E80: The Physical Domain of Pap Smears

Katie: Welcome to the "7 Domains of Women's Health." I'm Katie Ward. I'm a women's health nurse practitioner and professor at the College of Nursing, and I maintain a clinical practice caring for women across the lifespan. With me today, as always, is my co-host and mentor, Dr. Kirtly Jones. Kirtly is an obstetrician, gynecologist, and reproductive endocrinologist. And today, we're starting a new series on Pap smears.

Pap smears are a ubiquitous experience for women, one that touches on pretty much every aspect of women's health, from cancer screening to just the gynecologic visit itself. And we're going to explore this today as we usually do, through our seven domains of women's health, looking not just at the physical aspects of having a Pap smear but also things you might not have considered, the social, emotional, intellectual, financial, environmental, and, yes, even the spiritual aspects of this.

Kirtly: Little did you know that the Pap had all those things, of course.

Katie: I guess for two people that think about this a lot, I'm like, "Oh, everything. This covers everything."

Kirtly: It does.

Katie: Kirtly, do you remember your first Pap smear?

Kirtly: I actually do. I think I was sent to our family doctor, and he was a GP, they called him back then. He knew the whole family, and he delivered two of my siblings. And I had nothing to hide from him because I had nothing to hide.

Anyway, before I went off to college . . . so I went to see him before I went off to college, and he did a Pap smear, and he must have been gentle, as I was not traumatized. I had never had sex. I was a virgin. He gave me some advice, and not accurate advice. He assumed that if I was going off to college, I might become sexually active. He said that because I had irregular periods, I couldn't take birth control pills, and so, and I quote here, "I should be careful."

I was confused. What did he mean "be careful"? I had no clue. So for young women my age, I was 17 going off to college, it was kind of like a premarital exam. You got a Pap smear and a pelvic exam, it was my first, and a talk about birth control, which I sort of got if I knew how to be "careful." So I kind of got a talk about birth control, but "just be careful" isn't a great birth control method.

I mean, I know this was over 50 years ago, and ironically, thinking of the career that I chose, specializing in fertility and contraception. Over the years, I've probably performed 10,000 Pap smears, and most of them went well, at least from my perspective, which probably isn't the perspective that counts. 

But I don't do Pap smears on women who've never had any sexual encounters, as I know they are at very low risk for cervical cancer. So I probably didn't need my first Pap smear. And I trust women when they tell me about that, and that's important. Tell the truth to your gynecologist or to whatever. Your gynecologist or whoever's doing your female care, you tell them the truth.

Katie: Yeah. And I think a lot of people end up having a bad first experience with their gynecological provider with that exam, and we're going to delve into that a bit in future episodes because I think there's a lot to talk about there.

Today, though, as we're introducing this topic, I want to start with a little history. And I want to pay homage to someone who I think is an unsung hero of the Pap smear. So we all know about George Papanikolaou, or at least we sort of do, since that's who the Pap test is named after. And in other places where I work and travel, they do actually call it a Papanikolaou smear. But like Americans and Aussies, we're going to shorten it down to Pap. And so that's the phrase that most people know, but it's named after this guy that invented it.

But the unsung hero in this story is actually his wife, Mary. And I always like to just take a minute to reclaim the narrative of the hidden figures, the women who are behind the science, because this happens a lot.

So Mary Papanikolaou, she came to the United States from Greece with her husband, George. He was a researcher, and she was also his lab assistant, as his wife. And he was researching fertility, studying how hormones affect cells in guinea pigs.

While he was sorting out what he was learning from guinea pigs, Mary, who must have been just a really patient woman, allowed him to take samples from her human cervix. 

And so the folklore about this story is that she got a daily Pap smear. Maybe it wasn't daily, but that research continued for 21 years. So she might have been the person who had the most Pap smears in history.

Kirtly: Oh, good for her. Thank you, Mary. Thank you.

Katie: Which is why I always want to just take a minute and do the homage.

But I think she was dedicated to the science and, alongside her husband, developed this test that we called the Pap smear. So Dr. Papanikolaou was a scientist kind of doctor, not a physician. He didn't see patients, but he worked in a facility where there were a lot of other doctors who were doing patient care.

Someone brought a sample of cells from a patient with cervical cancer for Dr. Papanikolaou to look at. And he was able to compare this to the samples he had from his wife's cervical samples that he'd been staining and looking at.

And so he could immediately see that, one, there was a big difference between the normal cells and the cancerous cells. And then as he started to look at this more, he could tell that there were precancerous changes that were distinct in that transition between normal and cancer.

I think he knew from Mary putting up with this test for so long that it was a tolerable test. If not pleasant, at least it was something that people could abide.

