Women’s health testing: a guide for you

Abnormal Pap smears and HPV

by Marcy Holmes, Women’s Health Nurse Practitioner

When a woman receives an abnormal Pap result or hears she’s been exposed to high–risk human papilloma virus (HPV), it’s no surprise to hear her react with anxiety or disbelief. I often hear, “But how can this be so — I always use a condom,” or “But I’ve only ever had two partners in my whole life!,” or “Well, I’ve been married for 25 years and have never had an abnormal Pap smear before — why now?”

Human papilloma virus, or HPV, is the name of a group of viruses comprising over 100 different strains discovered to date, 30–40 of which affect our reproductive tract. Transmitted through sexual contact, these strains can infect the genital area of men and women, including the penis, vulva (area outside the vagina), and anus, as well as the linings of the cervix, vagina, or the rectum.

Like the unrelated herpes simplex virus that causes cold sores, human papilloma virus is so widespread that the majority of men and women carry some form of HPV, but most don’t know it — a well-functioning immune system does a great job keeping the virus in check until something in their life triggers an eruption, often many years later. One estimate even suggests that by the age of 50 approximately 80% of women have acquired some strain of the HPV virus. So we could say that it’s just part of being human.

Some of these various HPV strains can lead to genital warts (condylomata).  Some can lead to abnormal Pap test results. Most are found on further testing to be low–risk. But high–risk strains of HPV are responsible for initiating cellular changes that can lead to cervical, vulvar, or anal cancer.

So how do you know if you’ve been exposed to a high-risk strain? And what preventive measures can you take to prevent a dormant virus from becoming active in your body? The good news is that there is a lot that we can do. Let’s start by talking about detection.

Pap smears: a discovery that saves lives

Both traditional and alternative practitioners advocate for an annual pelvic examination and Pap smear. Why? The answer is that this standard of care has proven to be one of the best preventative combos we have to protect women’s health and longevity. And it is the only way to ascertain whether you’ve been exposed to HPV.

The Pap smear test was developed by and named after Dr. George Papanicolaou (1883–1962) for the purpose of early identification of cervical cancer. Soon after its introduction, the Pap smear proved effective at detecting precancerous lesions, which represent early — and still very treatable — indicators of cervical cancer risk. Scientists wish they could develop a screening device as effective as the Pap smear for identifying precancerous breast changes. While they are gaining ground daily, the closest tools we have today include ductal lavage technique to sample and analyze breast duct cells, and breast imaging studies, which include mammography, ultrasound, and MRI to screen for areas of suspicion.

The Pap test has saved the lives of many women. Cervical cancer was once the number–one cause of cancer-related death for women in the USA, but over the past 60 years Pap smear screening has dropped its standing to fifteenth. The Pap smear is an easy and, for the most part, reliable test to perform. (See our page on routine Pap test and pelvic exam for an explanation of what happens during these procedures, along with a description of the new ThinPrep Pap.)

With so much potential benefit, it surprises me that women ever receive mixed messages about the value of regular Pap testing. Cervical cancer kills around 270,000 women per year worldwide, 3700 in the US alone — needlessly. At our practice, where we integrate conventional and alternative ways of thinking, there has never been any doubt about the importance of annual examinations and regular Pap screenings for our patients.

And one of the reasons we feel so strongly is due to the rampant nature of HPV.

The Human Papilloma Virus (HPV)

The human papilloma virus is contracted through skin-to-skin contact during sex — vaginal, anal, or even oral sex. It is not passed through the semen of the male, but is harbored within the cells of the entire genital region. While we strongly encourage the use of condoms to help prevent sexually-transmitted infections such as Chlamydia, HIV, and gonorrhea, condoms are less likely to prevent infection with HPV.

There are around 100 different strains of HPV that have been identified to date. Each strain has been assigned a number, rather than a name. Some of the strains are considered “high-risk,” such as strain numbers 16 (most prevalent worldwide), 18, 31, 33, and 45, because they are associated more closely with cancer risks. Other strains are termed “low-risk,” such as strains that cause genital warts, because they are not likely to be associated with cancer — although science continues to unveil new HPV information daily.

Like many of the smallest life forms, HPV has the ability to hide, or to pop up when we are least expecting it. The virus will often flare up — whether or not external symptoms manifest —  when we are run down, under emotional stress, or the immune system is otherwise weakened. Think again of a cold sore — caused by the herpes simplex virus. Like HPV, that virus can lurk in a woman’s body for months, even years, with no signs because her immune system is keeping it in check. When times get stressful — and the immune system must fight bigger battles — up pops a cold sore.

