“The PAP Smear: Who, When, and Why” – with Dr. Stephanie Melka

On this episode of Healthful Woman, Dr. Nathan Fox is joined by Dr. Stephanie Melka to discuss the ins and outs of PAP smears, which are screening tests for cervical cancer.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Melka, welcome back to talk about the Pap smear.

Dr. Melka: Can’t wait.

Dr. Fox: Yeah, listen, this is a really interesting topic because it’s so common, everyone’s heard about it, and it’s ever-changing.

Dr. Melka: Yes.

Dr. Fox: I mean, just when I think about from when I was a med student to a resident to now, and I don’t do, like, annual GYN exams, but certainly I’m reading and listening and seeing how you guys are doing it, and obviously for people coming up pregnant or whatever, and it’s just like, it’s confusing for people, understandably.

Dr. Melka: Absolutely.

Dr. Fox: Yeah. I mean, you know, for doctors, and certainly therefore for those undergoing them, the patients, so to speak.

So I wanted to bring you on as our gynecologic expert.

Dr. Melka: Oh, dear God.

Dr. Fox: Yeah, to talk about Paps, sort of the rationale behind them, sort of what is one current, like, screening paradigm, the upsides, the downsides, and just give people a sense of sort of what’s going on, and what to expect.

Dr. Melka: Sure.

Dr. Fox: Are you ready?

Dr. Melka: Absolutely.

Dr. Fox: All right, so let’s go back to the basics, why do people get Pap smears? Like, what are we talking about here?

Dr. Melka: So a Pap smear is a screening test for cervical cancer. So it’s basically a swab of the cells of the cervix that are then looked at under the microscope to look at cancer, pre-cancer, or other changes that might go on to become cancer if left untreated.

Dr. Fox: Why are we specifically screening for cervical cancer, cancer of the cervix, versus, I don’t know, uterine cancer, ovary cancer, whatever it might be?

Dr. Melka: So the screening test is done to sort of catch things early. Cervical cancers are very slow-growing, and by doing the Pap, you’re catching those things early, and then treating it before it progresses.

Dr. Fox: Right.

Dr. Melka: It also doesn’t cause symptoms, you know, like you said. And like, you’ve brought up endometrial cancer, like that presents with bleeding.

Dr. Fox: Right.

Dr. Melka: Pap smear… The cervical cancer typically doesn’t present with any symptom unless it’s very far along.

Dr. Fox: Right. I mean in medicine, obviously, everybody would like to avoid getting cancer, right.

Dr. Melka: Yes.

Dr. Fox: True. And so the question is, how do we do that? And there are fortunately some cancers that are amenable to screening that are very effective, and there’s other cancers that are not. So cervical cancer is one that is amenable. And I mean, the basic principles is that typically, if the cancer’s slow growing, right, you can sort of catch it in a phase where it’s not so dangerous, and treat it, versus if sort of it’s very aggressive, so the second it comes, you know, it comes, you know, hot and heavy, so to speak, where you just can’t do anything about it. And also, there is the ability to do a screening test. So they’re really…yeah.

Dr. Melka: It’s an easy way to screen. You do it at a visit, speculum exam… You’re not doing a full, like, operating room procedure. It’s non-invasive…

Dr. Fox: Right. Right. So I mean, like, Pap smear is one for cervical cancer, obviously there’s screening for breast cancer, you know, mammograms, there’s skin cancer, to get looked at… But then there’s other cancers that, again, people are working on it, trying to get screening tests for all these cancers, but it’s very hard to develop a screen test for something like brain cancer. Like, what would it be? Do you have to get an MRI every year? I mean, like… And it’s complicated, because again, those screening tests can be difficult to obtain, and sometimes you might pick up things that are, let’s say, borderline, and if it’s on your cervix, and you get a biopsy of it, all right, it might be slightly uncomfortable, but unlikely to be dangerous. But if it’s in your brain or your heart or your kidney, like, that could be a big deal, to have, like, a false positive, and have to start digging in there. That’s really not… It’s part of the reason these things are not always amenable to screening.

So fortunately for cervical cancer, there is good screening. And I would say cervical cancer is typically going to be more dangerous in settings where people either can’t or don’t get screened, whereas where people can get screened, it’s much less likely to develop into invasive cancer, fortunately. It’s been like a big success, essentially, cervical cancer.

Dr. Melka: Yeah.