And so putting these things together, he came up with this idea that we could screen healthy women and look at their cervical cells and determine whether or not there were any precancerous changes going on. The test has borne his name ever since, although, and we're going to talk about this, what we use now is actually quite different than the original. But it's still a huge success. The implementation of this screening test reduced cervical cancer by 70%.

Kirtly: Right. The Pap smear is probably the paradigm for the most effective screening test for cancer. And I think to be an effective screening test, it has to be inexpensive, it has to be extremely low-risk, it has to be pretty good at picking up cancers, and it has to be pretty good at not saying something is cancer when it's not.

So it meets those criteria. It's inexpensive, it's not risky, and it does a very good job picking up squamous cell cancers of the cervix, the most common type, while it's still in the precancerous stage, so it can be treated.

Now, the downside, I think, like all of preventative medicine, is that it's unequally distributed. Women who are too poor, too afraid of going to doctors, too uneducated about their bodies, or don't have geographic access to healthcare, read live in rural areas away from healthcare, those people don't get screened. They're the very women who are at the highest risk of dying from cervical cancer.

We're going to talk a lot about that in the Social Domain of Pap Smears, but it's important to remember that the Pap smear and the new tests don't work if you don't get them.

Katie: Right. And when I say we've reduced cervical cancer by 70%, or even more lately, that's not true around the world. Cervical cancer remains one of the leading causes of death around the world. So, yes, the unequal distribution globally, and then even in our own country, there's very unequal distribution. So, yeah, we'll get into that a bit more.

The problem with the original Pap smear was it still missed things. It was a good test. Seventy percent is a great test, but each individual one had some flaws. So there might be abnormal cells on the cervix, but we didn't get them on the spatula. They got on the spatula, but they didn't make it onto the slide. Or they were on the slide, but they were hidden under another clump of cells. So they had what we call a high false negative rate.

And so, in order to make up for that, we did them every single year. The idea that you got that every year sort of became synonymous with the idea that women need an annual exam. So I still have patients all the time that make an appointment for their annual exam, and what they mean is a Pap smear. So whether they've had it recently or not, that term has become interchangeable, annual exam and pap smear.

So that's something that I think is important to start to unpack, that it's probably a good idea to see somebody for preventive care, check your blood pressure, make sure you're up to date on your vaccines and your prescriptions, and talk about your health and things like that. But nowadays, you probably don't need a Pap smear every single year. What you're making the appointment for, sometimes it's just managing people's expectations about what's going to happen when they come in.

Kirtly: Yeah, and it used to be that we actually held women hostage. We held their birth control hostage to getting a Pap smear. So you wouldn't get your birth control pills renewed if you didn't come in for your Pap smear every year.

It was brilliant, maybe 10 or 20 years ago, when finally . . . I think it was a national organization who said, "Now, wait a minute. There is no evidence you have to hook one to the other."

Some women want to come in and get their birth control renewed, and they want to maybe get their blood pressure checked, but they just don't want to have their Pap smear for whatever reason. So we separated having to get the Pap smear to get any other thing that you might get from your healthcare provider for women of reproductive years. So things have really changed, I think, for the good.

Katie: Yes. And the other good news is the Pap smear technology has completely transformed. So we don't do those traditional Pap smears anymore. We still look at cervical cells, but now we're using this liquid-based cytology, and it's really much more reliable. So the cells are preserved in liquid, it's processed by a machine, and examined with computer assistance. The testing is really much better, and we can go three to five years between those tests.

And the other thing that we're testing for now is HPV. So especially for women over 30, a negative HPV test is really reassuring. It means your risk of developing cervical cancer is very, very low. And the predictive value of that is longer, so every five years is as often as you need to go in for this exam if you're getting both a cytology and an HPV test and they're both negative.

One thing that's important to understand about Pap smears is what they're also not testing for. I see this a lot in my practice. A couple of things. One is maybe they've gone to the emergency room for appendicitis or something, and they got a pelvic exam, somebody put a speculum in and did an exam, and they think they had a Pap smear in the emergency room when in fact they did not. So just because you've had an exam doesn't necessarily mean you've had the Pap test for cervical cancer.

And when you do get a Pap test, you're not getting tested for ovarian cancer or endometrial cancer or, necessarily, sexually transmitted infections. Sometimes we get a hint about endometrial problems with a Pap smear, but it is a test specifically for cancer of the cervix and the presence or absence of HPV.

Well, let's talk about HPV, because that's really the key to understanding cervical cancer, right? The human papillomavirus. It's really a family of viruses. And I think there are some interesting things about it. Since I spend a lot of time in Pap smear care and Pap smear follow-up, I always like to explain this a little more to my patients. And so it's fun to talk about it here.

You have this family of viruses, papillomaviruses. And so the human in the name, the H in the HPV, is important because it turns out there are papillomaviruses for pretty much every other animal on the planet. Birds get papillomaviruses. Dogs get them. They're species-specific, and so the human papillomavirus only affects humans.

