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So you just had your Pap smear or your mammogram and it wasn't that bad was it? Or your colonoscopy. Okay, it really was that bad, but you didn't remember it. Are you wondering when you can stop doing these tests?

I asked a woman I know, who is in the health and fitness business, when she thought she could stop doing her cancer screening, you know, Paps, mammos, colonoscopy. She said, "Never," with a smile. She never wanted to stop her cancer screening, "It isn't all that bad, and it makes me feel safe," she said. I replied that cancer screening decisions about when and how often is a cost, risk, benefit analysis, and there are some data to inform that decision. She said, "You go with your brain, I go with my heart."

Well, let's go with the brain for a little while, okay? Let's start with Pap smears. The recommendations about Pap smears have been changing as we know more about what mostly causes cervical cancer -- the HPV virus -- and how fast it grows, usually not too fast. Cervical cancer does not increase with age for a lot of reasons. Sexual activity and the number of partners doesn't increase with age. Well, usually. And the cervix in postmenopausal women may not be as receptive to the virus. So there are good reasons to say that when you get to 65, if you've had normal Pap smears for the past 10 years, that means you actually have been having Pap smears in the past 10 years, and you haven't had an abnormal Pap in 20 years, you can stop testing. There's some pretty solid numbers to back this up, and the U.S. Preventive Services Task Force makes that recommendation.

Okay. How about colonoscopy? Well, colon cancer does not decrease with age. But if you don't have any family history of colon cancer and if your previous colonoscopies, that assumes that you've had some, have not shown any polyps or precancerous lesions, you can stop at 75. That's the recommendation of the U.S. Preventive Services Task Force and the American College of Physicians.

Lastly, mammography. Breast cancer does not decrease with age. It increases with age. The aggressiveness of breast cancer is less in older women than it is in younger women. But women still will get treated, which can be aggressive in and of itself. The U.S. Preventive Services Task Force said there's not enough evidence to recommend for or against mammograms at age 75 and older. But about a quarter of deaths from breast cancer each year are attributed to a diagnosis made in women after the age of 74. Women as they get older are less likely to get mammograms. About three-quarters of women 50 to 74 have had a mammogram in the past two years, but only 40% of women over 85. Of course, many women over 85 are in poor health, and mammography is just not on the list of things to do. And clinicians are less likely to recommend mammography if a woman is in poor health. The American Cancer Society suggests women should continue mammograms as long as their overall health is good and they have a life expectancy of at least 10 more years.

Well, how long am I going to live? I went online and Googled, "How long will I live?" There are lots of calculators because insurance companies and pension plans really want to know. Well, I tried a life expectancy calculator that was developed by the University of Pennsylvania and has been mentioned in the mainstream media. It asks sex not gender, age, height, weight, alcohol, smoking, diabetes, marriage status, whether I exercised, ate my veggies. I didn't fudge my weight or height. This calculator said I was going to live till 93 and I had a 75% chance of living to 85.

Another life expectancy calculator from confused.com asked me just a few questions, not my height or weight,or smoking, or alcohol, or diabetes. It did ask my relationship status, and options included happy relationship and married, but these were mutually exclusive. You could only pick one. Well, this one had my life expectancy of 97. And the calculator from Northwest Mutual, a well-respected life insurance company, cranked me out at 98.

Well, I really don't want to hang around the planet all that long. But I really hope that my savings will take me up there, and I'm going to have to have mammograms for a while yet.

Thanks for joining us for the "Seven Domains of Women's Health" on The Scope.

Dr. Jones: If you could do your PAP smear at home, would you be more likely to do it? This is Dr. Kirtly Jones from Obstetrics and Gynecology, at University of Utah Health, and this is about home testing on The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Your trip to your primary care clinician for screening tests such as PAP smears and screening for sexually transmitted diseases is not exactly what most women consider a fun time out from their work and home responsibilities. Although a half hour wait, at least, in the clinic does offer the opportunity to review magazines that are about a year old, catch up on whatever the Kardashians are doing and revealing, pick up some recipes that don't go out of date and watch other parents' parenting styles.