Dr. Fox: Okay, so that’s what the Pap smear is. And then I would say when we’re trying to decide how to do it, when to do it, and who to do it, how often to do it, we’re really balancing too little versus too much. So how would you explain that to somebody?

Dr. Melka: So by testing too much, you are picking up on every tiny little abnormality there is, most of which go away on their own in time. By not testing enough, you’re not catching the few that are slowly progressing.

Dr. Fox: Right.

Dr. Melka: So all of the guidelines sort of look at all of this, along with how old a patient is, what other risks do they have to try to find that ideal spot.

Dr. Fox: Yeah, and this is a really complicated subject in medicine, and it’s true of cervical cancer screening, it’s true of breast cancer screening, it’s true of a lot of things. On the one hand, if you don’t test enough, you can miss some, and some people can get the condition, and obviously that’s bad. On the other hand, if you test too much, number one, it’s annoying, number two, it could be painful, number three, it may not be possible, right, just sort of like, to screen everybody all the time, it could be expensive. And then, like you said, it can lead to a lot of anxiety, it can lead to a lot of actual procedures being done on people, which can lead to actual problems, you know, biopsies or follow-up surgery, it sort of depends on what the follow-up test is.

And so there’s sort of that happy middle ground between not too little, not too much, but people disagree on that, right? Some people are going to lean more towards, well, I’d rather overscreen a little bit, and you know, annoy a few more people, or burden a few more people to pick up a few extra cancers. And other people will be like, well, it’s not worth it. And there’s not a right or a wrong here, it’s really…there’s some subjectivity here. Which is part of the reason, number one, different sort of societies, I don’t mean like societies in the world, I mean like the Cancer Society, the OBGYN Society, different like, organizations come to different conclusions about this, and that’s reasonable, and it’s probably meant to be individualized for any given person, based on her sort of specific risk, that’s very hard to do.

Dr. Melka: Yeah.

Dr. Fox: Yeah, it’s hard to get, like, a one-guideline-fits-all.

Dr. Melka: Yeah.

Dr. Fox: So you’re going to see a lot of disagreement. I mean, how, just in your illustrious career, how have you seen sort of the guidelines change or evolve for Pap smears specifically?

Dr. Melka: They’ve gotten less and less frequent.

The other thing we haven’t even gone into yet is the availability of doing HPV testing, which is human papillomavirus.

Dr. Fox: Right.

Dr. Melka: So, it’s two things. With the Pap, the actual technology has gotten better, where it’s the thin prep, and it used to be the wet mount, and like, the doctor would like, take the sample, and spread it on a slide, and send it off, and…

Dr. Fox: Right. That’s where the word “smear” came from, for Pap smear.

Dr. Melka: Right.

Dr. Fox: You would smear it on a slide. Yeah.

Dr. Melka: Yes. So one, the technology has gotten better, so it’s more accurate.

Dr. Fox: Right. Right. Now it’s you sort of take it in the brush, and you stick it in liquid, and so you don’t smear it on anything.

Dr. Melka: Yes. And then, that liquid gets sent off, yes.

Dr. Fox: It should be called now the Pap dip, I guess, the Pap soak. This is when Melka and I go long…

Dr. Melka: You, and your jokes.

Dr. Fox: Yeah.

Dr. Melka: So…

Dr. Fox: The Pap dunk.

Dr. Melka: Oh, God. Are you done?

Dr. Fox: No, I could go forever. All right, the Pap plunge.

Dr. Melka: It’s the sweep.

Dr. Fox: The Pap sweep? Okay…oh, I like that. All right…

Dr. Melka: Also, some doctors use the broom, and then they say you have to, like, pop off the top of the broom, and like, just dunk that in, and send that off.

Dr. Fox: Right.

Dr. Melka: So that could be, like, the true dunk, you know?

Dr. Fox: Right. Whereas others just sort of swirl it around in the fluid, and send that…

Dr. Melka: Swirl it around, and toss it. Exactly.

Dr. Fox: Fascinating. Fascinating.

Dr. Melka: I know. Yeah.

Dr. Fox: Yeah, so but basically, Pap smear came because it used to be this wooden stick…

Dr. Melka: Yes, and we’d smear it on a slide, yeah.

Dr. Fox: …and you know, yeah, smear it on a slide, and send the slide, and they’d look on the microscope. And now you take the brush, or whatever it is, and you sort of dunk it in water, or saline or whatever, and that solution gets sent to the lab, and they find it from there. And then, someone has to actually look…yeah.

