The Pap test (a method of cervical screening) is a quick and simple test that checks for particular changes to the cells of a woman's cervix (the neck of the womb). These changes may lead to cervical cancer if left untreated. In Australia, regular Pap tests save more than 1,200 women each year from cervical cancer.
All women aged between 18 and 70 years who have ever been sexually active should have a Pap test every two years, or one to two years after first sexual activity, whichever is later. This includes women who have had the human papillomavirus (HPV) vaccine, as the vaccine does not protect against all cancer-causing HPV types or those to which you may already have been exposed prior to vaccination.Lesbians, women who are in a long-term relationship and women who are no longer sexually active should all have regular Pap tests. Some women need to continue having regular Pap tests after a hysterectomy and should speak to their doctor for more information.
The Medical Services Advisory Committee has recommended the Federal Government implement new cervical screening guidelines in mid-2017. Until this time, women should continue having Pap tests every two years, in line with the current national guidelines. For more information on changes to the program, visit the Department of Health website.
Cervical cancer and the human papillomavirus (HPV)
Cervical cancer is almost always linked to HPV, which is spread through genital-skin to genital-skin contact during sexual activity.
There are many different types of HPV. Some types cause warts on the hands, others cause papillomas on the feet. Around 50 types infect genital skin. Some of these (types 6 and 11) can cause genital warts, which are harmless, though unpleasant. The other types cause silent or invisible infection. Some high-risk types of HPV (most commonly types 16 and 18) can cause cervical cancer.
Most people infected with any of these HPV types develop immunity and clear the virus from their body without any problems. This can take one to two years and doesn't require treatment. HPV infection is so common that it can be considered a normal part of being sexually active. Four out of five women will have HPV at some time in their lives, although most women with HPV will not develop cervical cancer.
Occasionally, however, the virus can persist in a woman's cervical cells and cause cell damage. If these changes are left undetected and untreated, a woman's risk of developing cervical cancer increases.
The early stages of cervical cell changes have no symptoms. The only way to know if you have abnormal cells in your cervix is to have a Pap test.
Risk factors for developing cervical cancer include:
- the presence of some types of HPV on the cervix
- the presence of sexually transmitted infections such as chlamydia
- early age of first intercourse
- early age of first childbirth
- number of sexual partners
- long-term use of the contraceptive pill.
A Pap test does not check for ovarian cancer or any other types of cancer or conditions in the reproductive system. It does not check for sexually transmissible infections (STIs).
The Pap test procedure
A Pap test is a simple and quick procedure that is performed by a doctor, nurse cervical screening provider or gynaecologist.
During the test, the doctor or nurse gently inserts an instrument called a speculum into the vagina, so that they can clearly see the cervix. They then insert a small spatula or tiny brush to collect cells from the cervix. They smear these cells onto a glass slide and send it to a laboratory for analysis. The results are usually available within a week.
Pap tests can be uncomfortable, but should not hurt. If you feel any pain, tell your doctor, nurse or gynaecologist immediately.
Sometimes, the laboratory will report that the sample was unsatisfactory and another Pap test needs to be taken. This doesn't mean your original Pap test showed abnormalities. There may have been too few cells collected, or the cells may have been hidden by blood or mucus.
Pap test abnormalities
Cervical cells pass through a series of changes before they become cancerous. An abnormal Pap test result means either a less serious low-grade abnormality (squamous intraepithelial lesion – mild) or more serious high-grade abnormality (intraepithelial lesion – moderate to severe), where some of the cells of your cervix differ in some way from the normal cells. It rarely means cervical cancer is present.
Many women will require more frequent Pap tests for a period of time after an abnormal result. During this time, the cells of the cervix may heal themselves. Regular Pap tests will check for this and also pick up any further changes that might occur. The length of time between your repeat Pap tests will depend on the type of problem you have. Ask your doctor for advice on the right length of time for you.
Low-grade abnormalities detected by a Pap test
Most low-grade cell changes or abnormalities are caused by transient HPV infection. Low-grade changes are sometimes referred to as mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1). Some of these low-grade changes are also seen with other infections or occasionally in women after menopause (atrophic changes).
These minor cell changes usually clear up by themselves or require simple medical treatment. Most women with low-grade changes on their Pap tests will be asked to have another test in 12 months, rather than two years.