However, when you consider that you had to take a half day off work or get child care unless you want to watch people like me to watch your parenting style, maybe drive more than 10 miles, and then there is parking many women just don't do it. What if you could do some of this testing at home, without the gown, the table, the stirrups, and the speculum? Would you do it?

Well, let's talk about PAPs first. The PAP test is a screening test for cervical cancer that involves collecting cells from the cervix to look for precancerous or cancerous changes.

Over the past several decades it's become increasingly clear that cervical cancer is associated with and probably caused by a sexually transmitted virus. The virus, the human papillomavirus, comes in a lot of different types. Some types don't do anything that we know of, some cause venereal warts, and some types cause cancer. Oral, anal, penile, rectal, and cervical cancer are associated with HPV, and cervical cancer is the most common. The PAP smear as originally designed doesn't test for HPV, just for the abnormal cells.

The current guidelines are that young women should start testing at 21, and currently, the guidelines suggest that it should be the PAP test, the ones that collects cells from the cervix, with the stirrups, and the speculum, and the collection of cells. This is for the first PAP smear, and testing should be every three years if no problems are found. At some point, and the guidelines are changing, you can choose to change to just doing the HPV test, the test for the virus if you haven't previously had any precancerous cells found.

After age 30, you can get a PAP or just the HPV test looking for the dangerous kinds of HPV every 3 years. Or if you can do both the PAP and the HPV, and if they're negative, you only have to test every 5 years. But remember, if you just do the HPV test and it shows you have a dangerous virus, then you have to go see the doctor.

Now, the HPV test doesn't need the stirrups, the table, or the speculum. All of us health clinicians still do it in the office. By the way, the good news for all my ladies of a certain age, if you haven't had an abnormal PAP in the past, after 65 you don't need cervical cancer screening anymore.

Now what about the home test? HPV virus is shed into the vagina and can be found in vaginal fluids and cells. Numerous studies have found that different collection tubes put in the vagina by patients can collect fluids just about as well as can be done in the clinic. These studies have been done all over the world in Sweden, U.S., Australia, and they all show that women can follow the directions and do the test effectively.

One study in Sweden looked at a total of about 4,060 women, 39 to 60 years of age who had not attended PAP smear screening for 6 years or more. These women were randomized to two equal groups. A study group was offered to the self-sample test at home, and the other group was recommended to attend PAP smear screening in the clinic. Well, the participation rate was about 40% in the self-sampling group and only about 10% in the invited-to-go-to-the-clinic group. These ladies who hadn't had a PAP smear for over six years really aren't a compliant bunch of women, let me tell you. Anyway, the home test not only was done more frequently, but it revealed a higher percent of women who were then found to have pre-cancerous conditions of the cervix. So it was done well, by women, more commonly than an offer to go to the clinic, and it had more accurate results.

Okay, well, what about here in the U.S.? There are a number of tests available on the market, UDo, SoloPap, Eve Kit, myLAB. They cost from 79 to 140 bucks. The labs may also offer a kit that does screening for gonorrhea and chlamydia, or other sexually transmitted diseases. The tests offered usually give you result in about a week. If you have an abnormal test, the lab will give you recommendations for follow-up. You need to find a real clinician and have a PAP test with a table and the stirrups and the speculum. Some offer online counseling.

Now, some problems. Number one, the FDA has approved the lab test for the screening for the HPV virus in the lab, but probably has not yet approved the home testing part of the process. It's approved in other countries and may be approved here in the U.S. later. Number two. When you order your own test, your insurance won't probably pay for it. Of course, under the Affordable Care Act, most insurances cover recommended health care screening for women without a co-pay. However, if you don't have insurance or if Congress changes the Reproductive Care part of the Affordable Care Act, it might be cheaper just to pay for it.

And number three the biggest problem is justice, medical inequality. Most women who get cervical cancer have not been screened anytime recently. Cervical cancer disproportionately strikes poor women. They either don't have coverage, or if they do, they can't afford to miss a day's work or pay for child care. Or they don't even know about the risks and screening tests, or they have so much on their plate that getting routine health care just isn't really part of it. If women who need the PAP smears most don't get them, how will they afford to be able to pay for a self-test?