And then within this family, you're going to find all kinds of specific viruses. So they include the things that cause warts. These can be wart viruses that people get commonly on their fingers or on their feet. There's a special one for your eyeball. There are a bunch of HPVs out there, but for our purposes, we're talking about the one that targets mucous membranes and the genitalia.

Kirtly: And it's important to know that for human papillomaviruses, the kind that cause cervical cancer, these are sexually transmitted. You can't get them by breathing them, you can't get them on food, and you can't get them on toilet seats or in hot tubs. So this is a sexually transmitted virus.

Katie: Yes, and it's transmitted with skin-to-skin contact, so close, intimate contact. And that includes activities that are not exactly sexual intercourse. It is a virus that can be spread through oral contact or oral-genital contact, but still close, intimate things that we associate with intimate activity.

Kirtly: We won't go on, for the sake of our young listeners, to any more detail than that.

Katie: We'll keep that clean rating. So while there are hundreds of papillomaviruses for different parts of your body, there are about 40 that are the sexually transmitted strains that we worry about. And those can be either cancer-causing or wart-causing.

When we pick them up on the cervix . . . The cervix can hold both of those kinds, so there can be warts that aren't going to progress to cancer or the strains that have that cancerous potential. So when we're testing this, we're looking specifically for the cancer-causing strains. And that's why it's possible to have an abnormal Pap and a negative HPV test, because the tests that are included in this are just for the cancer-causing ones.

The other thing I want people to understand is that HPV doesn't just affect the cervix. So those same high-risk cancer-causing strains can cause other cancers that include rectal cancer and cancers of the throat and mouth, what we call oropharyngeal cancer. You see those oropharyngeal cancers a little bit more commonly in males. And it can cause some cases of penile cancer.

And while we have these excellent screening tests for cervical cancer, we don't yet have similar screening tests for HPV-related cancers in other places. So we can test women for HPV during their annual GYN exam . . . not annual, but regular GYN exam . . . along with their Pap smear, but we don't have that same test for HPV in men. And so that's what makes vaccination even more crucial.

What is revolutionary about the whole situation now is that we have a vaccine, Gardasil 9, and that protects people from seven strains of the cancer-causing HPV and then two additional strains that cause warts. So that's where the 9 comes from.

And this has just been a game changer, really, for cervical cancer. So if people get this HPV vaccine before they're ever exposed, it helps their bodies make antibodies prior to ever coming in contact with those viruses. If you encounter those worst actors, the ones that cause cancer or the two that are likely to cause warts, you're already immune. Your body recognizes the virus and is able to eradicate it. So that's the beauty of all vaccines, is immunity before exposure.

We're going to spend a lot of time talking about the vaccine in a future episode. But understanding that HPV is what caused cervical cancer really was an important game changer in how we approach this.

So the combination of having this really great test that detects this early and now being able to vaccinate people . . . In the United States, we actually see less than 14,000 cases of cervical cancer each year, which is really low. And of those, we see about 4,000 deaths, maybe less than that, from the disease. So we're able to intervene. We have good treatments. And really, when you think about it, in the entire United States, that less than 4,000 people die from cervical cancer, that is a big decline from even 30 years ago and certainly from 50, 60, 70 years ago when we first invented the Pap test.

Kirtly: And of course, we could do a lot better if more people got screened. I'm going to keep harping on that, because many women don't know that they have free testing available in almost every community. You just have to know about it.

Katie: Right. There's free testing. And then what's coming along that's pretty new and exciting is women are going to be able to do their own test in the privacy of their home, which I think is another big barrier for people, is just being able to get in and see a healthcare provider and the anxiety about having that exam.

So all these technological advances have made the Pap more accurate and less frequent. But let's talk a little bit about what happens when you have a Pap smear, because despite all these advances, it's still not anybody's idea of a good time.

As you were saying, I think that's one of the reasons people don't come in, is a little bit of fear about the exam and what that entails.

So of course, it currently is requiring a visit to a healthcare provider, but I think that's going to change. But when you do see a healthcare provider, they're going to insert a speculum into the vagina and visualize the cervix and take the sample.

That little collection itself can be uncomfortable. I'm someone who gets a bit of a cramp with my Pap smear, and I don't look forward to it, in spite of the fact that I do them all day. I'm very sympathetic that it's not pleasant, but it's fast. I know that for many people, that's a really vulnerable exam to have. And particularly if you've had a bad experience with a previous exam or for people who have had any sexual trauma, it can be especially anxiety-provoking.

So when I'm seeing patients, I always keep that in mind, and I focus on some things I can do to make that more comfortable. One is that I ask questions about any fears or anxieties or past bad experiences. I'm always tuned into that as I'm talking to my patients. And especially if people haven't been coming in regularly, I want to find out if that's a barrier for them, so we talk about it.

