Pap Smears During My Monthly Cycle?

This question worries more patients coming in for their pelvic exams and pap smears than any other general question we get when they come in for checkup.

Different doctors may have different policies on whether to do pap smears during the menstrual cycle. So if you start your cycle prior to your appointment call your gynecologist‘s office to get advice about rescheduling.

It is a very intimate exam and can be stressful because they worry about having to undress and be examined, and hope it won't hurt or uncomfortable. Hygiene is a big concern. Most of us in this country are very clean, but many women also make sure they have their legs and underarms shaved and all other areas trimmed or waxed, according to personal preference, and a lot of patients feel uncomfortable being examined during their cycle. It is always a patient’s choice to reschedule if she is uncomfortable.

What has changed for doctors? It used to be that if a woman started her cycle she had to reschedule because the pap sample was smeared on a slide and then sprayed with fixative. The pathologist would then have to examine the slide under the microscope. So if there was a lot of blood & mucous it would obscure their ability to see the cervical cells and make a correct diagnosis. Today we obtain the sample exactly the same, but instead of smearing it on a slide the entire sample goes into fluid. Once the pathologist receives it, the bottle is placed upside down in a centrifuge to separates the blood, mucous, and discharge from the cervical cells. Once separated those cells can be placed on a clean slide to be thoroughly examined.

That said it is usually best to reschedule if you are having your period. The pap test is the most effective screening tool for cervical cancer, and hormonal changes that occur during the time of the menstrual cycle can cause cell changes which make it slightly more difficult for the pathologist to interpret the sample. The changes would not be mistaken for cancer, but could cause the pap test to be reported in such a way that a repeat may be needed to clear up the confusion. I'm sure we all agree that one pap test a year is enough! So why go through that trouble and worry.

The best time during the cycle for a pap test is, day 10 to day 20 if possible. Day one is the very 1st day that blood is seen, even if it starts as spotting. You should also stay away from vaginal intercourse, douching, tampons, vaginal foams and jellies, vaginal inserts, and any sprays or deodorants 48 hours prior to the appointment. These can interrupt an accurate reading of the sample.

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How Often do I Need to Have a Pap Smear?

 "If I'm healthy, how often do I need to have a pap smear and pelvic exam?” 

The answer is not the same for everyone as it often depends on several factors, such as age, general health, and previous results of Pap smears.

A Pap smear test involves scraping a small sample of cells off of the cervix using a special brush. These cells are sent to a pathology lab to check for abnormalities that could indicate cervical cancer. Cervical cancer can be cured, and a pap test can detect changes that allow it to be treated before it becomes a serious cancer situation with symptoms.

All women should start getting pap tests once they become sexually active. Once sexually active, a woman is at risk for HPV (Human Papilloma Virus), which is the cause of cervical cancer. It is recommended that the first pap should be done within 3 years of becoming sexually active and then annually. Once there have been three normal paps in a row, one year apart, some women may be able to have paps every 2 - 3 years.

However, any woman with risk factors should continue yearly exams until the age of 65 years. The major risk factors for cervical cancer are HPV infection, history of abnormal paps, multiple sexual partners, sexual intercourse early in life, history of sexually transmitted diseases, smoking, and previous cervical cancer.

Some of you may have had abnormal pap smears and/or tested positive for HPV, and are worried about getting cervical cancer in the future. I also know many of you worry about being infected with HPV. The Human Papilloma Virus is passed sexually and is very common. It can lay dormant and flair up during times of stress. But, greater than 89 percent of all infections will spontaneously clear by age 45 and just need to have the pap tests followed until that time.

Since HPV is often passed through contact with semen, many women use WaterWorks, our personal vaginal cleansing system that uses only natural tap water with the special stainless steel nozzle to rinse out the vaginal area after sex to remove vaginal odors and excess semen. I know this makes them more confident about their hygiene and does not disrupt the normal vaginal flora that protects them from yeast and bacterial infections.