The social justice ideal, and I just invented this, would be for clinics to have free boxes of the self-test at the front desk along with condoms, and someone could just pick one up and drop it off with their contact info. How great would that be? Anyway, so the home diagnostics business is booming, and it started with the home pregnancy test. It has moved on to letting you test your entire genome. Well, that is great. In principle, home testing for the HPV virus for cervical cancer is a great idea. Women can do it correctly and the test works. The devil is in the details. And thanks for joining us on The Scope.

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Dr. Jones: Let's talk about ovarian cancer awareness. Let's talk about what you can do to decrease your risk of ovarian cancer. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is The Scope.

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Ovarian cancer is one of the deadliest of gynecologic cancers. We don't have an early detection test like the Pap smear, which is very good at early detection of cervical cancer. Ovarian cancer doesn't have an early warning sign like abnormal bleeding, which gives us a heads-up about early uterine cancer. Ovarian cancer is sneaky. The symptoms of ovarian cancer, bloating, abdominal fullness with eating, pelvic discomfort, all come when the cancer has spread at least a little bit. And these symptoms are pretty common in women so that makes it difficult to know exactly who you should work up.

We've talked before about the fact that cancers, in general, are about one-third genes, one-third environment and behavior, and one-third bad luck. We know we cannot change our genes and changing our luck is sort of a cosmic thing, but what can you do to decrease your risk of ovarian cancer? The most common kinds of ovarian cancers arise from the cells on the surface of the ovary. Some of these might actually be coming from the fallopian tubes with some types of ovarian cancers that just seem to arise from the uterine lining cells that find themselves in the pelvis.

A jillion years ago when I was on a GYN cancer service in Boston, we used to say that ovarian cancer was a nun's cancer. Boston had a lot of nuns and it seemed as if these lovely women had ovarian cancer more often than we would expect. Well, we do know that nuns have a slightly increased risk of ovarian cancer, compared to women in the general population.

What is true is that there's an increased risk of ovarian cancer in women who have never had children. This has been looked at a number of ways. First, there's a decrease in the risk of ovarian cancer by 50% in women who have had their tubes tied. Women who have had their tubes tied usually have had a bunch of kids. Two, there's an increase in ovarian cancer in women who are infertile. Is it being pregnant and having kids that protects you? Is it infertility treatment, all of those hormones and things that put you at risk? Is it the cause of infertility, like endometriosis, that both makes women infertile and puts them at risk? It might be all of these.

Having said all that, I don't want women to rush out and have a bunch of kids that they might not be prepared for just to decrease their risk of ovarian cancer. It turns out that the Centers for Disease Control did a big study on contraception, and hormones, and gynecologic cancers and lo and behold, taking birth control pills lowers the risk of cancer by as much as 50%. It even lowers the risk of ovarian cancer if you have the family genes like the BRCA mutations that put you at risk for ovarian cancer. How do hormonal birth control pills do that? We don't exactly know, but it could be that ovulation, which disrupts the surface of the ovary each month, is a little bit risky with respect to ovarian cancer.

So how do you decrease your risk of ovarian cancer? If you're thinking about contraception, you may want to consider birth control pills. We don't seem to find the same protection with IUDs or implants, at least not yet as implants haven't been around that long yet for us to really know.

Another ovarian cancer prevention strategy, because there's some suggestion, and it's controversial, but that cells from the fallopian tubes may play a role in ovarian cancer. There's some suggestion that women who have their fallopian tubes removed, not their ovaries, just their tubes, have a decreased risk of ovarian cancer. So if you're thinking about having an operation to have your tubes tied, either immediately after a baby is born or later with the laparoscopy, maybe you should talk to your gynecologist of having your tubes removed. Importantly, if you have a BRCA mutation in your family and you have that mutation that is one of the genetic causes of an increased risk in ovarian cancer, you may choose to have your ovaries removed.

