Pap Smears

Dr Ryen, what’s the deal with pap smears? I mean, it’s all about detecting STDs, right? So if my daughter, who’s finishing university, hasn’t had sex, does she really need to get them done? Her doctor is pushing her to get a pap smear, but she’s not comfortable with it. What should I tell her? 

- Yolanda, Tulsa, OK

Good question, Yolanda. This is a case where it’s easier (and safer) for public health officials to test everyone than to introduce a screening algorithm based on questions that young people are often not honest about. I’m certainly not condemning public health measures - I think it’s quite appropriate on a population level - but there are times when it’s reasonable to opt out of certain screening tests.

To begin with, cervical cancer is devastating. It develops silently for years and is usually detected only after it has spread throughout the pelvis. By then, it’s too late to cure. Pap smears take a small sample of cells from the surface of the cervix (i.e. the opening of the uterus at the top of the vaginal canal) during a pelvic exam and check them for cancerous changes well before a tumor has a chance to develop. 

Next, the vast majority of cervical cancer (over 99.9%) develops after an infection with certain strains of Human Papilloma Virus (HPV). This is a sexually transmitted infection that the majority of the population acquire at some point. Most cases of HPV are cleared without issue, but the virus can cause changes to the DNA of cervical cells. This is what leads to cancer.

Guidelines for pap smears vary region-to-region, but most suggest every three years, starting when patients are in their early twenties. However, if a person has never had sex, it’s nearly impossible to develop cervical cancer. In my medical practice, I never take anyone’s word for it - I always assume every female is sexually active simply because it’s safer than the alternative. However, I also educate my patients about all this and let them decide for themselves.

So, although I’m sure your daughter is honest with you, as a doctor, I don’t trust anyone to be honest about their sexual history. Most doctors feel the same way, which is probably where your daughter’s doctor is coming from. However, nobody is allowed to force a pap smear on an unwilling patient. So, if your daughter understands the rationale and the risks, it’s reasonable for her to decline cervical cancer screening until she feels she needs it. 

© D. B. Ryen Incorporated, August 2021.  

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