Dr. Melka: And Pap comes from Papanicolaou…

Dr. Fox: Yeah, a person.

Dr. Melka: …who I think was from Cornell.

Dr. Fox: He was at Cornell. There’s still a statue or something…

Dr. Melka: I visited a friend there once, and I walked past and I saw the statue, and I was like, holy crap, I know that name.

Dr. Fox: Yeah. Yeah. And basically, you know, they would take the cells, look under a microscope, and sort of say these look abnormal, these don’t, or whatever. And I think there’s also computerized technology to look under, to look at these now…

Dr. Melka: Everything’s computerized now.

Dr. Fox: Yeah, no, and I’m sure that, you know, ChatGPT is going to be, you know, reading your Paps at some point, if they’re not doing it already.

Dr. Melka: Yeah.

Dr. Fox: Okay, so that’s the Pap.

Dr. Melka: Yeah. So then there’s also…HPV is human papillomavirus, and there are many, many different types, some which can cause warts on the hands and feet, some cause genital warts, and some are linked to cervical cancer. There’s a grouping of high-risk HPV, and then there’s HPV-16, -18, and -45, which have also been the ones most commonly linked to cervical cancer.

Dr. Fox: Right.

Dr. Melka: So that’s like, a whole other can of worms when you get testing of, like, which is positive, which is negative, and then how does that affect how you interpret the Pap smear.

Dr. Fox: Right. And then, again, the HPV, that’s the thing for which there’s a vaccine.

Dr. Melka: Yes.

Dr. Fox: And that’s the virus that pretty much we believe causes all or most cervical cancers.

Dr. Melka: Almost all HPV…yeah.

Dr. Fox: And so the Pap smear is looking at the actual cells, like are the cells normal or abnormal? And the HPV is do you have the virus, which will put you at risk for that… I mean, you could have the virus and normal cells, which is good in that the cells are normal, but the virus puts you at risk. And then on the flip side, if you have abnormal cells, but you don’t have the virus, it means it’s probably not as important, you know, and they’re used in conjunction with each other.

Dr. Melka: Yeah. There’s even some talk in some of the medical societies of moving to HPV-only screening.

Dr. Fox: Right.

Dr. Melka: And not even doing the pap smear, just the HPV test.

Dr. Fox: Right. I mean, there are…for the screening test, there’s the option for doing the Pap alone, there’s the option for doing the HPV alone, there’s the option for doing both of them together, like Pap-plus-HPV, and then there’s also like, this reflex where you do the Pap, and if it’s normal, you leave it be, and if it’s abnormal, then you run the HPV, and decide what to do. And again, that’s another layer of if you’re doing testing, what exactly you’re doing, and how frequently?

Dr. Melka: Yeah.

Dr. Fox: HPV testing is also something that’s, like you said, is the past 20 years that’s new, that wasn’t done before. Yeah.

I think another thing that’s different is at what age do you start doing Pap testing?

Dr. Melka: Yeah.

Dr. Fox: It used to be if you were either over 21, or maybe even 18…

Dr. Melka: It was 18, or sexually active.

Dr. Fox: …right, or sexually active. And now it’s like you have to be over 21, or [crosstalk 00:11:22.491]

Dr. Melka: 21, regardless, yeah.

Dr. Fox: Yeah, pretty much. And then there’s also another variable about there are certain people who at baseline have a much higher risk of cervical cancer. Cervical cancer is fortunately not that common, but there are certain people who have a much higher risk of getting it, and so their screening paradigm is going to be different. So who might be at a significantly increased risk of cervical cancer compared to everybody else?

Dr. Melka: Patients that are immunocompromised, patients with infections like HIV.

Dr. Fox: Right. So who would be immunocompromised, so for example, just so people understand what you’re talking about.

Dr. Melka: Patients undergoing chemotherapy for cancer treatments.

Dr. Fox: Right. So that would be… I mean, this sort of, this came about a lot over the whole COVID pandemic, the people who needed to get vaccinated first are at higher risk, and this and that. So, their immune system is not working so well. Most of you, if you are immunocompromised, you’ll know. I mean, someone will have told you at some point, and you know, for other reasons.

Dr. Melka: Yeah.

