Q&A: Cervical health
By Clint Burrus, MD
January is Cervical Health Awareness Month and an opportunity to spread the word about important steps women can take to stay healthy. Here are some answers to frequent questions:
Are there any updates to the annual recommended well woman exam? Is it still annually?
Guidelines change often—probably most women have heard at this point that yearly pap smears are no longer recommended for low-risk patients. This is absolutely true; however, it is still recommended that women have an annual exam for health maintenance. This is an opportunity to address health concerns that may have arisen in the course of the past year as well as provide age-appropriate screening for breast and colorectal cancer, address issues related to osteoporosis, and to provide screening for conditions leading to increased risk for cardiovascular disease and other risks that may negatively impact life expectancy. Related to pap smears, it is currently recommended that low-risk patients have screening no more frequent than every three years, though this must be individualized to the patient. The ideal interval for breast cancer screening currently is being hotly debated—more to come on this in the future.
At what age should women start scheduling a well-woman exam?
In general, the recommendation is that women schedule a well-woman exam at the age that they become sexually active or at age 21, whichever comes first. Pap smears should not be performed in women younger than 21, unless they are at a higher risk for cervical cancer (usually secondary to other medical conditions causing immuno-compromise). Prior to age 21, the role of the gynecologist is to provide appropriate screening for sexually transmitted diseases, to educate women on their options for birth control, and to employ early health maintenance to decrease risks of preventable diseases.
At what age is it recommended that girls receive the HPV vaccine? What are some pros and cons associated with the vaccine?
Almost all cervical cancer is caused by HPV, and as a result there has been intense interest in vaccination of girls for prevention of cervical cancer. The current recommendation is that all girls be vaccinated with the HPV vaccine between the ages of 9 and 13. If patients have missed this original window, many organizations recommend vaccination of women up to the age of 26. The vaccine follows a three-dose schedule with the timing of doses dependent on the specific vaccine selected. There are two types of HPV that these vaccines normally cover: the high-risk HPV type, which can lead to cervical cancer, and the low-risk HPV types, which cause genital warts.
Cervical cancer is one of the very few cancers we could eradicate. Even in the absence of the vaccine, progression from cervical dysplasia (a pre-cancerous lesion) to cervical cancer is rare with appropriate follow up. That said, once dysplasia is present, it oftentimes necessitates frequent follow up with a gynecologist, cervical biopsies, and occasionally surgery. These interventions are often stressful to the patient and can have negative impacts on future fertility and pregnancies.
There have been some concerns regarding the safety of the HPV vaccine, although the data supports that the HPV is both safe and effective and has a similar risk profile to other vaccinations that are commonly given to pediatric populations. I think that most of the negative critique of the HPV vaccine has been related to the feeling that vaccination in some way encourages sexuality or promiscuity at a young age. I would counter that nothing influences children more than the attitudes regarding sexuality that parents instill in their children and teenagers. Even in the instance that a young woman chooses to abstain from intercourse until marriage, she is not protected from HPV infection and cervical dysplasia, as she can easily be infected by a husband whose prior partner(s) where carriers of high-risk HPV. The decision to choose vaccination for HPV is a personal one, but should always be approached with a commitment to educate our daughters about the risks of sexuality, and the importance of establishing healthy, romantic relationships.