The New Pelvic Exam Guidelines – Changes for The Change

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The Pap test has long been a part of your annual pelvic exam, serving as the gold standard for diagnosing cervical cancer for the past 60 years.  Named after Greek doctor Georgios Papanikolaou, the Pap has helped reduce certain cervical cancers by up to 80% according to the National Cancer Institute.

The NCCC (National Cervical Cancer Coalition) says that cervical cancer is very preventable and in fact can be prevented through early diagnosis and appropriate treatment of certain cells that become abnormal when impacted by the human papillomavirus (HPV); this is a process which begins long before actual cancer develops.  The Pap has been the top line test for HPV, but there are other, perhaps even better, options to spot the troublesome cells in women starting at an earlier age, according to one government agency.

The FDA has recommended a replacement screen to detect gynecological cancers, suggesting that the Pap is soon to become a thing of the past.  Does this mean that the days of lying on your back, scooting your bottom down to the end of the table, putting your feet in stirrups and waiting for the swab might be coming to a close?  Not necessarily.

The “Quiet Virus”

Physicians have known for some time that there is a critical link between cervical cancer and the human papillomavirus (HPV), which is transmitted via sexual intimacy and has a tendency to hang around like a bad boyfriend.

HPV is not very common after the age of 30, but if you test positive for this virus, you may have gotten it many years before and your immune system is still showing positive.  HPV causes changes at the cellular level only after it’s invaded and been in your system for a while.  That is why testing after age 30 is beneficial.

Recently, the FDA issued guidelines indicating the agency is ready to recognize the Roche HPV DNA test as the frontline check for women over the age of 25.  According to the FDA, this specialized DNA test provides not only a current snapshot of the health of your cervix, which is located at the bottom of your uterus, but also provides important information about your risk for developing cervical cancer in the future.   It works by detecting DNA from 14 high-risk HPV types, identifying HPV 16 and 18, as well as 12 other types of high-risk HPVs.  Doctors get the DNA by swabbing your cervix, much like the traditional Pap.

If you test positive for HPV 16 or 18, the agency recommends a colposcopy, which lights up and magnifies your cervix, so that your doctor can more closely observe what’s going on with your cervical cells.  If you test positive for one of the other types of HPV, then it’s recommended you have a Pap test to determine your need for the colposcopy.

One study, the ATHENA (Addressing the Need for Advanced HPV Diagnostics) found that taking a random biopsy at the time of the colposcopy was even more effective in detecting cervical cancer, whether there were visible lesions, or not.  In other words, the Pap smear might become just a part of, and not the centerpiece of, your annual pelvic exam.

But Wait—There’s More

Now several groups of physicians believe that bimanual palpation of your uterus and internal organs (when your doctor inserts two fingers and feels around your abdominal area) is not only unnecessary in most cases but also intrusive enough to cause some patients anxiety.

This past summer, the American College of Physicians (ACP) came out against routine pelvic exams which involve bimanual palpation, but only in women who are not at high risk for certain cancers, such as uterine or ovarian and those who are not pregnant, because the organization says this particular exam is not effective in detecting cervical cancers.

Those same guidelines do recommend regular exams of the cervix such as Pap smears because the Pap is still very effective in detecting cervical cancer in early stages.  However, the actual exam during which your doctor inserts two fingers into your vagina and checks the abdomen is not necessary, with ACP co-author Dr. Linda Humphrey stating specifically that it, “Rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost.”

The ACP, which is the second-largest physician group in the country, agreed that the diagnostic accuracy for detecting cancers utilizing this method is very low.

The American Congress of Gynecology and Obstetrics (ACOG) had a varying viewpoint insisting that women should continue to get annual pelvic exams including bimanual palpitation but acknowledged that the decision to include all components of the exam rested with both the patient and her physician.  ACOG, the leading group of physicians providing healthcare for women, says these ‘well-woman visits’ are an important part of the patient-physician relationship and along with breast exams, immunizations, and contraceptive care discussions help nurture that relationship and ensuring trust.

I chatted with Dr. Rebecca C. Brightman, assistant clinical professor OBGYN and Reproductive Science at the Mount Sinai School of Medicine in New York City, who says, “It is very important for women to realize that the Pap smear is only a portion of the annual gynecologic examination. An annual (and for some patients semiannual) evaluation of a woman’s thyroid, breasts, and pelvic organs remains essential.”

Dr. Brightman also notes that for some women, their OBGYN might be the one and only healthcare provider.

“As an OBGYN, we frequently screen for and diagnose other medical conditions.  Women confide in their OBGYNs and seek advice in many areas of mental health concerns to social problems.  So, it’s way more than just a pap smear!”

