a woman worried about an abnormal Pap smear or HPV should get all the facts

Your Pap test results are abnormal.” If your doctor’s office gives you this news, you can’t help but worry that somewhere along the way you’ve she’s been exposed to one or more of the high-risk human papilloma viruses (HPV). And often it’s a big surprise to women who’ve both consistently used condoms and had a limited number of partners over the course of their lives.

Even women who have been in monogamous relationships for decades can end up with an abnormal Pap smear. But how does this happen and — why now?

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

HPV: Widespread and stealthy

Human papilloma virus is so widespread that most men and women carry some form of HPV, but don’t know it. That’s because a well-functioning immune system effectively keeps the virus in check until something later in life triggers an outbreak, often many years later.

One estimate is that by the age of 50, approximately 80% of women have some strain of the HPV virus. Some of these various HPV strains can lead to genital warts, or condylomata, and some can lead to abnormal Pap test results. Most HPV strains carry low risk, but highrisk strains may trigger cellular changes that can lead to cervical, vulvar or anal cancer.

To help you stay healthy, your first step is to determine if you’ve been exposed to a high-risk strain. Then you can identify any preventive measures you can take to stop a dormant virus from becoming active.

Pap smears: a discovery that saves lives

Both traditional and alternative practitioners generally advocate for women to get an annual pelvic examination and Pap smear because these are the best preventive steps to protect health and longevity. Different health organizations have individual age-related recommendations and suggestions for intervals between tests but the Pap smear is still the only way to know if you’ve been exposed to HPV. To decide yourself, check out the basic parameters for Pap testing set by the Center for Disease Control and Prevention.

The Pap smear test has saved many women’s lives. It was developed by and named after Dr. George Papanicolaou for early identification of cervical cancer. Cervical cancer was once the top cause of cancer-related death for women in the US, but because of of Pap smear screening, it has dropped to fifteenth over the past 60 years.

Cervical cancer still kills around 270,000 women per year worldwide, 3700 in the US alone. And since the Pap smear is an easy and mostly reliable test, we recommend that women get regular testing.

(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.)

The Human Papilloma Virus (HPV)

The human papilloma virus is contracted through skin-to-skin contact during vaginal, anal, or oral sex. It is passed by the cells of the entire genital region. Even though condoms help prevent many sexually-transmitted infections, they are less likely to prevent HPV infection.

So far, there are around 100 different identified strains of HPV identified with each strain assigned a number. Some are considered “high-risk,” such as strain numbers 16 (most prevalent worldwide), 18, 31, 33, and 45, because they are closely associated with cancer risks. Other strains are “low-risk,” such as those that cause genital warts. New information about HPV continues to be released frequently.

Like the cold sores of herpes simplex, HPV can lurk in a woman’s body for months, even years, with no signs or symptoms because her immune system is keeping it in check. HPV can hide or pop up when we least expect it, especially when we are run down, under emotional stress, or the immune system is otherwise weakened. Sometimes the virus can lie dormant for decades. Even if you test negative for HPV, you could still be harboring the virus.

You had an abnormal Pap test. Now what?

If you’re told your latest Pap smear is abnormal, it is quite possible that your initial exposure to the HPV virus occurred long ago. An abnormal Pap at this point, is actually reflecting your current state of stress and emotional health and there is plenty you can do to improve both.

Many HPV strains are not cancerous and the strain affecting you may be the low-risk variety, making it inconvenient but not life-threatening. And while several high-risk strains do carry cancer risk, early detection by routine Pap smears can ensure that these strains are not the life threat they once were.

It is possible to be exposed to several strains during the course of your life, so you may test positive for more than one type of HPV. The earlier a woman begins having sex and the more male sexual partners she has, the higher her risk of contracting various strains of the HPV virus. Both women and men can transmit HPV to partners of either sex through direct genital skin-to-skin contact . High–risk strains need to be dealt with differently from low–risk strains.

Preventing HPV: start early

Delaying first sexual activity and limiting the number of partners are the top two HPV preventive measures for young women to consider. A young woman’s developing cervix is at its most vulnerable to all STDs so it’s very important to talk to girls about safe-sex strategies before they begin having sex.

