What Does a Pap Smear Tell the Doctor?

Gina asks: What exactly is the doctor looking for when she takes a pap smear?

GynecologistIf you’re a woman, the term “Pap smear” probably makes the hairs on the back of your neck stand up. The very thought of putting the appointment on your calendar makes little beads of sweat begin to form on your forehead. Similar to getting a prostate exam, this test, while necessary, can be both uncomfortable and force you to break down all the walls of modesty you possess.

Named after Dr. George N. Papanicolaou, who, in 1928, found that cancer cells in vaginal smears could help Doctors find early stages of cervical cancer. The procedure, also known as cervical cytology, involves a women lying on the exam table in stirrups. The doctor places a tool, known as a speculum, into the vagina. The speculum then expands and allows the doctor a better view of your cervix. They then scrape away cells, put them on a glass slide and send them off to the lab for analysis. The pathologist looks at what are known as squamous cells to see if they’re normal, or possibly pre-cancerous.

The test, at first, was not taken seriously by many in the medical profession, most likely because Dr. Papanicolaous’ first study on the topic was full of typos and inaccuracies. In 1941, he did a much better job on a paper published in the “American Journal of Obstetrics and Gynecology”. The theory was then embraced by OB-GYN’s and the American Cancer Society, who started promoting the test. It has become so popular, as of 2005, 86% of women age 18-64 had at least one Pap test in the previous 3 years.  Forty years ago cervical cancer was the leading cause of cancer deaths among women. Thanks to this screening technique, those death rates have decreased dramatically, though in 2008, it was still the third leading cause of cancer in women, accounting for 8.8% of cancers.

What doctors are looking for are abnormal squamous cells. Unlike other cells in the body that are square (cuboidal) or rectangular (columnar), these cells are flat. Coming from the Latin word “squamosus”, meaning scales, they resemble the scales on reptiles. These types of cells are found in numerous areas of the body, like the mouth/lips, in the outer layer of your skin (epidermis), and on the cervix. Any squamous cell can become cancerous. In fact, Squamous cell carcinoma accounts for 20% of all skin cancers.

When the pathologist looks at the cells from your cervix to determine your risk of cancer, they use a system known as the “Bethesda System” (named after Bethesda, Maryland where it was developed). Depending on how the cells look, they put them in 5 main groups:

  1. Within normal limits. The cells look normal.
  2. Atypical Squamous Cells of unknown significance (AGC). The cells are mostly normal but some have unusual shapes, colors or sizes.
  3. Low-grade squamous intraepithelial lesion (low-grade SIL). Some abnormal cells but cancer is rare.
  4. High-grade squamous intraepithelial lesion (high-grade SIL). There are a large number of abnormal cells.
  5. Atypical Squamous cells (ASC). You probably have cancer, but they will double check.

If your doctor gets the test results back and it falls into any category other than “within normal limits”, they may choose to do follow-up pap smears, or colposcopy (taking a magnified look at the cervix). They could also perform DNA testing to look for high-risk types of human papillomavirus (HPV).

HPV is the most common type of sexually transmitted disease. The CDC reports that approximately 50% of the US population will be infected by one of these viruses in their lifetime. It has been shown that approximately 30 of the over 100 types of HPV cause cancer. In 2000, the FDA approved a test to detect the DNA of HPV, and in 2006 a vaccine for the virus was approved.

This knowledge has led some people to think the Pap smear, as a means of detecting cervical cancer, will be phased out over time. This idea is extremely controversial. Currently most doctors use the Pap smear in conjunction with an HPV test, or carry out HPV testing if the Pap smear comes back abnormal. The controversy over how to use HPV testing in conjunction with Pap smears will remain for years to come. Time will tell what common practice will be, but I’m sure most women won’t mind not having that cold instrument shoved in there special “no-no” region.

If you do get diagnosed with cancer, you will be put in one of 5 categories, 0-4.

  • Stage 0 means your cancer cells are on the surface of your cervix and do not invade deeper
  • Stage 1 (is further broken down in 4 classes) means your cancer has invaded deeper into the cervix but still just remains there.
  • Stage 2 (further broken down in 2 classes) means the cancer has spread to nearby tissues but remains in the pelvic area.
  • Stage 3 (also broken down in 2 classes) means your cancer has spread into the lower portion of your vagina, and possibly to the pelvic wall.
  • Stage 4 (also broken down in 2 classes) means your cancer has spread to other parts of the body. If you are diagnosed with stage 4, you have the most advanced stage of cancer and have a poor prognosis. This is one result that the lower the number the better off you are.

While the Pap smear can be uncomfortable and make you feel a bit embarrassed, get one- especially if you are sexually active! It might just save your life. Since we mentioned it at the beginning…. boys, get a prostate exam as well! (If you’re over 40 that is.)