Now, there are some other things that may have an association with an increased risk of ovarian cancer. We don't know if these are a cause, but it seems to be an increased risk. There's a slight increased risk of ovarian cancer in women who take hormone replacement therapy after menopause. The risk is small and we don't understand the cause, but it's there to think about. And there seems to be a small increased risk of ovarian cancer in women who use talcum powder down there, on their perineum, on their lady parts. Even if the risk is low, it probably isn't necessary and we don't suggest it.

So I'm not suggesting that nuns should take birth control pills, although that has been suggested by some. And I'm not suggesting that women have more children that they're unprepared for. But there are some other health benefits of birth control pills: lighter periods, lower risk of uterine cancer, and if you're having your tubes tied or operated on to end your fertility, maybe taking the tubes out isn't a bad idea. And talcum powder on your lady parts isn't a good idea.

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Announcer: Covering all aspects of women's health. This is The 7 Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: So you just got a call from your doctor or probably your doctor's nurse, who told you that your pap smear was slightly abnormal or was abnormal and you need to come back in. Well, should you hang it up and write your will or is it going to be okay?

Well, here's the scoop on that. The Pap smear is a screening test to pick up pre-cancerous abnormalities in the cervix before they become cancer. So the vast majority of abnormal pap smears that you might get a call about are actually not cancer. They are pre-cancerous conditions that we want to investigate a little bit further and can treat these little local areas in the cervix before they become cancer.

So if you go back in, what might happen? Well, your pap smear may have been abnormal because for some reason the fluid got screwed up or they didn't collect enough cells. So sometimes you get a call not because there's anything wrong, but because there wasn't enough to look at. Okay. So that's not a scary thing, but your nurse should explain that you. "No problem. We just didn't get enough cells on your pap smear to look at."

So what's the chance that if the Pap smear said you have some abnormalities on your cervix that you really do have something, abnormalities on your cervix? So we mentioned that a pap smear is a screening test. It's not a diagnostic test.

How good is it as a screening test? How true is it? That's a difficult question, but I would say that if you have mild dysplasia on your pap smear, the chances of us not finding anything on a colposcopy may be as high as 50 percent to 60 percent. On the other hand, if you have severe dysplasia or high-grade dysplasia on your pap smear, the chances that we're going to find something is more like 90 percent.

So a few little mild changes, which will trigger the callback, may not mean that you have anything. So if you have a low-grade lesion, that may not mean that you really have anything to worry about. If you have a high-grade lesion, that doesn't mean cancer, but it does mean that you really need to have it looked at and probably treated because a high-grade lesion on a pap usually means there's something there to treat.

If there's an abnormality, or what we call dysplasia or cervical intraepithelial neoplasia . . .There are a bunch of scary words. Usually, what happens is you go in, and the doctor puts a speculum in that device to look at your cervix. And then he or she rolls up this little instrument that looks like binoculars on a stick.

So they use these very special binoculars to magnify the cervix so they can look for areas that might be a little bit abnormal. This is called colposcopy. The "colpos" is the upper vagina and "scopy" means to look. So they are going to look at your cervix with these kinds of binos.

They may put some vinegar. So if you smell like a pickle, that's because they're using just ordinary vinegar to clean off your cervix. And vinegar makes the areas that might be abnormal turn white. So then they can look at the cervix, paint it with a little vinegar, look for areas that might be a little bit abnormal, and then they will take a tiny bit of tissue. Now, you think, "Oh, my god. They're going to operate on my cervix." Well, the amount of tissue they take is about the size of a hangnail.

So they take a tiny little biopsy, and they send that to pathology. And they say, "Is this something to worry about or not?" And if it's not something to worry about, then people come back, and they may have a few more pap smears than every three years. Maybe they're going to have a few extra in the next couple of years.

If it is dysplasia that is moderate or severe, that isn't cancer yet, but then we can actually treat the cervix. Usually, we use freezing or sometimes we use a little laser, but freezing is very cheap and very common. And we make a little cold blister. So we make a little blister, and the abnormal cells just come off. And then new, healthy cells grow in.

Well, the treatment can get rid of abnormal cells about 98 percent of the time so that's really good news. Now, we know that new, healthy cells can get infected by the virus. So it turns out that almost all cervical dysplasias and cancers are caused by the HPV virus.