It’s all about the patient-doctor relationship, which provides the foundation for a healthier you!

Which Way Should You Go?

Like anything else in life, it pays to be informed about your own gynecological health, although it can be difficult to find a blanket one-size-fits-all answer.  Some experts say that if you are a woman with an average risk of cervical cancer, then this is the route to follow:

  • Ages 21 to 29: a Pap smear once every 3 years
  • Ages 30 to 65: Pap smear every 3 years or/combination Pap smear and HPV test every 5 years
  • Over age 65: routine Pap screening not needed if recent tests have been normal.

Really, though, it’s a decision best made between you and your gynecologist or family physician.  So, forming a good bond with your doctor early in the game is critical.

Gather the facts and ask questions until you are comfortable with the answers.

It’s up to you whether the bottom-scootin’ boogie, digital palpation, Pap or DNA should be a part of your annual visit!

Suffering in Silence is Out!  Reaching Out is In!

After struggling with her own severe menopause symptoms and doing years of research, Ellen resolved to share what she learned from experts and her own trial and error. Her goal was to replace the confusion, embarrassment, and symptoms millions of women go through–before, during, and after menopause–with the medically sound solutions she discovered. Her passion to become a “sister” and confidant to all women fueled Ellen’s first book, Shmirshky: the pursuit of hormone happiness. As a result of the overwhelming response from her burgeoning audiences and followers’ requests for empowering information they could trust, Ellen’s weekly blog, Menopause MondaysTM, was born.

  • New info to me….thanks.

    • Ellen Dolgen

      Things are always changing…..hard to keep up, Carol. It is also difficult to decide what you want to do with the new info. I for one shall keep getting a pap every year. I get comfort in that GYN visit…. I want to have my breasts checked….I want make sure I am not getting vaginal atrophy…………..all kinds of reasons! That being said, I do dread the pap itself – stirrups and all!

  • Stacia Fernandez

    Great and helpful info. Thanks!

    • Ellen Dolgen

      Happy it was helpful, Stacia!

  • Great info Ellen. Passing this on to nieces so they have bench marks! I always learn new things from you my friend!

    • Ellen Dolgen

      Yes…it is our job, Ruth, to help educate the younger sisterhood! Thanks for reminding us all to do that!

  • I love my gynecologist and will be curious to see what she says about the new guidelines when I go for my annual check up in a couple of months.

    • Ellen Dolgen

      Keep me posted, Lois!

  • Ugh. The “bottom-scooting boogie” is one of my very least favorite tests… even worse than a colonoscopy, I think. (At least you can’t remember ANYthing after a colonoscoppy.) No longer needing one in the later years — or at least needing fewer — is one of the true advantages of aging.

    • Ellen Dolgen

      It’s the damn prep on the colonoscopy….argh! I am not a fan of the pap either…but I plan on going and slipping into that gorgeous gown an stirrups – once a year!

  • Ah, the ritual of the pap. Kinda hate to give it up.NOT! Thanks for the info.

    • Ellen Dolgen

      I am old fashion about the pap………….not gonna give this up!

  • Helene Cohen Bludman

    Interesting to read about these new guidelines and I will discuss them with my GYN next visit.

    • Ellen Dolgen

      Good idea, Helene. I plan to do the same!

  • Thank you for the information. It reminded me that I need to schedule my exam for my well woman check-up – but now I feel I will go in armed with better information.

    • Ellen Dolgen

      This makes me smile, Ines! Thank you for letting me know that the info was helpful!

  • Always happy to have a reason to not have the horrible internal probing. Thanks!

  • I get so overwhelmed…..and my insurance is so awful….what will they cover is always a mystery. Along with the fact hot flashes have resumed. I took hormones for a long time and loved the fact my symptoms diminished. but now I am miserable. Luckily I sleep well…but it is still 88 here!! Maybe thats more the problem!!

  • So fascinating how they are constantly learning new and better things for all of us. Thanks for the news on this latest update. It’s always great to be informed.

    • Ellen Dolgen

      I agree, Wendy – knowledge is power.

  • Ellen –thanks for always providing quality, up-to-the-minute information on women’s health care. You rock!

    • Ellen Dolgen

      Shannon, you are so sweet. Thank you for your kind words. We are constantly hit with new guidelines and often it is quite confusing. I try to find the smartest brains on the topic to help us make decisions that help us lead happy, healthy lives!

  • Wow, good information! I think it’s good to know how the guidelines change for different age groups, as well as just due to new information. Thanks for always sharing your expertise!

    • Ellen Dolgen

      Happy you found the info helpful, Sherri.