HPV acts in a similar manner. We don’t yet have tests to pinpoint when or from whom a woman contracted the virus that triggered the abnormal Pap. Sometimes the virus can lie dormant for decades. Testing negative for HPV only means that there is no superficially detectable virus at that time — you could still be harboring the virus.

So if stress invades your life and you suddenly find yourself being told your Pap smear is abnormal, it is helpful to remind yourself that while the signs are manifest now, it is quite possible that initial exposure to the HPV virus occurred long ago. The fact that the results are appearing now is a reflection of your current state of stress and emotional health — which you can do something about!

It is also important to remember that many strains are not cancerous and the strain affecting you may well be of the low-risk variety. This makes it inconvenient but not life-threatening, and knowing that for certain through regular Pap screenings will ease your mind. And thankfully, today, while several high-risk strains do pose the risk of cancer, early detection by routine Pap smears can ensure that these strains are not the life threat they once were.

It is entirely possible to be exposed to several strains during the course of your life, so it is likewise possible to test positive to more than one type of HPV. Obviously, the earlier a woman begins having sex and the greater number of male sexual partners she has in her lifetime, the greater the risk of contracting various strains of the HPV virus. The challenge with testing, and with developing a course for treatment, is that high–risk strains need to be dealt with differently from low–risk strains. So let’s talk about prevention.

Prevention begins early

Delaying first sexual activity and limiting the number of partners is one preventative measure for young women to consider. A young woman’s developing cervix is most vulnerable to all STD’s, which is why talking about safe-sex strategies with girls before they begin having sexual encounters is very important. I recommend that any safe-sex strategy include a commitment to an annual exam and Pap test.

Young women should be prepared for the experience of an annual pelvic exam in their teens if sexually active, otherwise by age 21, with STD testing upon each new sexual partner and Pap smear testing within one to two years of their first sexual experience.

In my practice, I like to meet teenage women for a health interview and teaching session about reproductive health prior to her becoming sexually active. If she does enter into sexual activity, then she will be more emotionally prepared to return for the next step, her first full pelvic exam and Pap smear.

Soon, this first interview may possibly become the best time to offer and provide an HPV vaccine when indicated. With this kind of educational introduction, a young woman will be more comfortable and ready to care for her body. This can help set the stage for a positive, anxiety–free and responsible outlook for years to come.

Good nutrition is another key component of early prevention. A woman’s immune system is at a tremendous advantage if she maintains a diet high in folic acid, antioxidants, and essential fatty acids. Even if she eats well, she can reinforce cervical cell health by augmenting her diet with high-quality nutritional supplements.

New HPV vaccine protection

In an effort to protect women from some of the high–risk strains of the virus, HPV vaccines are being developed and brought to market. These are currently targeted at only two to four of the higher–risk strains most frequently seen in developed countries. The vaccine most recently approved by the FDA is Gardasil by Merck, with Cervarix by Glaxo in close pursuit.

Our position is that the protection afforded by these vaccines is limited and controversial. HPV vaccines will not fully protect those already exposed to a high-risk strain, but recent clinical trials seem to indicate that enough protection may still be conferred to women in that category to warrant their use as both a preventive and therapeutic measure.

The primary goal is to vaccinate young women before the onset of sexual activity, i.e., prior to HPV exposure. The best age and intervals at which to administer the vaccine and boosters have yet to be determined. Their overall success will need to be judged over time, but early findings suggest the potential for preventing the cervical and vulvar cancers associated with the HPV virus strains for which the vaccination is given.

Again, it’s important to remember that the vaccines only target a limited number of the known high-risk strains, so their protection will be by no means complete. Furthermore, it is not clear when the vaccines will begin to be implemented, and the politics and economics regarding their value remain controversial. So even with these advancements, the need for regular GYN exams and Pap testing will continue.

True, these vaccines represent a major medical breakthrough and may lead the way to vaccines in the field of other virus–related cancers, but we don’t know the long-term effects of the vaccine, and we always need to keep that in mind. So even once HPV vaccines become directly available to you — because having it will confer protection only against the most common high-risk strains — your best preventative course is an annual exam and regular Pap.

How often to get Pap testing done

The American College of Obstetricians and Gynecologists (ACOG) recommends Pap screening annually until age 30, then every two to three years if a patient has had three sequential years of normal results and does not fall into a high-risk category (e.g., DES exposure, known or previously-detected HPV exposure, a prior history of cervical cancer or cervical intraepithelial neoplasia II–III, or an immunocompromised status). If a woman is on hormones, she should be checked annually and her prescription monitored. The recommended age to discontinue Pap screening varies according to a woman’s situation, and this decision is one left for the most part to her GYN provider’s discretion.

