It can be scary having a PAP return abnormal.
The first thing to understand is exactly what the PAP is testing for, and the second thing to understand is that there are many degrees and types of abnormal, some less and more concerning than others.
About the "PAP" test
The PAP is short for "Papinicoulau smear". Dr. Papinicoulau recognized many years ago that by taking a small sample of cells from the cervix and looking at them carefully under the microscope, we could determine who was at risk for cervical cancer.
Remember that the cervix is the part of the uterus that extends into the vagina. So, just as back in Dr. Papinicoulau's day, the "PAP test" is checking ONLY for cervical cancer and precancer (not endometrial cancer, uterine cancer, tubal cancer, ovarian cancer, other female diseases). Unfortunately the "PAP" has come to be used interchangeably with a "pelvic exam", when in fact, it is just one small part of a pelvic exam.
In fact, the PAP is really good at detecting only one kind of cervical cancer "Squamous cell cancer". It can occasionally detect others, but not consistently. Fortunately, squamous cell cancer is the most common (95%) and because we have a screening test for it, it is the most easily preventable.
Now, fortunately we don't find squamous cell cervical cancer on PAP very often anymore in this country. (In developing countries, it is one of the leading causes of female death from cancer). That's because we do "PAP smears" and find it while it is in its long precancerous state.
The PAP results take about a week to come back. During this time, the cells are being carefully examined. The PAP has been improved vastly since Dr. Papinicoulau's day, and now sophisticated computerized analysis of PAPs collected in a liquid based medium has improved the sensitivity of the PAPs. In addition, we have recognized HPV as the (ONLY) cause of squamous cell cervical cancer, and have incorporated HPV screening along with the PAP with appropriate age groups.
About HPV
HPV stands for "human papilloma virus". It is sexually transmitted, and no other means of transmission has been documented. People that have never been sexually active don't have this virus, and their risk of cervical cancer is extremely low. So essentially, squamous cell cervical cancer is a sexually transmitted disease.
HPV infection is extremely common. Most people who have ever been sexually active have had at least a transient infection with some type of HPV. There are more than 85 types, and most are harmless, or at worst, cause genital warts, which are a nuisance, but not harmful from a cancer point of view. However, there are 13 types of HPV that are considered "high risk" in that they cause cervical cancers and precancers. Those are the ones that we are screening for in women more than 30 years old, in whom cervical cancer most commonly occurs. High risk HPV is carried by both males and females, and usually causes no problems for males except that they can transmit it to their female partners.
About Precancer
Precancer of the cervix, also known as DYSPLASIA, is what we are looking for on the PAP. There are two kinds grades of dysplasia that come back on PAPs, low grade and high grade.
When a cervical cell is infected with high risk HPV, it divides abnormally and the nucleus gets bigger. Your body can suppress the HPV much of the time, over a period of months to years, and the cells return to normal. However, sometimes your body is not able to do this and the cells stay the same or progress to high grade dysplasia. From there, they may, depending again on how well your immune system is functioning, revert back to low grade, or even to normal, stay the same, or progress to actual cervical cancer.
About 92% of PAPs return normal. 2% return as "low grade dysplasia". 1% return as high grade dysplasia.
What about the other 5%?
They are put in a category called ASCUS.
About ASCUS
ASCUS stands for "atypical squamous cells of undetermined significance". It is the "catch all" category for the pathologist who is looking at the PAP and a little confused because the cells don't neatly meet the criteria for normal, but don't neatly meet the criteria for precancer. When this happens, we have the pathologist run an HPV test on the PAP. If it is positive, we treat ASCUS like a dysplasia, and investigate further, usually with colposcopy. If it is negative, we treat it like a normal PAP.
Colposcopy
Colposcopy is a procedure similar to a pelvic exam, in which a large magnifying scope is used to examine the cervix with stains that are applied to the cervix to highlight which cells are turning over quickly. Cells that are turning over quickly could be precancerous, but not necessarily (could be just normal "wear and tear", could be a vaginal or cervical infection under repair, etc). So we take some tiny (1mm x 1mm) biopsied to give the pathologist to better determine exactly what is going on in these areas. Often we sample the canal of the cervix as well for any dysplasia that might be hiding higher up. About a week later, we can tell you if you have dysplasia, where it is, and whether it is mild, moderate or severe. For more information about colposcopy, please click here.
Treating Dysplasia
Mild dysplasia does not necessarily need to be treated. It can be followed carefully with PAPs and/or HPV tests every 6 months or so until it returns to normal, which it often does. If it does not, we typically look at freezing or excising the area, depending on where it is. Some people feel more comfortable if we freeze or excise right away, and if you are finished childbearing this may be a reasonable option.
Moderate or severe dysplasia, or any level of dysplasia hiding up in the cervical canal, almost always needs to be excised and removed. This can be done with an in-office procedure called a LEEP.
What is a LEEP?
(Click here for the ACOG Patient Information brochure about LEEP)
LEEP stands for "loop electrical excision procedure". It is an in-office procedure in which a small cone shaped area is removed from the bottom of the cervix. The aim is to entirely remove the moderate to severe dysplasia. If a woman is still planning to have children sometime in the future, then the aim is also to leave as much normal cervix intact as possible. The normal cervix is between 4.5 and 6 cm. Most LEEP procedures remove about 0.5 cm deep of tissue. Occasionally the LEEP does not remove the entire dysplastic area and needs to be repeated, or the dysplasia reoccurs a few years later. In these situations, a LEEP may need to be repeated. The risk of preterm delivery or premature rupture of membranes with future pregnancies seems to increase slightly after a LEEP, particularly if it is shorter than 3cm in length. But the risk of not doing it is having the dysplasia progress to a life-threatening cervical cancer, so the situation needs to be viewed in that perspective.
Preventing HPV - the Gardasil Vaccine
Immunization with Gardasil is recommended for females (and males) prior to sexual activity, typically around the age of 12, if possible. Insurance usually covers this vaccine up to age 26, and the FDA recently approved it for use to age 40. Gardasil prevents infections with HPV types 16 and 18. These are two of the "high risk" subtypes that cause 70% of all dysplasias. The other 11 high risk types that also cause dysplasia are not prevented by Gardasil. If you already have type 16 or 18, the vaccine will only protect you against the one that you don't have - it won't change in any way the infection that you already have on board or the dysplasia that might result. Gardasil can also prevent types 6 and 11, which are responsible for most, but not all, genital warts. The Gardasil vaccine is a series of 3 doses, a couple of month apart. For more information, visit www.gardasil.com, or view ACOG’s Patient Information brochure on The HPV Vaccine.