High-grade abnormalities detected by a Pap test
High-grade abnormalities mean the cell changes on the Pap test look more serious. High-grade abnormalities include:
- moderate dysplasia/cervical intraepithelial neoplasia grade 2 (CIN 2)
- severe dysplasia/cervical intraepithelial neoplasia grade 3 (CIN 3).
Further tests after an abnormal Pap test result
An abnormal Pap test sometimes requires a follow-up test. This may be either a repeat Pap test (for low-grade abnormalities) or further tests (for a high-grade abnormality). Further tests may include:
- colposcopy – a colposcope (an instrument that magnifies the cells of the cervix) gives your doctor a closer view of the extent and nature of the problem
- biopsy – your doctor may take a small tissue sample from your cervix during the colposcopy and examine it in a laboratory.
Treatment of Pap test abnormalities
If a high-grade abnormality is confirmed with colposcopy and biopsy, your doctor will usually recommend treatment to remove the abnormal cells from your cervix. Techniques for this can include:
- diathermy – a special heat-generating instrument is used to kill the abnormal cells. This can be done under general anaesthetic, or local anaesthetic if you prefer
- laser therapy – the cells are killed using a precisely targeted laser beam. This is usually performed under local anaesthetic and takes around half an hour
- wire-loop excision – the cells are gently scraped from the surface of your cervix using a loop of wire. Often performed under local anaesthetic.
Pap tests after treatment
Women who have had treatment for high-grade abnormal cell changes need more regular Pap tests for the first two years following treatment. A test for high-risk HPV types is also used to monitor whether the HPV infection has cleared from the woman's body. This test, along with a Pap test, will be done every 12 months after treatment. Once a woman's Pap and HPV tests return to normal for two years in a row, she can return to two-yearly screening.
Pap tests for older women
Menopause does not protect women from cervical cancer. In fact, most cases of cervical cancer occur in women older than 50 years. The most common type of cervical cancer usually takes around 10 years to develop. Older women often mistakenly believe their risk of cervical cancer is low, perhaps because they have had a hysterectomy, are widowed, or are no longer sexually active.
Pap tests after hysterectomy
A hysterectomy is the surgical removal of the womb (uterus). Women who still need regular Pap tests following a hysterectomy include those who:
- still have their cervix
- had their hysterectomy as part of treatment for gynaecological cancer
- have ever had a significant abnormality detected on a Pap test
- have never had a Pap test in their life or have not had regular Pap tests.
Some women undergo hysterectomy as treatment for cervical cancer. Even if the cancer was totally removed during surgery, you need to continue having Pap tests (usually every year) for as long as your gynaecologist tells you it is necessary.
Some women who have had a hysterectomy don't need to have any more Pap tests. This is the case when:
- the operation was performed to treat non-cancerous conditions, such as endometriosis, uterine prolapse or menstrual problems
- the woman's cervix was removed during the hysterectomy (total or radical hysterectomy)
- before the hysterectomy, the woman had regular Pap tests every two years and never had a significant abnormality detected.
Some women aren't sure what kind of hysterectomy they have had. The easiest way to check is to ask your doctor. If this isn't possible, or if your doctor doesn't have the information on file, an internal examination or a cell sample can be done.
Stopping Pap tests at 70 years
Women who have had at least two normal Pap test results in the five years before turning 70 can stop having Pap tests. Those women over 70 who have not been having regular two-yearly Pap tests or have had abnormal results from recent Pap tests may need to keep having Pap tests for a few more years. If you are over 70 and you want to keep having Pap tests, that's fine too. Discuss this with your doctor.
Lesbians and Pap tests
Lesbians should have Pap tests every two years, as HPV is spread through genital-skin contact.
Long-term monogamy and Pap tests
Many older women who have been married and monogamous for decades wrongly believe that screening is only needed by women who have multiple sex partners. However, HPV can be passed on the very first time someone is sexually intimate, which is why regular Pap tests are important for women who have ever been sexually active, regardless of how many partners they've had.
Long-term abstinence and Pap tests
Since cervical cancer has been associated with sexual activity, women who have been celibate for some time – such as some divorced and widowed women – may wrongly believe they are no longer at risk. No matter how long it's been since you last had sex, you should have regular Pap tests until the age of 70.
Social stigma and Pap tests
Since cervical cancer has been associated with sexual activity, some women may avoid having Pap tests because they believe other people might think they are promiscuous.