Bonus Facts:

  • The American Cancer Society recommends that a woman should get a Pap smear at least once a year. They do go on to say, if you get the liquid-based version of the test, or you are over 30, you can have one every 3 years, as long as you have had three consecutive normal tests.
  • 90% of cases of HPV are cleared by your body’s immune system within two years. If they are not, some can cause genital warts, or warts in the throat, known as recurrent respiratory papillomatosis. If you do get these warts, you can always look on the bright side. The types of HPV that cause warts are not the same as the ones that cause cancer!
  • HPV viruses can also cause cancer of the vulva, vagina, penis, anus, and areas of the mouth including the tongue and tonsils.
  • Doctor Papanicolaou received his medical degree from the University of Athens, Greece in 1904. Before he changed the way we test for cervical cancer, he chose to get his doctorate in zoology from the University of Munich, Germany in 1910. The discovery of the benefits of his procedure were an accident. While developing a vaginal smear that was intended to track reproductive cycles, he began to notice cancer cells. So the idea to make women everywhere uncomfortable was born. Uncomfortable, but alive! He died February 19, 1962 from an apparent heart attack.
[Image via Shutterstock] Expand for References
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  • #1, why do you have a picture of a doctor eating a sandwich while looking at a woman’s private area? That’s not relevant and sort of gross and disrespectful. #2, I don’t know who told you women fear pap smears. There may be some women who fear it, i.e. the hairs on the back of your neck stand up or little beads of sweat begin to form on your forehead, but most women just go, get it done, no big deal. It’s not scary or degrading. A woman’s body is not something shameful, to be kept secret and never touched or looked at. Men are the ones who think it’s a big deal.

    • I don’t literally break out in sweat, but I do always leave after a pap smear feeling violated because it hurts like crazy when they do it, even just the speculum hurts me. I’m not a virgin or anything either. They tell me to “just relax”, well you try relaxing when someone’s painfully poking and prodding around in the most sensitive region of your body!

  • @FFS: On both your #1 and #2 points, it’s pretty clear the author is just making a joke. Of course women just go and get it done (as do most men with prostate exams), but nobody likes it.

    “A woman’s body is not something shameful, to be kept secret and never touched or looked at.” I don’t see anywhere where that is said or implied. I think perhaps you need to take a deep breath and relax.

    Thanks for answering my question Today I Found Out!

  • Funny story my mom told me before I went to my first Gyn visit. She was getting her annual exam done and hadn’t noticed she had to pee before going in and pretty soon matters became dire, but as the exam was almost over, she didn’t say anything. But then while the doctor had her face in close examining, she pushed on my mom’s abdomen… Luckily my mom was able to hold most of the flow back, so the doctor didn’t get pee in her face, but the dribble that came out was embarrassing enough!

  • The American healthcare system is nothing more than a money scam! And any woman who thinks they need pap/pelvic exams on a regular basis needs to stop listening to the money greedy doctor they are seeing. Most insurance companies give doctors monetary incentives to get woman to submit to pap smears whether you need one or not. If you want to live a healthier life stay away from pill pushing doctors. Big Pharma also pays doctors to prescribe their pills. Its all a money scam!!!!

  • Elizabeth (Aust)

    “This idea is extremely controversial”
    Actually, it’s not, the new Dutch program is 5 HPV primary tests or HPV self-testing at ages 30,35,40,50 and 60 and a 5 yearly pap test will ONLY be offered to the roughly 5% who are HPV+ and at risk, MOST women are HPV- and having unnecessary pap testing that simply exposes them to risk. (false positives, excess biopsies and over-treatment are quite common, especially in the States and Australia – these things are made worse by early screening and by over-screening)
    So this is mostly about maximizing medical profits, vested interests want regular pap testing, they love annual or 2 yearly testing because that produces the most false positives (for no additional benefit to women) and they want to test those 30 and under, because this group produce the most false positives. (yet after decades of testing, not one country has shown a benefit pap testing those under 30) Non-evidence based testing and excess wastes money and worries and harms a lot of women.
    So the only controversial thing with HPV primary testing, vested interests would lose a lot of money. (especially if it’s used correctly, like the Dutch program)
    Doing HPV AND pap testing on all women generates the most over-investigation for no additional benefit to women.
    Pap testing should be confined to the roughly 5% of HPV+ women who are aged 30 to 60…they have a small chance of being helped, everyone else is risking their health, HPV- women cannot benefit from pap testing but can be harmed. You can also, test yourself easily and reliably for HPV, no need for a speculum exam.
    Almost every routine medical intrusion on the symptom-free female body is unnecessary and motivated by medical power and profits.
    The routine pelvic exam is not recommended at all, at any age, it’s far more likely to harm you, even send you off for unnecessary surgery. The use of this exam in the States may partly explain your high hysterectomy rates and the loss of healthy ovaries. (see articles by your Dr Carolyn Westhoff)
    Routine breast exam – not recommended, of no proven benefit and leads to excess biopsies.
    Mammograms, now they ARE controversial, I’ve declined to test. The best summary of the evidence on breast screening is on the website of the Nordic Cochrane Institute, an independent, not for profit, medical research group. Over-diagnosis is a serious risk, about 50% of screen detected breast cancers are over-diagnosed and any benefit of screening is wiped out when you consider those who die from cancers and heart attacks after treatments, so the risks of screening exceeds any benefit. Powerful vested interests will continue to protect screening, that’s why it’s so important to get decent information and make an informed decision about screening.
    I’d urge every woman to do her reading and make informed decisions about screening and yes, you can say NO. If your doctor doesn’t agree, find another one, your health is more important. Any doctor using coercion to force excess or screening should be challenged and/or reported.
    In my opinion, women have been used in the worst possible way by those entrusted with our care, it should be a scandal. Having said that, things are changing, more women are aware of the evidence and can better protect themselves; some doctors are also, equally appalled at the shocking treatment of women. Change comes with individual women demanding evidence based screening and some respect for informed consent and our right to choose.
    I was delighted to see the Pill will be OTC in California and Oregon, another positive step that will greatly improve the lives of many women.