We recommend that all safe-sex strategies include an annual exam and Pap test. Young women should be prepared for the experience of an annual pelvic exam in their teens especially if they’re sexually active, or by age 21. Every woman should have STD testing with each new sexual partner, and Pap smear testing within 1–2 years of her first sexual experience.

A young woman’s first talk with a doctor before she becomes sexually active is the best time to consider the HPV vaccine when indicated (see below for more information). Good nutrition is another key component of early prevention. A diet high in folic acid, antioxidants, and essential fatty acids is great support for the immune system. A daily high-quality nutritional supplement with a complete selection of key vitamins and minerals helps reinforce cervical health.

HPV vaccine protection

The HPV vaccines currently on the market target only 2 to 4 of the higher-risk strains most frequently seen in developed countries. These vaccines include Gardasil by Merck and Cervarix by Glaxo.

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

Since the vaccines target only a limited number of the known high-risk strains, HPV protection is not complete. The politics and economics surrounding the vaccines are evolving and remain somewhat controversial. Women will still need to get regular GYN exams and Pap testing.

There are some limitations to these vaccines for women already exposed to high-risk HPV strains. While women in this category won’t be fully protected, clinical trials seem to indicate that they may still get enough protection from the vaccine to warrant their use as both a preventive and therapeutic measure.

These vaccines represent a major medical breakthrough and may lead to vaccines for other virus-related cancers, though we don’t know the long-term effects yet.

How often should you get Pap testing?

The American College of Obstetricians and Gynecologists (ACOG) recommends Pap screening annually until age 30, and then every 2-3 years if you’ve had 3 sequential years of normal results and don’t fall into a high-risk category. If a woman is on hormones, she should be checked annually and her prescription monitored. The recommended age to discontinue Pap screening varies so this decision is best made by a woman and her doctor.

At Women's Health Network, we suggest having a Pap smear just about every year for routine screening of sexually-active adult women. Since every woman’s HPV risk status can change over time, sometimes they need Pap testing more often:

  • after any minor abnormal cells have been found on previous Pap smear tests.
  • when women change sexual partners.
  • when monogamous women might have been exposed via their partners.
  • because changes in stress levels and immune response can lead a previously normal–testing woman to suddenly test abnormal.

The Pap test is a good warning system for your overall health because abnormal cervical cells are a sign of weakened immune system function. Delayed testing can place you at greater risk by reducing the probability of detecting abnormal cell changes early — the key to preventing cervical cancer.

There are also some special considerations to discuss with your healthcare provider. If you’ve had a hysterectomy with complete removal of the cervix and no prior abnormal Pap, it may be fine to discontinue Pap testing. If hysterectomy surgery leaves the cervix intact, Pap testing should continue.

So what happens if you’ve had annual screenings, and then one day you get an abnormal Pap smear reading?

Abnormal Pap test results

Ideally you have a GYN practitioner you trust with whom you can discuss your next steps.

Here’s what’s likely to happen: you’ll be contacted if anything is detected on your Pap test beyond a “satisfactory” sample with visibly normal cells. If the clinician was unable to obtain an adequate cell sample, the results will be “insufficient” and you may be called back. For a low-risk woman or if you’re in menopause, re-sampling can often wait until the next pelvic exam in a year.

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

The scale of abnormal Pap test results ranges from slightly atypical to major cellular changes. If needed, HPV testing/typing can be added to the Pap test analysis. Some women ask for this with their Pap test before anything abnormal is found, but the guidelines 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 showing your practitioner the path toward further testing, a more accurate diagnosis, and — if necessary — a care management plan.

Next steps — follow up with your practitioner

Pap testing is a screening tool and there is a margin of error each time it is performed. A false reading can be more favorable or worse than it should be. This is another reason for those at risk to have yearly Pap testing, and why repeat testing is done 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. The results of colposcopy drive decisions about what is needed next and when. The colposcopy may also be repeated within a reasonable time-frame to ensure healing or for early intervention if precancerous changes are found. Repeat testing is routine and ensures that nothing was missed.