At Women to Women, we suggest a Pap smear just about every year for routine screening of sexually-active adult women, and occasionally more often to follow any minor abnormal cells found on previous Pap smear tests. This is because women may change sexual partners; monogamous women can have partners who stray; and ultimately, everyone’s risk status can change over time. Changes in stress levels and immune response can also lead a previously normal–testing woman to suddenly test abnormal.

We view the Pap test as somewhat of a Geiger counter for your overall health — especially because we interpret the presence of abnormal cervical cells as a sign of weakened immune system function. The fact is that delayed testing can place women at greater risk, and could reduce the probability of detecting abnormal cell changes early — which is the key to preventing cervical cancer. For while the progression of abnormal cells to a cancerous state typically takes a decade, in rare cases this proliferation transpires very quickly.

There are also some special considerations for women to discuss with their healthcare provider. For example, if a woman has had a hysterectomy with complete removal of the cervix and no prior abnormal Pap, it may be fine to discontinue — although we continue to screen most of our hysterectomy patients at some regular interval. The future of hysterectomy surgery is likely to evolve into a range of procedures that leave the cervix intact, which will require continued Pap testing.

So what happens if you’ve been diligent about annual screening, and then one day you get an abnormal Pap smear reading?

Abnormal Pap test results

Ideally you will find yourself in a relationship with a GYN practitioner you know and trust. If so, your abnormal test results will be discussed in a collaborative and thoughtful manner — as they should be. If you aren’t, I encourage you to find a practitioner you can talk with openly.

A woman will likely be contacted if anything is detected on her Pap test beyond a “satisfactory” sample quality with visibly normal cells. If the clinician was unable to obtain an ideal/adequate cell sample from inside the cervical canal, the results will be reported as insufficient, and you may be called back for a new attempt. If a woman in such a case is menopausal or at low risk, re-sampling can often wait until her next pelvic exam in a year’s time.

Occasionally a Pap report can indicate infection with yeast or bacteria, and possibly even atrophic vaginal changes from low estrogen in menopause. These findings are easily managed and are unrelated to HPV and cervical cancer.

The scale of abnormal Pap test results ranges from slightly atypical to high–grade cellular changes. Currently, the Bethesda system is used among pathologists and healthcare providers to classify findings consistently. There is also a well established algorithmic approach to match next steps to abnormal findings. (Both the classification system and suggested management are continually updated by new research findings). If needed, HPV testing/typing is considered and can be added to the Pap test analysis. Some women will electively seek this with their Pap test before anything abnormal is found, but that varies and the guidelines for this are still evolving.

Click here for a listing and brief overview of the most common abnormal Pap results using the Bethesda system. If your test yields any of these results, remember it is only a signpost showing your practitioner the path toward further testing, a more accurate diagnosis, and — if necessary — a care management plan.

Next steps — following up with your practitioner

Remember that Pap testing is a screening tool. It is not perfect, and there is a margin of error each time it is performed. A reading can be either falsely more favorable than it should be, or falsely worse than it really should be. This is another reason why we suggest yearly Pap testing for those at risk, but this is also why we sometimes do repeat testing at shorter intervals after any abnormal findings.

If you have an abnormal Pap, your practitioner will likely repeat the Pap test or move on to one or more other diagnostic measures, such as colposcopy or endometrial biopsy. It is the results of colposcopy that drive our decision about what is needed next and when. The colposcopy may also be repeated within a reasonable time-frame to ensure healing or provide opportunity for early intervention if precancerous changes are found. Repeat testing is routine and ensures that nothing is missed.

If you have any confusion or uncertainty regarding your follow-up plan after an abnormal Pap smear or colposcopy, don’t hesitate to call your practitioner’s office to clarify what you are to do next and when. We’ve seen many women have abnormal readings that return to normal once stress is reduced and the immune system is back on track! Close monitoring is always warranted to ensure this. (Click here for some frequently asked questions about Pap smear results.)

There are a number of advanced treatment procedures available, if necessary, all geared toward removing any suspicious tissue that persists on the cervix. For persistent abnormal biopsy results or ongoing presence of abnormal cells (cervical dysplasia), these treatment procedures may be warranted. Most of these decisions are based on well-established guidelines and are made collaboratively between you and your practitioner along a tried-and-true timeline. The goal is to intervene before the dysplasia worsens and spreads into the tissue of the cervix or uterus, and to prevent true cancer.

