1. Your Pap smear was
abnormal-now what?
SARAH FELDMAN MD MPH
MEDICAL DIRECTOR AMBULATORY GYNECOLOGIC ONCOLOGY
BRIGHAM AND WOMEN’S HOSPITAL
HARVARD MEDICAL SCHOOL

2. Disclosures
 I write chapters on cervical cancer screening and colposcopy for Uptodate
 I have several grants from the NCI to study how best to screen for and manage
patients with abnormal screening results
 I sit on multiple national and international committees aimed at preventing cervical
cancer
This slide deck was prepared in collaboration with Kelly Welch from Team
Maureen. Team Maureen has been working to end cervical cancer through
education since 2007.
For more information on Team Maureen, visit TeamMaureen.org

3. Goals
 To explain the why, how and what of cervical
cancer prevention
 To discuss “Pap screening” and other ways to
prevent cervical cancer
 To suggest what to do after an abnormal Pap
test, including questions to ask your health
care provider

4. Cervical cancer
 Cervical cancer is a cancer that affects the cervix or opening to the uterus
in women. It usually affects women in their 30s and 40s, but 20% of cases
occur in women over the age of 65.
 Historically, cervical cancer was prevented by having an annual “Pap
Smear.”

5. Cervical cancer is PREVENTABLE
 Prevention relies on a two piece approach
 Vaccination
 Screening with management of abnormal results

6. What is screening?
 Screening refers to testing all healthy people with a cervix with no
symptoms and a history of normal tests between the ages of 21 and 65
 Once a patient has an abnormal test result, they no longer undergo
“screening.” In order to prevent cancer abnormal result needs further
evaluation, and then if there is a precancer (also known as a high grade
lesion) they need treatment and more frequent testing known as
“surveillance.”
 Women who are immunosuppressed or have a history of abnormal results
or cancer will get more frequent testing.

7. New knowledge has improved
screening for cervical cancer…
 Cervical cancer is caused by persistent
infection with a high risk HPV virus.
 Ultimately persistent active infection (more than 2 years) with a hrHPV virus
will cause changes at the cellular level that can be detected by a Pap test (an
improved version of the historic “Pap smear.”)

8. What is HPV?
 HPV is a sexually transmitted infection and can (rarely) cause
cancers of the cervix, vagina, vulva, anus, throat/base of
tongue, and penis.
 It is transmitted through sexual skin to skin contact.
 In most cases HPV infection ‘clears’ without knowing you ever
had it.
 There are 5 FDA approved HPV tests in the US.
 These HPV tests are not all used for the same purpose. Some
tests may be used alone (without a Pap) and some need a Pap
to determine next steps-ask your doctor which type you’re
getting

9. Cervical Cancer Screening 2023- the modern
“Pap smear”
Many clinicians still refer to all screening as a Pap smear, but you are likely getting one of these tests:
 A Pap test (similar to a Pap smear) but more accurate
 An HPV test which screens for 14 types of HPV.
 The HPV test can be done by itself (called “Primary HPV
testing”) or as a co-test (done at the same time as a Pap
test).
 If an HPV test is positive, then a Pap test is needed to
determine if there are abnormal cells present. The HPV test
is the most reliable test (for your risk of developing a
precancer) especially if it is either repeatedly positive or
negative over time.

10. What are possible results of screening?
An abnormal Pap:
• Possible results: Normal, ASCUS,
LSIL, HSIL, AIS, Ca
A positive HPV test:
• Positive for a group of HPV types
that have EVER been associated
with cervical cancer, but most of
these types are actually rarely
related to cervical cancer
• Sometimes your provider will ask
for “genotyping”to determine if
you have one of the highest risk
types (HPV 16 or 18/45).

11. If my HPV test is positive what does that
mean?
 Most unvaccinated people get HPV at some point (80%), but most infections clear and
do not cause any precancerous changes
 A positive HPV test means you have an active infection of the cells which can, if it
persists over time (years) cause cervical cancer
 A negative test does not mean that you have not ever been infected with HPV, but
rather that the infection is not active and therefore your risk of developing cancer or
precancer is lower. A negative test is very reassuring.
 Some patients (especially older women) may have dormant infections that then
reactivate- does not require a new sexual exposure
 Some HPV types are more aggressive than others

12. What about my partner?
 If you tell your partner, it’s helpful to mention that:
 Most unvaccinated people have HPV.
 Especially in older people, a positive HPV test could just be an old infection that has
reactivated, not a new infection.
 If you have HPV and are in an intimate relationship of any kind, your partner probably has it
as well.
 Encourage your partner to keep up with screenings too:
 Dental exams
 Cervical exams
 Regular wellness appointments

13. Who needs colposcopy?
 Most patients with an abnormal Pap test, or a normal Pap
but repeated positive HPV tests will need a colposcopy
 Ask your doctor about your particular case
 You can also access this website and put your information
in:
www.cervicalrisk.com
Most abnormal results will require colposcopy and biopsy.

14. What is colposcopy/biopsy?
 Colposcopy is when a clinician looks at
your cervix (and vagina and sometimes
vulva) with magnification.
 It allows a clinician to see the cells in
better detail to determine where to
biopsy.
 A biopsy is a piece of tissue that is sent
to a lab and a diagnosis is made (such
as normal, low grade (not precancer) or
high grade (precancer).
 Most of the time you will have at least
one biopsy at the time of the
colposcopy.

15. What to expect at colposcopy? (and
will it hurt?)
Your provider will put a speculum into the vagina to see the cervix.
the speculum is a little wider than usual so they can get a good look at the
as well as the vagina. Most patients get use to this within a minute.
They will place acetic acid (white vinegar) on the cervix and look for areas that stain
The white stain just means the cells are actively dividing- it does not mean that the
precancerous. This may burn a little at first.
Biopsies are taken from white areas. Unfortunately you cannot be numbed for this as
changes our ability to see abnormal areas.
Patients are very different in terms of pain. Some suggestions to improve your
take ibuprofen 600mg PO before, distract yourself (talk, meditate, listen to music).
someone to support you. Some providers will prescribe Ativan before if you feel
anxious.

16. Results and next steps
How long it takes to get
the results from your
biopsies will vary.
Ask your provider how
and when to expect
results.
Possible results include a
normal or low grade
lesion or a more
concerning high grade
lesion.
Next steps and treatment
will depend on these
results, your age, your
fertility concerns and your
medical history.

17. Need for ongoing surveillance
 All patients with abnormal screening results, whether or not treatment is
needed, will start a more frequent surveillance testing regimen. After an
abnormal result, you are no longer considered a routine screening patient.
 Treatment is often a LEEP---or removal of the abnormal cells.
 After evaluation and/or treatment you will be advised as to whether you
need to return in 6months, one year, or 3 years depending on your prior
and current results and age.
 Keep a record of any abnormal Pap, HPV tests, biopsies or treatments and
make sure any future clinicians know your results as they affect how often
you should be tested.

18. Questions to ask your doctor: AFTER
Courtesy of
American Cancer
Society Patient
Group
How long to get
my results?
How will I learn
about my
results?
What does an
abnormal result
mean?
Should I get the
HPV vaccine?
Will my
insurance pay?

19. Thank you!