Dr. Fox: But those people, again, since we believe that the cancer is mostly caused by a virus, people who have a reduced ability to fight off infections like viruses have an increased risk of cervical cancer from HPV. Because most people get HPV, your body fights it off, you don’t get cancer. It’s not like if you get HPV, you will get cancer, it’s just a possibility.

Dr. Melka: Right. Yeah.

Dr. Fox: Okay, so that’s the background. We’re trying to balance not testing too frequently, not testing too infrequently. So, where have we landed now? In the end of 2023, or if this podcast drops in the beginning of 2024, where are we? How do you, in your practice…

Dr. Melka: Are we that ahead on our podcasts, that we might not drop ’til 2024?

Dr. Fox: So, it’s a possibility. We’re borderline.

Dr. Melka: Oka, cool. Cool. Okay.

Dr. Fox: I usually try to be, like, four to six weeks ahead. So since we’re now in the middle of November…so for those listening who are wondering when we recorded this, it’s mid-November 2023, so whenever this… I don’t think there’s any major changes in Pap recommendations in the next six weeks, right? I hope not. If so, we’ll record an addendum to this.

Dr. Melka: Oh, God, I hope not.

Dr. Fox: All right, so like, how do you talk to your patients, or recommend to them in terms of screening? Again, let’s focus on sort of typical, low-risk, meaning someone who does not have HIV, is not immunocompromised, sort of somebody who’s at standard risk or low risk, how would you counsel them about this?

Dr. Melka: Sure. Yeah. So standard recommendation is to have the first Pap smear at age 21. So that means if I’m seeing a patient under age 21, I’m not typically doing a Pap smear. I’ll often talk about it because a lot of people come in asking for one. Like, their mom told them to go get a Pap smear, or they heard about it somewhere, and I’ll go over everything, and explain why it’s not recommended ’til age 21. From age 21 to 29, it’s Pap smear, with the reflex to HPV. So meaning if the Pap comes back abnormal, then testing the HPV.

Dr. Fox: Right.

Dr. Melka: And if it’s normal, it’s testing every three years. And then at age 30, you start Pap with HPV, and then f they’re both negative, it’s every five years.

Dr. Fox: Right, so I want to break that down a little. Let’s start with the group that’s under 21.

Dr. Melka: Yes.

Dr. Fox: So why, specifically, do we not recommend doing Pap smears in that population, typically? Or… Because we used to, right?

Dr. Melka: Yeah.

Dr. Fox: So what was the problem with it?

Dr. Melka: So the majority of the abnormalities you see, even the ones that are more concerning, will resolve. So when you’re testing, and you’re getting the result and you’re treating it, you’re ending up doing more harm than good because you’re treating them for something that ultimately would have resolved if it wasn’t treated.

Dr. Fox: Right. I think that’s important because it’s not like the Pap smear itself is dangerous. Like, whatever, it’s an exam.

Dr. Melka: Yeah.

Dr. Fox: It’s uncomfortable, annoying, but it’s not dangerous to get it. And if you get the results, and you don’t do anything about them, and you sit and wait and you watch it over time resolve, again, no harm will have happened, maybe some anxiety, maybe some visits that aren’t necessary…okay, fine, but no harm. But the issue is for abnormal Paps, typically there’s follow-up, right, that involves procedure. So what would typically be the first follow-up if there’s an abnormality that someone deemed was concerning?

Dr. Melka: Some of the more mild ones could be just follow-up, another Pap in one year.

Dr. Fox: Right.

Dr. Melka: Which again, not that big a deal. Probably someone is coming back in a year anyway. Some of the more concerning abnormalities, the next step would be what’s called colposcopy.

Dr. Fox: Right. So explain what a colposcopy is.

Dr. Melka: So it’s similar to the Pap in that it’s a speculum exam. So we’re looking at the cervix, and then we basically use a little device that’s like a microscope to look at the cervix, and then do small biopsies of the cervix. So whereas with the Pap you’re just sort of doing, like, a general scraping, this is taking a very directed sample of the cervix.

Dr. Fox: Right, you take a little biopsy, and you send it to a pathologist. Now the biopsy itself, again it’s a little more invasive, obviously, than doing a Pap smear, but it fortunately does not tend to be particularly painful or dangerous. But okay, but it’s definitely more invasive, right? It’s definitely a little more painful…

Dr. Melka: It’s uncomfortable.

Dr. Fox: Yeah, no…yes. Fair. But what I’m saying, it’s not like a surgery. Like, you don’t typically need anesthesia for it…

Dr. Melka: Right. Correct.