If you have any confusion about your follow-up plan after an abnormal Pap smear or colposcopy, call your practitioner’s office to clarify what to do next and when. Sometimes 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 procedures may be warranted. Most decisions are made by you and your practitioner, based on well-established guidelines. The goal is to intervene before the dysplasia worsens and spreads into the tissue of the cervix or uterus, and to prevent true cancer.

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

Try these steps to help care for yourself while supporting your body’s natural healing abilities.

1. Good nutrition with a balanced diet and basic nutritional supplements.

See our Nutritional and Lifestyle Guidelines for more specific information. Consider a rich multivitamin high in folic acid and antioxidants, along with essential fatty acids to help with inflammation. With abnormal Paps, 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. Talk to qualified a healthcare provider about these.

2. Be honest about the facts.

If you have been sexually active at any point, you may have been exposed to HPV. Get regular pelvic exams and Pap tests to help ensure any cellular changes are caught early and treated, before cancer can develop.

3. Avoid cigarette smoke.

Many studies have shown a measurable link between smoking and increased cervical cancer risk, as nicotine actually concentrates in the cervix. Avoid second-hand smoke whenever possible because smoking weakens the immune system.

4. Help your system detoxify.

Good digestive habits and regular bowel movements with ample water and fiber intake, along with good sleep, all encourage proper detoxification and elimination — more key factors for a strong immune system.

5. Minimize stress.

Stress can wreak havoc on your immune system. Some physicians note more abnormal Paps toward the end of the year, perhaps due to holiday stress. Addressing emotional issues is important because our physical bodies often can’t tell the difference between daily stress and life-threatening emergencies. Choose stress relief that works for you.

6. Follow good guidelines.

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

You can make a difference in the outcome

It can be scary to get an abnormal Pap smear but having the facts is calming and empowering.

With so much new and existing technology to identify and treat abnormalities, we have the power to change the outcome. But don’t delay testing. Yes, if abnormal tissue poses a risk, more advanced procedures may be necessary but surgery is not always involved, and monitoring the situation may be all that’s required.

Your Pap test is one piece of your health story and you hold the power to set the stage for a positive outcome.

References

1 Vachani, C. 2005. HPV and cervical cancer. OncoLink (Abramson Cancer Center of the University of Pennsylvania) URL:  http://www.oncolink.com/types/article.cfm?c=6&s=17&ss=131&id=9531 (accessed 05.16.06).

2 White, W., et al. 1998.  In vitro infection and type-restricted antibody-mediated neutralization of authentic human papillomavirus Type 16. J. Virol., 72 (2), URL: http://www.pubmedcentral.gov/articlerender.fcgi?artid=124566 (accessed 05.16.06).

3 American College of Obstetricians and Gynecologists Office of Communications. 05.09.2006. Press Release: ACOG recommends first ob-gyn visit in early teens. http://www.acog.org/from_home/publications/press_releases/nr05-09-06-2.cfm (accessed 05.30.2006).

The American College of Obstetrics & Gynecologists Committee on Adolescent Health. 2006. ACOG Committee Opinion No. 335: The initial reproductive health visit. Ob. & Gyn. 107 (5), 1215–1219.

Further reading

American Society for Colposcopy and Cervical Pathology (ASCCP): http://www.asccp.org/

American College of Gynecology (ACOG):
http://www.acog.org/

Hudson, T. 2001. Preventing and treating cervical dysplasia: a natural medicine perspective. Alt. Comp. Therapies, 7 (1), 15–20.

National Cancer Institute. 2005.  Vaccine protects against virus linked to half of all cervical cancers. URL: http://www.cancer.gov/clinicaltrials/results/cervical-cancer-vaccine1102

Sattler, C. 2005. Efficacy of a prophylactic quadrivalent human papillomavirus (HPV) (Types 6, 11, 16, 18) L1 virus-like particle (VLP) vaccine for prevention of cervical dysplasia and external genital lesions (EGL). 45th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), Washington, DC.

Wright, T., et alia. Revised 2003. 2001 Concensus guidelines for the management of women with cervical intraepithelial neoplasia. Am. J. Ob. Gyn. 189 (1), 295–304.

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