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Chinn GYN, LLC

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The down & dirty on women's wellness

Pap Smear

At Your Cervix

January 1, 2020

The dawn of 2020 brings with it the year’s first mention of the elusive and poorly understood cervix, which is not quite an organ, but which has nevertheless come to represent women’s health almost as much as its sister not-really-an-organ breast. Not to be outdone by the pink ribbon awareness campaign, cervical celebrants have crafted a ribbon in a fashionable teal and white motif and have adopted the slogans “fight like a girl” and “choose hope.” Despite these efforts and the fact that nearly half of Alaska’s population had (or once had) a cervix, local awareness of the existence of this anatomical tunnel and its role in women’s health as well as understanding of screening tests and results remains poor. This is partly the result of the breast cancer campaign’s old friend, Taboo: the cervix is, after all, the endpoint of the vagina (gasp!), and it is responsible for such gruesome things as, shudder, menstruation, and is associated with such grotesque words as, ew, mucus. In an effort to shed some light on this otherwise enshrouded topic, let us begin with the original spelunking endeavor: the all-famous, much-feared, oddly titled pap smear.

“Pap smear” is a gross term for a very important test, partly because it involves smearing and partly because, well, what is a “pap,” anyway? The original pap smear was conducted by Georgios Papanicolau, the father of cytopathology. Dr. Papanicolau had a really long, hard to pronounce, Greek last name. So, we Americans, impatient & ethnocentric as we are, shortened the name and labeled the test accordingly. Georgios P. determined that collecting a specimen of cells from the outermost surface of the cervix and smearing them onto a slide, then evaluating them beneath a microscope would allow for detection of cellular changes that were indicative of the development of eventual cancer and developed a system for tracking changes to allow for detection of different degrees of precursors to cancer. Read that again. The pap smear screens for changes suggestive of cells that could eventually become cancerous. It is not a diagnostic test for cancer. Which means that having an abnormal pap smear is not the same thing as having cervical cancer. An abnormal pap result also does not mean that you are somehow dirty, or that you have gonorrhea. The same is true of your sister, your cousin, your bff, and your neighbor’s bff’s cousin. Abnormal pap results are not cancer diagnoses, nor are they indications of your promiscuous lifestyle. Phew.

Where are these cells coming from? From deep inside the vagina, which, it turns out, is not a black hole, but more of a cul de sac that terminates in a dead end in the center of which is a 2-4 centimeter firm, protruding nubbin with a rich blood supply, varying sensation, and such an extremely important job that, when this nubbin fails to uphold its duties, it is declared “incompetent.” The cervix is composed of a mixture of cells, and those of utmost importance are surrounding and just inside the endocervical canal, or the gateway to the sterile cavity of the uterus. The cervix is, in other words, a sort of bouncer for entrance to (and exit from) the uterus. Throughout a woman’s reproductive life, the cervix has an inside job introducing that cyclic friend, aunt flo, determining which sperm are suitable suitors for any eligible eggs that happen to be briefly released, and protectively holding in what might result from the courtship of these two tiny cells while protectively keeping out any potential threats, which all involves, you guessed it: mucus.

So, what’s the big deal with paps, anyway? Why do you need a pap? And why is your provider trying to kill you by refusing your pap and telling you that it’s ok for you to go ahead and wait a few more years? Isn’t a pap scary, long & painful? A pap smear is the process of collecting the above-mentioned external cervical cells and those just inside the tiny tunnel towards the uterine cavity. It involves the placement of the fearsome speculum (ask your provider to warm it, please!), and a very quick sampling (no scraping, roto-rooting or cutting involved!) of the cells, which are then sent for evaluation by a pathologist. It may be uncomfortable, but it should not be painful. If something is painful, say something--not to your friends at the mall or over a glass of wine at book club--but to the person wielding that duck-billed speculum.

The pap smear is not, in and of itself, a screening for sexually transmitted infections, just as a screening for sexually transmitted infections is not synonymous with “getting a pap.” A pap smear is not done any time a speculum is placed, but rather is performed at regularly scheduled preventive visits and as indicated by prior pap test results. We used to think this had to happen every single year for every single woman from the moment she first had sex. And then we discovered that this was not actually true and that our screening every single year of every single woman who had ever had any kind of sex was actually causing more harm than it was benefitting these lovely ladies who came reluctantly and religiously to subject themselves to our specula every single year. The screening guidelines have thus evolved to now recommend that an initial pap smear be performed at age 21 (and not before), regardless of sexual activity, and then be performed as recommended by the results of the preceding pap smear(s). This means that, for women with normal pap smears under the age of 30, the screening interval could be extended to 3 years and, for women with normal pap smears who are over the age of 30, even 5 years, with no decrease in cervical cancer prevention rates.

What?! So that means I only have to see my provider every 5 years?! No. Why not?! Women are not cervixes any more than they are breasts. Women are human beings with a whole host of hidden body parts (like a heart!), that also require annual evaluation, sort of like a tune-up for your car. Problem visits to your provider generally get you in the door once something has already happened, but preventive visits are as important, if not more, because they can potentially (like a pap smear) stop the disease (like cervical cancer) from progressing as it’s just begun. But this is possible only if the changes that tell your provider that something is wrong are detected. And for that to happen, you have to see your provider annually, regardless of your relationship with the speculum. Although there are loopholes and insurance carriers invariably find them, federal law does require that all insurers pay for your preventive care visit. This is precisely because those visits are designed to detect problems before they progress, saving us all time, money, heartache, and, with appropriate employment of the pap smear, sometimes a cervix.