Dr. Fox: And we’re going to have a separate podcast talking about that. But it’s not considered a very high-risk procedure, but it’s definitely next level, right?

Dr. Melka: Mm-hmm. Yeah.

Dr. Fox: Because you’re now taking a biopsy. And okay, so someone says, all right, I’m under 21, I had a Pap smear, and it was slightly abnormal, and someone went and did a biopsy. Again, annoying, maybe not the end of the world, but what’s the next thing, if that’s still abnormal, potentially…

Dr. Melka: So if that’s abnormal, the next step is then what’s an excisional procedure, what we call a LEEP or a cone biopsy, where you actually are doing a surgery, typically in an operating room, to remove that layer of cells from the cervix.

Dr. Fox: Right. And I think that’s really, in addition to the…you’re testing too much, it’s going to go away, you’re causing anxiety that’s unnecessary, you’re bringing people in for visits they don’t need, again, which is all…they’re all good reasons not to do it. But I think that the big one was it led to a lot of people who were younger, before they had kids, getting this procedure called the LEEP or a cone, and for many of them, it had no effect on their life whatsoever, but for some of them, it could impact their pregnancy, maybe a higher risk of needing a cerclage, or a higher risk of preterm birth. And again, we’ve discussed that, and that data itself is complex, but that was the concern, that if we start overscreening, we’re going to start going on this road that’s going to lead to an excisional procedure that has the potential to be…I don’t want to say dangerous, but complicating for a future pregnancy.

Dr. Melka: Yeah. Yeah.

Dr. Fox: And I think that that was really sort of the reason behind sort of, like, shutting it down for people under 21. It’s like it’s just not worth it because it’s so unusual you’re going to find and prevent the cancer, but it’s so common that you’re going to start doing operations on people that they probably didn’t need. Yeah.

Dr. Melka: Yeah. There were concerns about the sort of psycho-social implications of this.

Dr. Fox: Yeah.

Dr. Melka: You know, these are young women that are then going in for colposcopy, which again can be painful. You had many stories of women basically being told this happened because you had sex. Like, again, the link is HPV, HPV is sexually transmitted, you got this because you were having sex, and having a bad experience where they then don’t go see a doctor for years afterwards.

Dr. Fox: Right. Yeah.

Dr. Melka: You know, and I see a lot of that in women in their young to mid-20s, talking about whatever happened years ago, you know, and how difficult it was.

Dr. Fox: Yeah.

Dr. Melka: You know, not all of that is linked directly to the Pap itself, you know? Some of it is how you counsel a patient.

Dr. Fox: Right.

Dr. Melka: But that’s often what these teenagers were being told, you know? You had sex, you got HPV, that’s why this happened.

Dr. Fox: Right. And so when someone is now in let’s say in their 20s, and they do get routine cervical cancer screening, they get the Pap, plus/minus HPV based on the results, and then, again, let’s say every three years, I think it was sort of the same concept that they said, all right, women in their 20s can get cervical cancer, so we don’t want to, like, ignore it. But on the other hand, they’re young, most of them aren’t going to have it, so they sort of fell on every three years is everything’s okay.

Dr. Melka: Yeah.

Dr. Fox: Yeah. Is three years absolutely better than two years, or four years? No one knows.

Dr. Melka: No.

Dr. Fox: But that’s sort of where it came to. And then in their 30s, it’s with HPV, but now it’s every five years.

Dr. Melka: Correct.

Dr. Fox: So what’s the reasoning behind that? Is it less common in your 30s? Or it’s just less common if you don’t have HPV?

Dr. Melka: In the 20s to 30s, the rationale of not doing the HPV testing is there’s a higher incidence of it, and it’s going to clear over time. So again, when you’re testing Pap with HPV, you’re going to get more positives.

Dr. Fox: Right.

Dr. Melka: Whereas in your 30’s, that risk sort of shifts a little bit. So it’s not that it becomes less common, it’s that you can rely more when you have the negative for both.

Dr. Fox: Got it. Okay.

Dr. Melka: Does that make sense?

Dr. Fox: Makes sense to me.

Dr. Melka: Okay.

Dr. Fox: We’ll see if we get any questions from our listeners. And do we do this indefinitely, age-wise? You know, is there a certain point where you sort of say, all right, you’re good to go, no more Paps the rest of your life, you’ve graduated?

Dr. Melka: This is a tough one.

