This is a topic that is always relevant, and without the right information, it causes stress and panic for no reason. Here are the exact scientific facts in as understandable a language as possible. I apologize for the many details, English terms and statistics, but they are all important and will contribute to clarity and understanding.

A Pap smear simply means taking a few cells from the tip of the cervix, where cancer usually develops. Its aim is to identify changes in the cells that are precancerous, i.e. they precede cancer by a few to many years. Therefore, a positive or pathological test does not mean that there is cancer, but that it may develop in the future if proper monitoring and local treatment are not done.

The cells are examined under the microscope and the cytological result may be:

• “Negative for malignancy” i.e. absolutely normal. Expected in 85-90% of samples.
• “Evidence of inflammation” which means normal but cervicitis is probably present and a culture may be indicated. However, if the inflammation persists when the test is repeated, a colposcopy is recommended.
• “ASCUS” i.e. atypical cells of undetermined significance. It sounds vague and suspicious but it usually isn’t. It simply covers the cases where the cells are not clearly healthy, but do not have the clear changes that are considered precancerous. The risk of eventually having serious lesions is 5-17%, while the risk of hidden cancer is 0.1-0.2%. Colposcopy is recommended by many, but follow-up with a new Pap test in 6 months also has its place.
• “HPV lesions”, that is, of the wart virus. It’s a common response that panics unnecessarily. This virus is present in 30% of young women and rarely causes precancerous lesions and cancer. Many reputable centers abroad simply recommend regular repeat Pap tests. The role of this virus is then described in detail.
• “Mild cell lesions” or LSIL according to the Americans. If the test is repeated in 6 months, in 60% of cases it will have become normal. It can be checked with a colposcopy immediately or the Pap test can be repeated in 6 months and then, if it persists, a colposcopy is required. Immediate colposcopy is the safe route as in 15-30% it will reveal hidden serious lesions and rarely (2 in 1000) cancer may be present.

Inflammatory lesions/ASCUS and mild lesions are expected in 5-10% of samples.’

• “Moderate cellular changes”.. Colposcopy is recommended.
• “Severe cellular alterations”. Colposcopy is recommended. Risk of coexisting cancer in 1-2%.

Moderate and severe lesions are expected in 1.5% of samples and the Americans describe them as HSIL.

No girl will get invasive cancer by the time she’s 21, according to authoritative American studies.

The Pap test should be done between the ages of 20-64 every year. In America, in the first 20 years of the program, cases of cervical cancer fell by 45%, although the program was poorly implemented – half of the women who got cancer had never been tested. Adherence to the follow-up program leads to an even greater reduction in the incidence of cancer.

However, a single Pap test is not perfect. It can detect precancerous abnormalities (sensitivity of the test) at a rate of only 50% Also when it comes out normal it can be wrong (false negative) at a rate of 30% simply because they did not happen to collect cells from a focus of alteration in the cervix. It is therefore important to take the test frequently and regularly as the many negative results give it credibility. Of women who get cervical cancer in Britain, half tell us they had a test 3-5 years ago that was normal, as well as all the previous ones at irregular intervals.

However, the test rarely (1%) will worry us unjustly, as when it shows an abnormality in 99% it will be confirmed colposcopically.

If a colposcopy is recommended, even this development should not frighten and worry the woman, who usually at this stage is overwhelmed by the multitude of examinations, feels that ‘something is wrong’ and justifiably wants to know exactly what is happening.

Colposcopy is the examination of the cervix with a special microscope, the colposcope, and at the same time the painless smearing of the area with special dyes. These help us distinguish whether the pathological cells in the test come from some ‘visible’ damage (corrosion, wound, call it what you want) on the surface of the cervix. From this position we can take a small biopsy (a small pinch that many women don’t understand at all) to make sure and rule out precancerous lesions.

Now we are no longer looking at scattered individual cells under the microscope as in the pap smear but a piece of cervical tissue from the biopsy. This makes the diagnosis much more certain but the answer is now histological, the terminology changes and the woman is even more confused.

So we have

“Normal”, i.e. everything is fine.

“CIN“ (Cervical Intraepithelial Neoplasia) i.e. local dysplasia, which is the confirmation of pre-cancerous change.

Depending on the depth of the lesion, we describe CIN1, CIN2 CIN3 with 1 being the mildest and 3 being the worst.

At this point, completely scared, the woman just wants to know if she has cancer and the answer is of course no.

If it has CIN2-3 and is not treated, in 10 years he will get cancer at a rate of up to 70%. The CIN2-3 unlike CIN1 is unlikely to resolve spontaneously without treatment.

If he hasCIN 1 and is not treated, in 2 years 30% will return to normal, 30% will remain CIN1 and the remaining 30% will progress to CIN3.

The treatment is the local incision with diathermy of a ‘slice’ from the edge of the neck and thus the focus of these lesions is removed. CIN2 and CIN3 lesions should be treated, many experts believe the same for CIN1.

The treatment is usually done under local anesthesia and the cervix heals wonderfully without affecting the woman’s cycle, sex life or fertility. Lesions can recur with a frequency 4 times greater than women without a history, over the next 8 years.

The Pap smear program and treatment of the lesions reduce the risk of invasive cervical cancer by 97%.

But what causes cervical cancer?

HPV or HUMAN WART VIRUS

Today we know with absolute certainty that the human papilloma virus (HPV) is responsible for cervical cancer, but this happens slowly and in a few women. The association is more clear than that of smoking for lung cancer. The virus has been found to be present in over 95% of cervical cancer cases.

There are many strains of this virus, and the ones that are dangerous for women are those that cause visible warts on the genitals of men and women. Cancer-dangerous strains do not cause visible lesions or other problems in women or men.

The virus, and indeed the dangerous strains, is present in 20% of women aged 20-25 and is acquired when they become sexually active. It is sexually transmitted but is not considered such a disease since it has also been found in young children, even infants. The important thing is not how it is obtained but that fortunately 80% of women abort it with defensive immune mechanisms within about 8 months and so after 30 it is detected in only 5% of women. So finding the virus in women over 30 or persistence of the virus in successive tests in younger women should make us more cautious.

Those few women (the 5%) where the virus persists are at risk of developing CIN3 in 4-5 years and ultimately even less cancer over a total of 13 years (only 1-1.5% of women develop cervical cancer).

HPV Initially in 20% > HPV Finally at 5% > CIN1 > 30% in 2 years will become CIN3 > CIN2> CIN3 > 70% in 10 years will become cancer > Cancer

Viral persistence is essential for progression to severe CIN3-type lesions. Also CIN1 and CIN2 often regress, while CIN3, which is always accompanied by the virus and its harmful effect, does not regress without treatment. A woman who carries the HPV virus is 13 times more likely to develop CIN 3 than a woman who does not carry the virus.

Often the Pap test describes wart lesions and so panicked women are sure they are carrying the deadly virus. So it must be emphasized that even if she carries the virus (and the simple Pap test is not very specific to detect it) this is very common, especially if she is a young girl, and it does not mean that she had an unstable sex life that caused it. Extending the life of the virus in older women (and smoking facilitates its survival) can eventually lead to precancerous changes and cancer and is just one more reason for regular monitoring. A special test (HPV DNA test) is gradually being recommended after the age of 30 to detect persistent presence of the virus.

There is no specific treatment. The virus is eradicated from its focus by local treatment and it seems that the local destruction is a stimulus for the immune system to help fight it. Nevertheless, simply detecting the virus without cervical lesions is not enough to subject so many women to local treatment.