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HPV - Human Papillomavirus: What You Need to Know

I know many of you are worried when you are sent to me from your primary care doctor (or return after a pap I have done showing abnormal results) with dysplasia or Human papillomavirus - HPV. HPV is the name for a group of more than 100 types of viruses; more than 40 types of HPV can be passed through sexual contact.

We may feel like we are the only ones who have such a thing when we get it, but HPV is so easy to get and so common that over 70% of sexually active people will have HPV at some point in their lives. In fact, HPV is the most common STD in America, with well over 25 million cases and rising. Some people will never know they even have it because they never break out with warts or never have an abnormal pap test. HPV usually has no symptoms, but can have periods of flaring up and then hibernating. Most of the time there are no signs of infection or "flare ups" (such as abnormal discharge or itching) to alert us of a problem.

The pap test is designed to detect abnormalities of cervical cells and also HPV infections. The pap test will focus on High Risk abnormalities, as these types are known to cause cervical cancer. Low Risk types can cause genital warts - which are obvious when they are present and which can be removed. The HPV that causes cancer cannot be seen visibly when your doctor looks at your cervix or anal area. HPV is a flat warty virus that is invisible to the naked eye. The vaccine focuses on preventing only the top High Risk types of HPV.

If you have an abnormal pap test it is important to follow-up for further testing by your doctor to determine the reason for it. Sometimes yeast or bacterial infections, cervical irritation or hormone changes can be the cause. An abnormal pap does not always mean HPV infection or cervical cancer. A colposcopy is often done to help your doctor see the abnormal tissue on the cervix. It is a lot like getting a pap smear except a special magnifying scope can be used with a strong iodine solution or acetic acid solution that causes the HPV to show up white. This helps your doctor know where to do a biopsy to send a sample to pathology for further evaluation. Some colposcopies are being done with colpo biopsy brushes which are much faster and less painful.

If you do have HPV, there are different ways it can be treated right in your doctor's office. Using Cryosurgery, abnormal tissue is frozen off. The Loop Electrosurgical Excision procedure (LEEP) uses a hot wire loop to remove tissue. Laser treatment uses a beam of light to destroy abnormal tissue.

Cone biopsy, where a cone-shaped sample of abnormal tissue is removed from the cervix and looked at under the microscope, is done in the operating room and reserved for instances when biopsies show early signs of cancer. This biopsy also can serve as a treatment if all the abnormal tissue is removed.

If you have had the HPV vaccine, it does not mean you do not need to worry about HPV or about getting a pap test. HPV can lay dormant for years, and even undetected HPV can show up after the vaccine because the vaccine does not cure HPV. It simply prevents us from getting infected or reinfected.

Being in an exclusive relationship is the best way to prevent HPV infection or reinfection. Note, condoms don’t always protect you from HPV. But, they may reduce your risk of getting genital warts and other STDs.

Just remember, the best thing is to follow up with your doctor and get your annual pap smears, so you know you are healthy. Encourage your partner to visit the doctor as well.

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When Should I Get a Pap Smear?

So what is the truth about pap smears? Everywhere we read, it says something different about how often we need to get a check-up with the gynecologist. And we hear, “. . . if you've had a hysterectomy you never need to have a pap again.”

The so-called guidelines suggest that no one needs a pap smear until age 18 – 21, regardless of the age of the first sexual experience. But, consider how prevalent HPV is, and how easily it is transferred to women during sex – and knowing it is the #1 cause of cervical, anal, and oral cancers.

There is also the worry of infertility that can be caused by STDs. When exams are encouraged at an early age, this can be minimized and treated, if necessary.

Pap smears may be discontinued after surgery for a total hysterectomy, unless it was performed for cervical cancer or any type of pre-invasive diagnosis found on pap smear. This includes high risk HPV, uterine, ovarian, breast, bladder or anal cancer. Yearly paps and pelvic exams should be continued if you have ever had, or currently have, any of these cancers.

Having a compromised immune system for any reason – from diabetes, HIV, Lupus or other auto-immune disorders – can put you at risk for cancer and pre-invasive disease, even if you have never been diagnosed with it. It is so important to get yearly exams and not assume that you are not at risk just because you are too young, too old, not currently having sex, or because you have had a hysterectomy.