Keeping HPV in a dormant state — 7 ways to boost immune system function and protect reproductive health

I encourage my patients to look at each test as a messenger bearing information about your overall wellbeing — once you know what’s going on, you and your practitioner can take steps geared to your unique history. But there are several complementary principles you can follow to care for yourself and more fully support your body’s natural healing abilities.

• Good nutrition grounded in a balanced diet and basic nutritional supplements.
  
  See our Nutritional and Lifestyle Guidelines for more specific information. A rich multivitamin high in folic acid is one foundation for a healthy immune system and cervix. The role of specific vitamins, antioxidants, and essential fatty acids in fighting inflammation is well-documented (see our article on the natural anti-inflammatory approach). In addition, with abnormal Pap’s, supplementing with extra folic acid, indole–3 carbinol (I3C), and/or DiM can help keep the immune system healthy, minimize cellular changes, and promote healing (do this under the guidance of a qualified healthcare provider). If you give your body the tools that it needs, your immune system will be more prepared to keep HPV in check and your cervix healthy.

• Accept the facts.
  
  If you have been sexually active at any point in your lifetime, consider the possibility that you have been exposed to HPV. Know that you are in good company, and don’t let this notion add to your stress. Do take it as call to get regular pelvic exams and Pap tests because doing so will allow any cellular changes to be caught early and treated, long before any cancer can develop.

• Avoid cigarette smoke.
  
  Many studies have shown a measurable link between smoking and increased cervical cancer risk, as nicotine actually concentrates in the cervix. Just as importantly, this includes avoiding second-hand smoke whenever possible. Smoking depletes the body of precious nutrients and weakens the immune system. If you do smoke, consider quitting, and be sure to take additional antioxidant support over and above the nutritional basics mentioned above. OPC’s (grape seed extract) is one we often suggest to smokers — and smokers may need 2–3 times more vitamin C daily as well!

• Help your system detoxify.
  
  Good bowel and digestive habits enhanced daily by ample water and fiber intake, along with sleeping well, encourage proper detoxification and elimination, thereby setting the platform for a strong immune system.

• Minimize stress.
  
  Stress can wreak havoc on your immune system — so mastering coping strategies to deal with life’s challenges is a must for everyone living a busy, demanding life. Anecdotally, some physicians note more abnormal Paps toward the end of the year, perhaps due to holiday stress. Addressing emotional issues is likewise important. The female reproductive tract is strongly linked to second-chakra issues that begin in childhood and build throughout adulthood. Here again we simply cannot separate our biography from our biology. Emotional Freedom Technique (EFT) and the Quadrinity Process are two excellent resources we recommend to our patients for emotional work. For many women, even visualizing and nurturing the thought of a healthy pink and normal cervix is a very positive and relaxing meditative process to promote healing.

• Follow directions.
  
  If you do get an atypical Pap reading, follow your doctor’s guidelines and remember to go back for repeat testing. Don’t let your fear get the best of you! It is quite likely that further testing will relieve your anxiety.

You can make a difference in the outcome

We want all women to be well-informed and proactive about their health. But even with all the knowledge abounding in our world, it can still be a scary experience for a woman to get a call from her doctor’s office about an abnormal Pap smear. For some women, that fear can generate fantastical thoughts that are not grounded in reality. That’s why getting the facts can be calming and empowering. At our practice, we try to approach the Pap and any warranted follow-up with support from all directions — physical and emotional.

Embracing both the physical and emotional aspects of your cervical health is a very positive and health-affirming act. With so much new and existing technology to identify and treat any abnormalities, we have the power to change the outcome. We encourage women not to delay testing because the sooner we know, the sooner we can intervene.  Yes, if abnormal tissue poses a risk, more advanced procedures may be necessary. But we also want women to understand that the road leading from an abnormal Pap smear result to surgery is rarely a straight one. In fact, it twists and turns and will often fall back upon itself in the monitoring process.

One way to prevent abnormal Pap smears is through proper self-care, including measures such as eating well, fortifying your diet with supplements, and reducing stress. If your test is abnormal, consider it a wake-up call and take some positive steps towards helping your reproductive system heal. Your Pap test is just one small piece in your evolving health story, and by supporting your immune function and getting regular follow-up, you hold the power to set the stage and impact the outcome.

Related to this article:

References & further reading on abnormal Pap smears and HPV

 

Last Modified Date: 04/27/2012
Principal Author: Marcy Holmes, NP, Certified Menopause Clinician