Pap tests and women with disabilities
Women with sensory, physical, intellectual or psychiatric disabilities are less likely than other women to have regular Pap tests. But it is just as important for these women to have Pap tests.
Women with disabilities may face a number of barriers in getting a Pap test, including:
- lack of clear, accessible information
- difficulties with transport and access to buildings
- lack of money, particularly when living in areas with few or no bulk-billing services
- pain during the Pap test – for example, some women with cerebral palsy have severe pain caused by muscular spasms
- being unable to find a suitable doctor or nurse cervical screening provider – for example, a hearing-impaired woman may not be able to find a provider who can use sign language
- the demands of coping with their disability leave little time or thought for other health matters such as Pap tests
- previous experience – a woman who has had a bad experience with medical staff in the past may be reluctant to have a Pap test
- reliance on a carer or attendant to attend tests
- lack of emotional support from partner, family and friends
- healthcare professionals who wrongly assume that women with disabilities are not sexually active and don't need Pap tests
- healthcare professionals who focus on treating the disability, but neglect to discuss other healthcare matters
- lack of information on general health matters (such as regular Pap tests) for women in institutions.
Overcoming barriers to Pap testing for women with disabilities
Suggestions to overcome these barriers include:
- Contact the various medical and community health services around you to find one that is appropriate for you.
- Tell the receptionist about the nature of your disability, so that you can discuss your support needs in advance of your appointment. For example, you may need to book a longer consultation time.
- Ask if there is an outreach or home visit service.
- Visit the PapScreen Victoria website to search for an appropriate service provider. You can search for a provider based on disability access, including ramped entry and disabled parking.
- Take a family member or friend to your appointment.
- Discuss your concerns with your healthcare professional and tell them how they can provide a better service for you.
- Tell your doctor what position is most comfortable for you. Pap tests are usually taken with the woman lying on her back, but let your doctor or health professional know if being on your side is more comfortable for you.
- Ask the service for appointment reminders.
- Ask for a sign interpreter if you need one. They are available from Vicdeaf on 1800 287 526 (voice) or (03) 9473 1143 (TTY), but need to be booked well in advance.
Pap tests and survivors of sexual assault
Women who have experienced sexual assault may feel uncomfortable undergoing some gynaecological procedures, and are less likely to have regular Pap tests.
Issues that women who have experienced sexual assault may face when having a Pap test include:
- being reminded of the sexual assault
- feeling embarrassment, fear, dislike, pain or discomfort
- feeling traumatised by the Pap test both physically and emotionally
- needing support and sensitivity from the healthcare provider when performing the Pap test – this strongly influences whether the Pap test is a positive or negative experience
- reluctance to disclose information to their healthcare provider about their sexual assault
- reluctance from their healthcare provider to enquire about sexual assault
- a gender preference for a female healthcare provider.
Women who are survivors of sexual assault may feel more comfortable seeing a Pap test provider with specialised knowledge in this area. PapScreen Victoria, in conjunction with the CASA Forum, has compiled a list of CASA Forum Endorsed nurse cervical screening providers to enable women to find a nearby provider who has received specialist training. You do not need to disclose your sexual assault history if you choose not to.
Where to get help
- Your doctor
- Specialist gynaecologist
- Your local community health centre or women's health nurse
- Family Planning Victoria Tel. (03) 9257 0100 or 1800 013 952
- PapScreen Victoria Tel. 13 11 20
- Cancer Council Victoria Multilingual Cancer Information Line Tel. 13 14 50 (Monday to Friday, 9 am to 5 pm) and state the language you need
- Women with Disabilities Australia Tel. 0438 535 123
- Vicdeaf Tel. (03) 9473 1111, TTY (03) 9473 1199, toll free for country callers Tel. 1300 780 225, TTY 1300 780 235
- Victorian Centres Against Sexual Assault (CASA Forum) Tel. 1800 806 292
Things to remember
- All women aged between 18 and 70 years should have regular two-yearly Pap tests, even if they have had the HPV vaccine.
- An abnormal result from a Pap test rarely means cancer.
- You should discuss the results of your Pap test with your doctor or nurse.
- Some women who have had a hysterectomy may mistakenly believe they no longer need to have Pap tests.
- Your risk of developing cervical cancer increases with age.
- Over 80 per cent of women diagnosed with invasive cervical cancer have not had regular Pap tests.