The most important thing is to put yourself first. We, as women, can easily ignore our own needs and health as we take care of our families. Let me say this, it's not worth it, because you deserve to be healthy and feel good. Most cancers, if caught early, are curable and never advance to the point of even needing drastic treatment like chemotherapy or radiation. You and your family deserve to have you happy and healthy.

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Is Cervical Cancer Preventable?

Cervical cancer can be preventable with regular Pap tests and pelvic exams. Unlike many cancers, cervical cancer can be detected very early, and Pap tests can detect if you are at risk for getting cervical cancer way before it is there.

The reason I'm bringing this up is because I was recently in surgery with my favorite Gynecological Oncologist (a cancer specialist for women) and we were very busy removing tumors from one patient after another - large tumors in the pelvis from the ovaries and the uterus. We were at the end of our day with one patient left who had been diagnosed with cervical cancer by a recent Pap test in her doctor’s office.

Cervical cancer is the type of cancer that grows from the origin of the cancer out until it invades the vagina, bladder, colon and moves up into the uterus. It can invade blood vessels and lymph nodes along the way, and that can help it to travel to other parts of the body.

It is important that we physically examine every patient prior to starting surgery and make sure all their vital signs are normal, like blood pressure, heart rate, and temperature. We do physical exams after someone is asleep (Exam Under Anesthesia - EUA) to determine if someone is a candidate for surgery or if they need to go directly for chemotherapy and radiation instead. Unfortunately, when we examined her, the cervical cancer had grown into her vagina and had become very large. We had to make the decision at that point to wake her up and recommend chemo and radiation as that would give her the best possible chance for a cure. Seems strange, but true.

I know we all like the idea of "getting the cancer out" and then chemo and radiation if necessary, right? I know the nurses in the room were really shook-up about this: “Wow, Dr. Boyd is it because she didn't get her paps every year? How fast did it get to this stage?” I know it is shocking and something we all worry about.

So could you have cervical cancer and not even know it? The truth is, yes, because it causes no pain or symptoms and is caused by the HPV virus that needs to be detected when you go in for your yearly exams and Pap tests. It cannot be detected on a blood test.

A Pap test can save your life. It can find the earliest signs of cervical cancer. If caught early, the chance of curing cervical cancer is very high. Pap tests also can find infections and abnormal cervical cells that can turn into cancer later on. Getting regular Pap tests is the best thing you can do to prevent cervical cancer. In fact, regular Pap tests have led to a major decline in the number of cervical cancer cases and deaths.

It is important for all women to have Pap tests, along with pelvic exam as part of their routine health care. If you are 21 years or older and have been sexually active, then you need a Pap test. Even women who have gone through menopause still need regular Pap tests. Even after a hysterectomy, paps and pelvic exams are very important as Vulvar, vaginal and anal cancer are caused by HPV, and with oral sex many women are getting oral and throat cancer from the virus.

Bottom line, put your health first. Find a doctor you trust and can talk to. You are worth it.

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Can I still get pregnant after a Leep procedure?

“Dear KnowYourV, ,

My husband and I have been trying to get pregnant and now with my abnormal pap results my doctor wants to do a ‘LEEP procedure’ to remove the abnormal tissue from my cervix. Will this interfere with my ability to get pregnant?”

I hear this from so many woman because, with the ‘LEEP procedure’, a very small portion of the cervix is actually removed. Therefore, many women worry that this will weaken their cervix and cause them to miscarry their pregnancies.

The Loop Electrode Electro-cautery Procedure (LEEP) is done in the doctor’s office. It replaced the cervical cone biopsy which was performed in the OR (Operating Room) under anesthesia. The LEEP procedure removes a small, flat, nickel-sized portion of tissue. By contrast, the Cone Biopsy was developed for cervical cancer diagnosis and evaluation, so a very large, deep biopsy was taken, and often it did extend so deep that the risk was higher.

Once the tissue is removed with the LEEP procedure, it is sent to pathology to be examined by the pathologist. It is important to determine if there are any cancerous cells present and also if the margins (or edges) of the specimen are clear of any abnormality. That way, healthy new tissue can replace the diseased or infected tissue, so the next pap results should be normal.