Dr. Fox: Well, you know, this isn’t a fluff podcast. We’re throwing fastballs at you, Melka. That’s why I brought you in.

Dr. Melka: I know. It’s a hard conversation to have with a patient, because the recommendation is to stop, or consider stopping at age 65. Because at age 65, a patient…

Dr. Fox: Was that linked to, like, Medicare benefits? Like, what…?

Dr. Melka: It’s linked to risk of death.

Dr. Fox: Yeah.

Dr. Melka: That a patient is more likely to die from other causes than of cervical cancer at age 65. And like, women that are 65 don’t want to hear that. Like, they don’t want to hear life expectancy, and not getting a Pap, and…you know? Yeah.

Dr. Fox: Yeah. So is that something that’s uniform, or is that something that’s individualized, typically?

Dr. Melka: I mean, the recommendation is what it is, but I know nowadays, more and more doctors are doing Paps beyond 65.

Dr. Fox: Right. I mean, it’s the same thing. There’s, you know, for how many years you do…until when do you do mammograms? I mean, again, whatever it is, again, you have to sort of take into account if I find something, what’s that going to lead to, and is that going to lead to an overall better or worse… And these are pretty depressing things to think about, obviously.

Dr. Melka: Yeah.

Dr. Fox: Like, you don’t want to have to do that sort of mental exercise, you know, with every person, every time, and so I get it.

Dr. Melka: Yeah.

Dr. Fox: So that is definitely a discussion to have with your own doctor, about if you’re coming up on 65, what’s that going to mean with the Paps.

Dr. Melka: Yeah.

Dr. Fox: Now with all these recommendations regarding Pap smears, a few things. Obviously, these are just general guidelines. Things are individualized based on what your prior results were, based on what your risk factors are, based on…you know, there’s a lot, like you said, your immune status, this, that. So this is not meant to be like gospel, but this is sort of the baseline. But I think that another thing that comes into play, both on the patient side and the doctor’s side, is, well, if I’m getting a Pap smear every three years or every five years, why am I coming to the doctor every year, right? Because it used to be, like you were saying, all right, you should come to the gynecologist every year because you need a Pap smear every year. That was sort of like, the way people’s arms were twisted to go to the gynecologist. So if it’s every three years or five years, do they no longer need to do that? Or if they do, why?

Dr. Melka: They’re still recommending yearly visits. Check a weight, check a blood pressure, overall check in on health, pelvic exam, still evaluate the uterus, evaluate the ovaries, potentially picking up early ovarian cancers based on symptoms or exam findings.

Dr. Fox: Right.

Dr. Melka: That might be a whole separate podcast to talk about.

Dr. Fox: Yeah. Yeah, no, I mean I think that it’s still… I mean, it’s still recommended to have an annual GYN exam, all right? And again, some of it is going to depend on if you’re also getting a primary care exam every year, what are they doing, right?

Dr. Melka: Right.

Dr. Fox: So if your primary care provider is your OB-GYN, then yeah, you should see them every year. If you’re getting a primary care visit with a general practitioner, a family practitioner, you know, internal medicine, and they’re doing things like a breast exam, they’re doing a pelvic exam, they’re asking you about, you know, sexually transmitted infections, they’re asking you about, you know, contraception, you know, all the things that we typically focus on maybe a little bit more, and they’re doing those things, yeah, then you may not need to see a gynecologist. Again, if they’re doing all those things, they’re probably also doing Pap smears.

Dr. Melka: Yeah.

Dr. Fox: So it really depends on what kind of care you’re getting. Someone…you should be seeing a doctor pretty much every year for something or another. And for a lot of women, that’s going to be their gynecologist because they’re often the only ones who are able to or willing to or comfortable to do all these things. But again, obviously there’s a wide range of practices, you know, in the country and the world, and there’s certainly tremendous, you know, family practitioners and general practitioners who do this very well, very comfortably.

Dr. Melka: Sure. Yeah.

Dr. Fox: It really just depends, you know, where you live, and what’s available to you.

Dr. Melka: Yeah.

Dr. Fox: Yeah, so I think this is a great review of the Pap.

Dr. Melka: Yeah.

Dr. Fox: Good job, Melka.

Dr. Melka: Two other things.

Dr. Fox: Two other things, hit me.

Dr. Melka: A Pap smear is not a pelvic exam.

Dr. Fox: Okay.

Dr. Melka: I get this a lot.

