Important: This is intended as general information only. It may not apply to your specific situation. It is not a substitute for medical advice. If you have a question or concern, please raise it with me at your next appointment or contact me sooner if it's urgent.
Abnormal Pap Smears
What are pap smears?
A pap smear is a test in which a few cells are gently scraped off the cervix and examined under a microscope. With this test, we are looking for evidence of any changes in the cells of the cervix which, if left untreated, could progress to become cervical cancer. A pap smear is a screening test. This means that it is a test performed in healthy women with no symptoms. The purpose of a screening test is to detect problems in their early stages so that we can intervene to prevent further problems down the track.
A pap smear can detect very early changes in the cervix which gives us plenty of time to work out exactly what’s going on and how best to treat it. These early changes are called cervical dysplasia. Not all cases of cervical dysplasia will progress to become cervical cancer. However, since this is a possibility, we take all cases seriously. Cervical cancer usually doesn’t cause any symptoms until it is very advanced which makes it difficult to treat, so it is particularly important to pick up these early changes.
It’s important to understand that a pap smear doesn’t actually make a specific diagnosis. What it does do, however, is tell us that something in going on and we need to look more closely at the cervix to work out what it is and what treatment, if any, is required.
In Australia, it is recommended that all women who are, or who have ever been, sexually active have a pap smear every 2 years. Women who have never been sexually active do not need to have pap smears.
What causes cervical dysplasia?
Cervical dysplasia is caused by the Human Papilloma Virus (HPV). There are many different sorts of HPV, some of which can infect the skin in the genital area and the cells in the vagina and cervix. Other forms of the virus are responsible for the common warts that people get on their skin in other parts of the body. The virus is spread by skin contact during sex and almost everyone who has been sexually active will have come into contact with it. Although, technically, it is a sexually transmitted infection (STI), it’s better to think of it as a normal part of having sex as almost everyone who does so will become infected. Condoms, which are very effective in protecting against other STIs, offer only limited protection against HPV.
Most people pick the virus after becoming sexually active but their immune system eventually gets rid of it. However, the virus is quite good at hiding from the immune system and can persist in the cells of the vagina and cervix for many months or even years. This is not necessarily a problem, but it can result in changes to those cells. It is these changes that we see on pap smears. It is still possible for the immune system to clear the virus after these changes have occurred. In a small number of cases, however, these changes progress and can, eventually, turn into cancer.
There is nothing you can do to ‘boost’ your immune system in order to make it more likely to clear the virus. However, you can make it harder for your immune system to clear it by smoking. There are plenty of other reasons not to smoke, of course, but it is well established that being a smoker makes it much harder for your immune system to clear HPV and, in turn, more likely that cervical dysplasia will progress to cancer.
Some women may need, for medical reasons, to take drugs that suppress the immune system which may cause them to have persistent HPV infection. Generally speaking, these women need to continue their medication (immunosuppressant drugs are usually only required for quite serious illnesses so stopping the medication is not an option) so they need to be followed very closely and may require pap smears more frequently than the general population.
Abnormalities on pap smears
A number of different things can be found on a pap smear. The two most common abnormalities reported are Low Grade Squamous Intraepithelial Lesions (LSIL) and High Grade Squamous Intraepithelial Lesions (HSIL). If you have one of the less common abnormalities on your pap smear, I will explain it to you in detail at your first appointment
This means that the cells show minor changes of cervical dysplasia. In previous terminology (which you may still hear used) this was call CIN-1. It also includes changes in the cells associated with the presence of the HPV virus but falling short of actual dysplasia.
This means that the cells on the pap smear show more significant dysplastic changes. In the old terminology it was called CIN-2 and CIN-3.
What happens when a pap smear is abnormal?
As discussed above, a pap smear tells us that something is going on with but doesn’t actually make a diagnosis. In order to do this, we need to take a closer look at the cervix. This involves a small procedure, done in the rooms, called a colposcopy.
In young women with a single pap smear showing low grade changes, particularly if they have had normal smears previously, we often wait six to twelve months and repeat the pap smear. This is because these abnormalities are common in young women and, in many cases, they fix themselves. If the abnormality persists (ie it is still there when we repeat the pap smear in six to twelve months), we would then go on to perform a colposcopy. In older women, women who have abnormal smears in the past and women with other significant health problems, we may perform a colposcopy after a single smear showing low grade changes.
If the pap smear shows high grade changes, we always perform a colposcopy.
A colposcope is a microscope with an attached light. Women having a colposcopy lie on a gynaecology couch to support their legs and a speculum (exactly like that used for a pap smear) is inserted into the vagina. Because of the special leg supports, this is usually more comfortable than having a speculum examination on a standard bed. I then use some dyes to (temporarily!) stain the cervix and look at the cervix with the microscope to see if I can see where the abnormal cells are coming from. If I can see anything abnormal, I will then take a small biopsy which will be sent to a laboratory to be examined by a pathologist. Although the biopsy is very small – a couple of millimeters – it is usually big enough for a skilled pathologist to make a definitive diagnosis of high or low grade dysplasia.
There is sometime a small amount of light bleeding or spotting from the biopsy site and often a dark discharge as the dye used to stain the cervix works its way out. It is recommended that women who have had a cervical biopsy avoid using tampons or having sex for about 48 hours or as long as the discharge persists. The whole procedure takes between five and ten minutes.