The other popular method for cervical tissue removal is ‘cryotherapy’, where the cervix is frozen, causing the abnormal tissue to be destroyed. Again, healthy tissue will generally take its place. This is done in only mildly abnormal cases, because all the tissue is destroyed in the freezing method, leaving no specimen for the pathologist.

So, in answer to your question about pregnancy, the ‘LEEP procedure’ is not going to interfere with your body’s ability to become pregnant or maintain the pregnancy. I have had many women have successful pregnancies over and over after having this procedure done.

I hope you all stay safe, and enjoy life and work wherever you may be this week. Write to us if you have anything on your mind that we can help you with.

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What does HPV and Dysplasia mean, for me?

Dear KnowYourV,
I just got the results of my pap smear back and it showed 'high risk HPV with mild to moderate dysplasia'. I'm worried because someone told me HPV is an STD and that dysplasia is pre-cancerous."

Well, Vanessa let's back up a little bit. First of all, the reason you come in once a year for your pap is to screen for cervical cancer. And since so many more women do get tested yearly now, we rarely see advanced cases of cervical cancer like they saw years ago.

These days, if a woman has an abnormal pap, we do repeat paps or biopsies immediately to evaluate the cervical tissue. If necessary, any abnormal tissue with HPV can be removed so healthy tissue can grow in its place. This way, dysplasia or high risk HPV never have a chance to progress to a cancerous condition.

HPV (Human Papilloma Virus) is transferred through sexual contact and belongs to the wart family. It can show up as visible genital warts or flat 'invisible' kind that can cause cervical cancer. Men harbor it in their semen and women carry it in their cervical tissue and cervical/vaginal fluids.

There are two types of HPV: 'low risk’ and ‘high risk'. High risk is the one reported on pap smears and is responsible for cervical Cancer. It can also cause penile cancer, anal cancer, vulvar cancer and oral cancer. Therefore, it can be transferred though anal sex and oral sex as well.

It's possible to get HPV from your first sexual partner and not know you have it. There are no symptoms and it can lay dormant for years. Just like the herpes virus, it may erupt during times of stress or during pregnancy. When HPV begins to flare up, it causes cellular changes in the tissues. When your pap specimen is taken, the cells are looked at under a microscope and the clinician can see the HPV infection and any affects it is having upon your cervix.

Dysplasia is not cancer; it is not even pre-cancer. It is only a descriptive name given to tissue at a certain point in time so that it can be compared with another point in time to note changes. With dysplasia, the terms ‘mild’, ‘moderate’ and ‘severe’ are used, and then it may go to cancer. Most of these changes take several years to happen, and most women choose some form of treatment long before cancer would become an issue.

What about the men? That's what women worry about when they find out they have HPV - shouldn't the men be tested too? Unfortunately, it doesn't do much good, because HPV is in their semen, and there is no way to treat them. They are not at risk for cancer the same as we are.

Fortunately, the new HPV vaccine, which can be given starting at age 8 to boys and girls, should start making a huge impact in the future.

The most important thing is keep getting your pap smears on a regular basis. Over 75% of the U.S. population has HPV, and it is as high as 85% worldwide. So, you are definitely not alone in this. It is a battle we've been working hard to win, and the vaccine is one step along with regular pap tests.

As I've told you, one of the best things you can do daily to help yourself feel fresh and clean is use the new WaterWorks feminine cleansing system. This is so wonderful because it can be used when you shower, and does not require special formulas or chemicals - just plain tap water. And, it can be used more than once a day. Most women will use it right after sex to rinse out semen, which helps them feel clean and fresh right away. Plus this can also immediately rinse away any semen infected with HPV or other STDs. This is important, since a woman's body acts like a little incubator for bacteria or viruses. That is why so many women love using their WaterWorks - it gives them confidence and they feel they are working towards better health with better hygiene. Plus WaterWorks is FDA cleared for vaginal cleansing to remove unwanted odor with or without discharge.

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