  Cone biopsies, which involve cutting away a portion of the cervix, has more of a risk of weakening the cervix.  Lately, there have been some reports in the literature have implied LEEP may also be damaging beyond that of simple laser or cryo.

 

Causes of Abnormal Paps

 

The causes of an abnormal Pap are numerous. A simple vaginal infection, such as yeast, can push a patient into a needless colposcopy--but no one can say it's needless until after it's done. An area of healing from recent infection (metaplasia) can mimic disease. Also, a bacterial infection, such as from rectal bacteria, can cause the non-specific finding that prompts colposcopy.

The overwhelming main cause of truly abnormal pap smears is infection with the sexually acquired Human Papilloma Virus (HPV). Different strains of it cause either warts or cervical dysplasia (a truly pre-cancerous lesion: "abnormal growth"), and some strains cause both. Not all dysplasias cause cervical cancers, but all cervical cancers usually start with dysplasias. Often an HPV infeciton can be a mixed infection of more than one type, so if there are warts, dysplasia must be suspected and ruled out with colposcopy.

Don't go gunnin' for anyone

Since HPV is sexually acquired, making cervical dysplasia a sexually transmitted disease (STD), a woman may want to know if she should go home and start shooting.  The answer is no.  Unless she and her sexual partner, husband, boyfriend, etc., were both virgins when they first made sexual contact, this is an infection that could have been there from many partners ago from either of their histories.  Remember, dysplasia or warts are NOT the HPV, but the body's reaction to HPV.  The HPV could have sat silent a long time before cellular changes showed on a Pap smear.

Repeating Paps

One of the biggest questions a gynecologist must answer is when should a Pap smear merely be repeated, and alternately, when should a Pap warrant colposcopy? Different gynecologist will give different answers. A conservative doctor will repeat all paps that show only inflammation. Any infection will be treated first, and then if the repeat is normal, the patient will be followed routinely. This is a reasonable approach if all but the obvious inflammatory Paps are colposcoped. But a doctor who repeats all abnormal paps and then bumps the patient for another six months if the re-pap is falsely normal may be too conservative, for this may delay treatment of an on-going lesion.

An aggressive doctor will colposcope all abnormal paps, but this may be too aggressive--the "overkill" approach explained above.

The perfect doctor, who each woman hopes she has, will find the best balance between the two extremes. Unfortunately, no methodology is perfect; but if one were to lean one way or the other, a patient is best served undergoing a more aggressive--and more definitive--approach. Colposcopy is harmless. The biggest risk is to the pocketbook, but your health is worth it. And it is still a bargain.

The price of colposcopy, in my and many other practices in Louisiana, has not had a substantial rise in over ten years. So if you are notified of an abnormal Pap smear, don't panic. It's probably O.K. But if it isn't, we gynecologists enjoy great success in preserving total child-bearing potential thanks to the diagnostic certainties of colposcopy and treatments like cryo, laser, and LEEP. An abnormal Pap may end up costing more when you're pushed into colposcopy, but the truism applies: you get what you pay for.

 

How Often Should You Get A Pap

Since the idea is to pick up malignant or dysplastic cells, and since this is considered a result of HPV infection, it stands to reason that your lifestyle could call the shots here.  If you're a virgin, then exposure to HPV is impossible, and a Pap probably isn't necessary at a young age. If you're monogamous and you've had negative Paps all along, the timing could be spread out longer than the usual once a year. Many are advocating going to every three years in low risk persons (always normal Paps in the past and in a monogamous relationship or virginal). On the other hand, if you're sexually active with several partners--and frequently--then even the once-a-year rule might not be close enough.  This is the reason risk factors for cervical cancer include multiple sex partners and intercourse at a young age, because all it takes is one indiscretion with the wrong man to be exposed.

The recommendations are changed frequently, so I don't list them here. Check with your own doctor to see how often.

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