Don’t time first teen visit to first Pap test

The next patient in your exam room is 20 years old. When you note that this is her first gynecologic visit, she tells you that she didn’t think she needed such a checkup until her first Pap test.

Adolescents and their parents may have become confused on when to schedule a teen’s first gynecologic exam when updated cervical cancer screening guidelines were issued in November 2002 by the Atlanta-based American Cancer Society (ACS). The 2002 guidelines called for Pap tests beginning either at age 21 or three years after a woman first has sexual intercourse;1 previous recommendations advised an initial Pap screen shortly after first intercourse or by age 18, whichever occurred first. The Washington, DC-based American College of Obstetricians and Gynecologists (ACOG) followed up with similar guidance in July 2003.2

Now ACOG is clarifying its guidance with the issuance of a new committee opinion on the subject.3 Because of the changes in cervical cancer screening guidelines, there is concern that teens will delay important preventive care and sexually transmitted disease (STD) testing until they come in for their first Pap screening, says Paige Hertweck, MD, immediate past chair of ACOG’s Committee on Adolescent Health Care and associate professor in the department of obstetrics, gynecology, and women’s health at the University of Louisville (KY) School of Medicine.

"If the first exam is done around ages 13-14, we can assess their reproductive health and do some risk-taking analysis," she explains. "If a person waits until age 21, we will miss determining such conditions as PCOS [polycystic ovarian syndrome], eating disorders, and screening for STDs."

ACOG recommends that an adolescent girl’s first visit to an OB/GYN for health guidance, screening, and preventive health occur between ages 13 and 15, ideally before sexual activity has occurred. It is estimated that 24% of 15-year-old girls have had sexual intercourse.4

A teen’s initial visit does not necessarily have to include a pelvic examination or a Pap test. Annual adolescent visits, whether they include a Pap or not, are strongly recommended, are strongly recommended by ACOG.

Do your adolescent patients understand the difference between a Pap test and a pelvic exam? Few teen girls do, according to the results of a just-published study.5 In a survey performed at the UMass Memorial Adolescent Clinic in Worcester, MA, researchers asked 111 teens ages 14 and older and any mothers accompanying them to give a definition of a Pap test and to identify whether a Pap test is equivalent to a pregnancy test, a test for sexually transmitted diseases, a cervical cancer screening, a pelvic exam or a checkup. Just 2.7% of the teens could give an accurate definition; 68% believed that a Pap smear was the same as a pelvic examination. Only 40% of the mothers could properly define a Pap test.5

Such findings don’t surprise providers such as Melanie Gold, DO, associate professor of pediatrics at the University of Pittsburgh School of Medicine and associate professor at the University of Pittsburgh Graduate School of Public Health.

"The biggest confusion is that people don’t understand that the Pap smear is a test and a pelvic exam is a type of a exam," she notes. Women may incorrectly assume that a Pap smear is being performed any time a speculum is inserted during a physical exam unless each portion of the procedure is explained to her, she notes.

Don’t overdo treatment

The new ACOG opinion also stresses the need to avoid overtreatment of abnormal cervical cytology in adolescents. Adolescents may be more susceptible than adults to human papillomavirus (HPV) infection due to biologic or physical factors. Risk factors for HPV include multiple sexual partners, having a male partner with multiple sexual partners, history of other STDs, and early age of first intercourse (including sexual abuse).3 Teens also have a higher prevalence of abnormal Pap test results compared with adult women, but the severity of their cervical lesions generally is lower.6

According to ACOG, adolescents with abnormal Pap screen results should be counseled and monitored closely to avoid aggressive treatment of benign lesions because most lesions regress on their own without treatment and do not result in cervical cancer. Surgical excision or destruction of cervical tissue in the adolescent female may affect future fertility, ACOG notes.3

"There is a lot of confusion about what an abnormality is," says Gold. "We usually talk about the fact that just because your Pap smear is abnormal doesn’t mean you have cancer."

References

1. American Cancer Society. FDA Approves New Cervical Cancer Screening Test. Atlanta; March 31, 2003. Accessed at: www.cancer.org/docroot/NWS/content/NWS_1_1x_FDA_Approves_New_Cervical_Cancer_Screening_Test.asp.

2. American College of Obstetricians and Gynecologists. Cervical Cytology Screening. Washington, DC; July 2003.

3. American College of Obstetricians and Gynecologists. Cervical Cancer Screening in Adolescents. Committee Opinion No. 300. Washington, DC; October 2004.

4. Abma JC, Sonenstein FL. Sexual activity and contraceptive practices among teenagers in the United States, 1988 and 1995. Vital Health Stat 23 2001; 1-79.

5. Blake DR, Weber BM, Fletcher KE. Adolescent and young adult women’s misunderstanding of the term Pap smear. Arch Pediatr Adolesc Med 2004; 158:966-970.

6. Simsir A, Brooks S, Cochran L, et al. Cervicovaginal smear abnormalities in sexually active adolescents. Implications for management. Acta Cytol 2002; 46:271-276.