Changes to cervical cancer screening a.k.a. the PAP smear test

This blog is written by our clinicians and aims to keep patients informed with up to date information on medical conditions. The editor of the blog is Dr Cristina Romete.

Lets get back to basics – what is a cervix? This is the neck of the womb that joins with the vagina and looks like a mini donut! The opening in the middle is called the ‘os’ which allows blood to flow out during your period, and sperm to get in when trying to conceive. The cervix is muscular and when pregnant, it holds the foetus inside the womb until birth. During labour, the cervix gradually widens to allow the baby to be born.

 

Human Papilloma Virus (or HPV) is an extremely common virus affecting the skin and is easily transmitted through intimate skin-to-skin contact i.e. full intercourse is not required for HPV transmission. There are more than 200 type of HPV, of which 14 are cancer-causing ‘high risk’ HPV subtypes (HR-HPV). Most types are usually cleared by the body’s own immune system, but in 20-30% of women this does not happen and they are at risk of cervical cell changes from persistent HR-HPV which may, much later, develop in to cancer.  It is not clear why persistent HR-HPV infection causes more cell changes in some women than in others, but additional risk factors that increase a woman’s change of developing cervical cancer include smoking, having a weak immune system, loss of virginity at an early age, and having multiple partners.

 

It is these changes to the cells of the cervix that conventional smear tests are looking for, by sampling cells from just around the os and slightly inside the opening. In order to perform a smear test, the woman lies on her back on the examination couch and using a speculum (the disposable plastic instrument that looks a bit like a duck’s beak) the doctor widens the upper part of the vagina to allow the cervix to be seen. A soft brush is quickly rotated in the os which will feel strange but should not be painful. The brush is then rinsed vigorously in the small plastic container of liquid preservative. A chaperone is always offered to the woman before performing this intimate examination.

 

OK, got it. So what is new?

 

Well, since the introduction of the HPV vaccine Gardasil to 12-13 year old girls in 2008, infections with the 2 HR-HPV types most responsible for cervical cancer cases (types 16 & 18) have reduced by 86% in England. These vaccinated women are now beginning to enter the UK’s cervical cancer screening programme.

It was recommended in 2016 by the UK National Screening Committee that HPV testing should be the first test in cervical screening, rather than looking at cervical cells under the microscope (‘cytology’). They also recommended that cytology should only be used as a triage on what to do next in a woman found to be HR-HPV positive. HPV testing is also a more appropriate test for previously vaccinated women because the incidence of cell changes seen on cytology will be much lower.

This has come in to effect since the start of 2019, although some areas in England have been piloting HPV testing as first line for some time.

HPV testing is done on the same sample taken like a conventional smear test so there are no changes to the way a smear test is performed, it is just the results that will look different to you by saying either HR-HPV negative or HR-HPV positive, rather than the usual ‘normal cells/negative’ or ‘abnormal cells’.

Up to 90% of women will test negative for HR-HPV on their smear test and will quickly be returned to the routine smear screening interval, as the chances of developing cervical cancer within the next 5 years without HR-HPV are very small.

It a woman turns out to be HR-HPV positive, then their sample will undergo further tests for cytology and if this is normal, then they should be set for a recall test in 12 month’s time. If the cytology is abnormal, then the woman will need a specialist referral for colposcopy (a more detailed look at the cervix via a microscope).

We have already seen a few women in clinic who have received their smear test result with HR-HPV positive and have been upset about this result as they can not understand how they got the virus and assume it must have been from an unfaithful partner as they never tested positive for HR-HPV before. However as explained above, HR-HPV was not routinely tested for in smear tests before, so the likelihood is that they have probably had it for a while and are in the unfortunate 30% who don’t clear the virus within 2 years of infection. In these circumstances, I take my time to listen to her concerns, explain to the woman about persistent HR-HPV with no blame able to be placed on a partner as is often done with a ‘typical STD’, and explain that with further testing and treatment, we can stop progression to cervical cancer, so it is good we found out now with the new testing.

 

Take home points:

  • Women should have cervical screening, even if they’ve only had vaginal penetration by a finger or a sex aid
  • Men who have transitioned from female and still have a cervix should also be screened.
  • There is no change to the smear test procedure, it is just the results that will be displayed differently.
  • Cervical screening saves lives. Such a quick and simple procedure should not be put off for the sake of embarrassment over genital appearance or smell.
  • Participation in national screening programmes is a choice, and women are freely entitled to opt out if they are fully counselled on the implications of missing said screening. Even if a woman withdraws from cervical screening, she can change her mind at any time and re-enter the programme easily.

 

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