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
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
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
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
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
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
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
- 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