Dr. Fox: Talk about that.

Dr. Melka: So, I’ll have someone… One example is somebody who has bleeding. They go to the emergency room, they’re evaluated, and they’re told follow up with your GYN. And then they make an appointment with me, and I ask them when their last Pap was, and they’ll say, “I had one in the ER last weekend.”

Dr. Fox: Right.

Dr. Melka: No.

Dr. Fox: Right. Well, maybe, but probably not.

Dr. Melka: Love to the ER docs, it’s just not part of an emergency evaluation.

Dr. Fox: Yeah. Right.

Dr. Melka: So many pelvic exams are not including the Pap smear.

Dr. Fox: Right. A pelvic exam is typically…

Dr. Melka: It could be a speculum to look at the cervix, and look at the vagina, it could be a bimanual, where you’re feeling the uterus and ovaries…

Dr. Fox: Right, right. And it’s possible they even did a speculum, and stuck some Q-tips in there, which could have been for cultures…

Dr. Melka: Yes. Yeah.

Dr. Fox: I mean, you know, the Pap smear is a very specific test that has to be ordered and collected in a certain way. So just because someone did an exam, and used a speculum, and even if they use some Q-tip and swabs, it does not mean a Pap was sent.

Dr. Melka: Right.

Dr. Fox: I mean, maybe it was, but if it was in an emergency room, probably not. Agreed.

Dr. Melka: Yeah. Yeah.

Dr. Fox: All right, so that was point number one, Pap does not equal pelvic exam.

Dr. Melka: Yes.

Dr. Fox: Good. What was the other?

Dr. Melka: Many patients don’t want to follow these recommendations because they want Paps more frequently.

Dr. Fox: Ah, okay.

Dr. Melka: I assume you did not grow up reading, like, “Cosmo” or “Teen Vogue” or anything like that…although you have surprised me before.

Dr. Fox: So I would say, good assumption. “Cosmo” is “Cosmopolitan?”

Dr. Melka: Correct.

Dr. Fox: Definitely did not grow up reading that. I don’t…I wonder if we got it in my home? We may have gotten in my home. And “Teen Vogue?”

Dr. Melka: Something like that.

Dr. Fox: No…yeah.

Dr. Melka: Like, every magazine you’d read as a woman says, like, get your Pap every year. And it’s not like get an exam every year, it’s not see a doctor, it’s get your Pap smear every year. You will get cervical cancer if you don’t get your Pap, and it, like, scares the crap out of you growing up. So like, you’re told to do this, and you do it, and then, like, I come in the room and I’m like, oh, you had a negative Pap last year, with negative HPV, you don’t need a pap for five years, and some women are like, great, and others are like, what the hell are you talking about? Like, I want to do it every year.

So in that case, it just becomes a conversation, you know, why is it not recommended…

Dr. Fox: Right.

Dr. Melka: I’m not going to refuse to do one. Like, if someone wants it, I’ll do it. But then it’s tough because sometimes you do pick up a mild abnormality that you can’t then ignore.

Dr. Fox: Right.

Dr. Melka: Which is sort of, like, contra… It doesn’t make sense in your brain. It’s like, well, you said I didn’t need this, so now why do I have to do something about this result? So it’s sort of like you’d rather not see it, or you’d rather just see it, like, a few years later, which is something to consider.

Dr. Fox: Yeah, they definitely did not cover this in the magazines I read regularly in my youth, which would basically just be “Sports Illustrated,” and “ESPN” the magazine. I don’t think they covered… Maybe they did, but I missed those sections.

Yeah, no, listen, it’s definitely something that I can see why many women would say, listen, this is just…again, this is what my mom told me to do, or this is what I used to do, right? I mean, this is…you know, people have a long career with Pap smears, right? And then it changes over the course of their lifetime. And some people are probably very happy to hear that, and other people are a little bit, like, rattled, wait a second, like, what do you mean you’re not checking? I want to know.

Dr. Melka: Yeah. There are doctors out there that have done Paps more often than recommended, and have caught one thing early, and then say they’ll always do Paps, every year.

Dr. Fox: Yeah. And that is, again, that’s the upside to doing it more frequently. There’s no question about it. But then, unfortunately, there’s also a downside. It’s a conversation, I agree.

All right, Melka, good job.

Dr. Melka: Cool. All right, thank you.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast, or any other topic you would like us to address, please feel free to email us at HW@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only, and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health, and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.