I always ensure that my patients know they're in control. So I will always say to them, "You're in charge here. You can tell me if I do anything that hurts you. You can ask me to stop. You can have someone come in and hold your hand, whatever you need to help you get through this." So again, I want to make sure that I know my patient is in control, and I will stop at any point if they're too uncomfortable.

The other thing I try to do is offer options like letting them position themselves in whatever way makes them most comfortable. So we typically use stirrups in the GYN setting, but that's not always comfortable for some people, both physically it's challenging or it just, again, feels really vulnerable. So we can brainstorm about different positions. That's one thing we can do to make it more comfortable.

I might tell people they can put the speculum in themselves if they feel more comfortable with that, and then I can work with that once they've inserted it. So there are a lot of little tricks that we have that can help.

Certainly, I explain everything I'm doing step by step. And for first-time patients, before we even get started, I might show them the speculum, let them hold it, let them sort of see how it works so that it doesn't feel like an instrument that they have no idea what's happening.

And then, of course, little practical things like warming the speculum and having everything prepared before I ask people to get into that uncomfortable position so that I can do this as quickly and efficiently as possible. These are things I do with my patients, and I teach my students to do that as well.

So at the same time we do the Pap test, we can also test for vaginal infections like yeast and bacterial vaginosis and sexually transmitted infections like gonorrhea and chlamydia. But these are not automatic with a Pap, so you have to make sure to discuss those with your provider if you feel like those are tests that you need or want.

And as we mentioned before, the Pap doesn't screen for other cancers like ovarian cancer. I think that's always an important thing to just make sure you understand what's getting covered here and what's not.

Of course, you shouldn't wait for your regular screening if you have symptoms or concerns. There are many reasons to see your provider between your regular exams, whether or not that exam includes a Pap test. So first and foremost, bleeding. If you're having bleeding after menopause, that absolutely needs to be checked out. It's not normal to bleed after menopause, even if it's just a little spotting. And for people who are still having periods, bleeding between a period or after sex needs attention.

Kirtly: It's important to know here that cervical cancer in its pre-cancerous conditions is completely asymptomatic. There is no way that you would know if you had the early signs of cervical cancer.

But the number one symptom of cervical cancer, invasive cervical cancer, is bleeding and often is bleeding after intercourse. So if you have bleeding that is unexpected either with intercourse or unexpected in timing, it's important to see your clinician about that.

Katie: Absolutely. Pain is another important symptom. So usually, cervical cancer is not painful, but if people are having pelvic pain, that can indicate another problem. So new pelvic pain or pain that doesn't go away or pain with sex that's new or getting worse, those are all reasons I want people to come in for an exam.

And also discharge. All women make a little bit of vaginal discharge. It's kind of how the vagina protects and cleans itself. So we all have a normal discharge, and it changes a little bit throughout the menstrual cycle. But if it has an unusual color or odor or if there's itching or irritation, those are all things that we can evaluate you for. And so those also should not be ignored between visits.

So before we wrap up our discussion, there are two crucial things I want everyone to know. First, the symptoms we just discussed should never wait for your scheduled exam. They deserve immediate attention, and we are happy to see you for those.

And the second is something I wish more people understood, is that your gynecological provider does not care if you've shaved your legs or shaved anything else. Our job is to look after your health. And people often just apologize, "I haven't shaved my legs." Really don't worry about that.

Kirtly: I'm only laughing, not because they didn't shave their legs, but because they thought it was important. It's very dear to me that ladies have this sense of what's just right. To us, it doesn't matter. We just want to take care of their health.

Katie: There's a writer I admire who talks about how every human has two eyes, one nose, and one mouth, and yet we all look completely different. And it's the same throughout our bodies. We all have basically the same anatomy, but everybody's body is unique, and they're all beautiful.

When you're there as my patient, it's my job to take the best care of you that I can. And I admire each and every human as unique and a perfect expression of billions of years of evolution that made you you. Yeah, I don't care if you haven't shaved your legs.

All right. Well, hopefully this has answered some of your questions about Pap smears and maybe made you want to learn a little bit more. We have a lot more to talk about as we continue to explore the Pap smear through all the domains of health in the coming weeks. We hope you'll stay along for each episode.

As always, the "7 Domains of Women's Health" is available on all the podcast platforms, and it's online at womens7.com. 

Kirtly: Katie, thank you for an amazing introduction to Mary Papanikolaou. That's such a great story, and I'll hold it in my heart. What women have done for science.

Katie: Right? And not always getting the credit that is due for being the person behind the scenes. So I do like to share her story. One day, I'll write a book.

Kirtly: Thanks, everybody, for joining us.