Abnormal Pap Smears Discussed

The HPV Virus
Pap smear guidelines are changing, and will continue to change. The biggest changes in recommendations are for when and how often to get your pap smear. If you have gotten a call about an abnormal pap smear, or an abnormal pap smear with a positive High Risk HPV test, you probably want to know a lot about what this means. Especially if you've not had an abnormal result before. It is a big subject to try to cover all the important aspects of this topic in a simple blog post and I always encourage women to write down their questions and know that when you come in for your consultation or your second opinion appointment with us we will provide you with hand outs and pictures that will help you tell the whole story! When patients come for consultation and discussion of management of a prior abnormal pap smear it's important we know their age, their previous STD history, their actual pap smear results, any prior cervical treatments, and of course their desire for future fertility. The current classification system for pap smears is the Bethesda 2001 classification. You probably have been told whether this test is showing a cancer, a precancerous or an indeterminate type of cell that needs further study. Most of the pap smear abnormalities are due to changes in the outer cervix, in the tissue with squameous cells. Other changes are due to the cells of the inner cervix called the glandular cells. Most changes take a relatively long time, so no need to panic if you get the call that the test is abnormal. Most likely you have acquired an infection.  Human Papillomavirus (HPV) is a virus that causes genital warts and may cause cell changes leading to cervical cancer in women, and causes virtually all the significantly abnormal pap smears that women have. HPV disease occurs in men as well, and if you have a partner you probably want him to get evaluated for lesions and if you are of appropriate age you and your partner may be candidates for the Gardasil vaccine. HPV is one of the most common viral infections in humans. The virus can be transmitted to men and women through sexual contact including vaginal, anal, or oral sex, and while condoms offer protection the protection is not complete. Even if you have an abnormal pap smear, if you have not yet been vaccinated against HPV disease with Gardasil, you are still a candidate if you fall within the right age groups. And watch the medical news, as information becomes available on HPV vaccine boosters, and the new and improved vaccines we are expecting to be released in 2012 or 2013. HPV is one of the most common sexually transmitted diseases and affects over 20 million Americans. Estimates from different studies vary, but approximately 50 percent of sexually active adults worldwide will be infected with HPV at some point in their lifetime, and one million new cases are diagnosed each year.  The most worrisome HPV viruses are HPV 16 and HPV18, they together are responsible for about 75% of all cervical cancers. Specifically 50% of cervical cancers have HPV 16 DNA, 20% have HPV 18. But only 1% of women infected by high-risk HPV will ever develop preneoplastic or neoplastic change. These viruses can be tested for, and after an abnormal pap that may be the next best test. Pap smears and HPV tests signal the need for more extensive evaluations to determine what your real diagnosis is. And exactly how that will be done is determined by your age and history. Swab tests and biopsy tests are really the next step. Newly developed are tests that show whether the HPV virus has caused the cells to have actual genetic changes. Before a woman gets an actual cancer of the cervix they usually are diagnosed with a precancerous change called Cervical Intraepithelial Neoplasia, known as "CIN" . That diagnosis has to be made by a microscope test called a colposcopy.  If you get CIN II or III only 12% ever progress to invasion. Other co-factors are the complexities of our biology, like our HLA type, variations in the form of our p53 gene, variants of the high risk subtypes of the HPV itself and own immune system health such as other STDs and whether you are a smoker. Most women (about 90%) completely clear their HPV infection in 40 months, but some seem to clear more quickly. Therefore follow up HPV tests are used to determine who persists with infection and who has gone back to less risk because their HPV infection has cleared. If your partner has infection still, it's your own immunity that seems to work to clear your virus and thus it's not typical to get reinfected by a partner. Thus, partner testing wouldn't really be too helpful, and there are no reliable HPV tests for men. At greatest risk for the eventual development of cervical cancer are the 10-15% of women who have had HPV and who never clear their HR HPV types. In other words one bad pap test, not very worrisome; pap tests that stay bad for years do lead to worry. Average age for developing cervical cancer is 40 in spite of the fact that first abnormal pap smears occur at a much younger age, usually in your 20s. So there is time to become cured of pre-cancer of the cervix if you do have that abnormal pap. If you have that abnormal pap, the first step will be to understand the actual test result. The next step is to see if additional tests, like an HPV test or an STD test is necessary. For a firm diagnosis a colposcopy with a biopsy probably has to be done. And finally then can the treatment plan be undertaken. Treatment plans also depend on your plans: for pregnancy, for contraception, and your age. We welcome the opportunity at Womens' Health Practice to consult on your diagnosis in the future.


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