I will, of course, tell you what I can see when I look at the cervix and what I think the diagnosis is. The final diagnosis (and therefore the plan for follow up and treatment) will depend on the results of the biopsy. In most cases, I can discuss this with you over the phone once the results are available.
Treatment for cervical dysplasia
LSIL, particularly in young women, may not require treatment. In most cases it will resolve spontaneously. However, it is extremely important that women with a LSIL pap smear have regular follow up. In the first instance, it is recommended that the pap smear be repeated in six to twelve months. If the pap smear remains abnormal, it is important to have a colposcopy performed to make sure that there is not something more severe there that the pap smear is missing. Once it is confirmed that the abnormality is low grade, it is important to keep an eye on it to ensure that is does go away. It is unlikely that the abnormality will get worse but, if it does, treatment may be required. In older women or women with previous abnormalities or other health problems, we may move on to treatment a little earlier.
It is recommended that HSIL be treated. This is because, over time, the cells may become significantly more abnormal and progress to become cervical cancer. This does not happen to all cases of HSIL. In fact, may of them will resolve without treatment. Unfortunately, however, we are not very good at predicting which ones will resolve and which ones will progress or persist so it is recommended that all be treated.
There are a number of different ways that cervical dysplasia can be treated. They all involve a small procedure to destroy or remove the abnormal cells. This is usually done under general anaesthetic. The most common procedure performed is called a LLETZ (which stands for Large Loop Excision of the Transformation Zone – the transformation zone is the area on the outside of the cervix where the abnormal cells are seen). A small wire loop with an electrical current running through it is used to shave off the abnormal cells. The electrical current cauterizes blood vessels to reduce bleeding from the cervix. This is done in a day procedure unit. The procedure itself only takes 10 – 15 minutes although the whole process of coming into hospital, having the anaesthetic, have the procedure and waking up enough to be able to go home again takes three to four hours. You will usually require two days off work. It is normal to have some mild crampy pain after the procedure and a light, bloodstained discharge for up to a few weeks after the procedure. It’s recommended to avoid using tampons, having sex, swimming or soaking in a bath or spa until the discharge has completely settled. If you require treatment for HSIL, I will discuss this with you in more detail.
More severe abnormalities or abnormalities that are higher up in the cervix or involve the glandular cells, may require a cone biopsy. This involves a larger, cone shaped piece of tissue being removed from the cervix. As well as the ability to excise a larger abnormality, this also gives the pathologist a larger piece of tissue to look at under the microscope so may be used in situations where there is uncertainty about the diagnosis or if we are particularly suspicious of an early cervical cancer. If you find yourself in the situation, I will, of course, discuss it with you in detail.
Follow up after treatment
After you have received treatment for cervical dysplasia, it is important that you have regular follow up to ensure that the abnormality has completely resolved and that the HPV has been cleared by your immune system. During treatment, we aim to remove all the abnormal cells. However, the treatment cannot actually get rid of the HPV virus. As your body heals after the procedure, hopefully your immune system will be get in and find the virus and get rid of it. It is recommended that you be followed up for 2 years after treatment, during which time you will have repeat colposcopies and pap smears as well as DNA tests to see if the virus is still present. Once you have had two normal pap smears and two negative DNA tests, 12 months apart, you can then return to having a pap smear every two years.
A vaccination against HPV – Gardasil – has been available since 2007. Currently it offered to all year 8 students (the idea being that it would be good to vaccinate young people before they become sexually active). The vaccination protects against four common strains of the virus, two of which are known to cause cervical cancer and two of which cause genital warts. Three doses of the vaccine are required, over a six month period. Hopefully, this will mean many fewer abnormal pap smears and cases of cervical cancer in the future. Most of my patients are too old to participate in the government funded year 8 immunisation programme. It is possible to get the vaccine through your GP and I recommend this, particularly for women in their twenties who have not previously been vaccinated. It is likely that older women have already been exposed to the virus so vaccination may not be as useful for them. Its not necessary to have the vaccination if you are coming to see me with an abnormal pap smear – we already known that have been exposed to the virus (that’s what made the pap smear abnormal in the first place) and hopefully, over the course of observation or treatment, your immune system will clear the virus and you will become immune as a result.
Its important to remember that you still need to have pap smears even if you have been vaccinated. This is because there are lots of different strains of the HPV virus. The vaccine protects against four of the most common strains but you may still come into contact with one of the less common strains.
Abnormal pap smears and pregnancy
Occasionally, an abnormal pap smear will occur during pregnancy. If you are pregnant and your pap smear is due, please let me know so that I can advise you on the best time to have it done. It is quite safe to have a pap smear during pregnancy.
If your pap smear shows a low grade abnormality during pregnancy, it is usually fine to wait until after delivery to investigate it further. If a high grade abnormality is found, particularly if it is found early in the pregnancy, it is usually a good idea to have a colposcopy straight away. We don’t generally treat cervical dysplasia during pregnancy, although this can be done safely if necessary. Because the abnormalities progress slowly, it is usually fine to wait until after delivery to think about treatment. If you were planning to have treatment and found yourself pregnant before the procedure it’s fine, in most cases, to defer the procedure until after delivery. However, it is important that we keep an eye on the abnormality to make sure that it doesn’t progress during the pregnancy. It is completely safe to have a colposcopy during pregnancy.