So now you have all these pretty new cells covering your cervix. Well, they can get infected, too. So first, you want to make sure that you're in that 98 percent cure rate. So they'll probably ask you to get pap smears more frequently, maybe twice a year for a couple of years. If they all stay normal then you are back on to your every other, every third year screening. If, for some reason, you're at high risk, meaning you have a high-risk virus or you have a high-risk lifestyle where you might get more viruses, then you probably need to be screened a little more often.

So the treatment is about 98 percent effective at getting rid of the dysplasia that you have, and new, healthy cells will grow in. But as long you've got the virus or are exposed to new viruses, it's possible that you could get these changes come back. So once a woman's been treated for dysplasia, she's very likely to be cured, but she has risk factors for getting it again. Not that it wasn't cured the first time, but getting it all over again.

Think of it as sun exposure on your face. So you're a little bit older, and you've got this little area on your face that the dermatologist wants to burn off. You can burn off that one, but it's very likely that a year or so from now you'll get another someplace else. So it's not unlike that with cervical cancer as well.

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updated: July 26, 2018
originally published: May 11, 2015

Dr. Kirtly Parker Jones: So what is your cervix? What is it for? Why does cancer happen down there? And what can you do to prevent it? This is Your Cervix on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier, healthier life. You're listening to The Scope.

Dr. Kirtly Parker Jones: Every woman just can't wait to get her pap smear, right? No, that's not right. So what is a pap smear for and what does your cervix do? What should you know to prevent cervical cancer? This is Dr. Kirtly Parker Jones from the Department of Obstetrics & Gynecology at University of Utah health care and today we are going to have a little reproductive biology session that might make it a little more reasonable to go ahead and get your pap smear. Cervical health today on The Scope.
A woman's cervix is attached to the uterus. The uterus is shaped like an old fashion, incandescent light bulb. We won't be seeing too many of those in the future, or sort of an upside-down pear shape. The cervix is the lower part, the part that attaches into the lamp in the light bulb, or the part with the stem of the pear. Its part of the uterus, not separate, and it's about the size of a really great big grape. It's a miraculous structure with several functions.
One, it functions to anchor the uterus and the pelvis by its firm attachments to the pelvis. Two, it keeps germs and sperms in the vagina from getting up into the uterus, except during the fertile period every month when the cervix's mucus changes during ovulation to serve as a safe pathway for sperm into the uterus and the fallopian tubes to find the egg. Three, it's very firm and tight in the non-pregnant woman and in early pregnancy, like a rock, and it's closed. But at the end of pregnancy and during labor, it gets very soft and opens up very big to let the baby out. And then in days to weeks it closes and gets really hard again. Magic, huh?
The outside of the cervix is covered with skin cells, like the vagina. And the inside of the cervix canal, that goes into the uterus is covered with mucus producing cells, that for several days a month, make the mucus safe haven for sperm. These mucus producing cells are very delicate and where they meet the vagina, they're exposed to bacteria, viruses, chemicals, sperms and other stuff that makes them change into skin cells as a protective mechanism. During this process, any chemicals or viruses that can badly affect DNA can make the change that can proceed to cancer. About 1 in 125 American women will get cervical cancer.
Now, smoking and a sexually transmitted virus, called the HPV virus, are the biggest risks for cervical cancer. Cervical cancer is preventable. Cervical cancer is detectable before it becomes cancer. That is what the pap smear is for. It's cheap and nobody ever died from a pap smear. Maybe you thought you would, but you wouldn't. If the pre-cancer stage is detected with the pap smear, it can be treated before its cancer and save your cervix and uterus. Cervical cancer, if it's detected in the early stages of cancer by a pap smear, can be treated and cured surgically.
Cervical cancer is one of those diseases that is differentially expressed among the poor, among immigrants, and among people who don't have access to health care. So if every woman were screened, as recommended, the chances of getting cervical cancer would go almost to zero.
So, the cervix is magical. Take care of it. Don't smoke. Use condoms if you have new partners. Use the HPV vaccine before you're sexually active. Get your daughters the vaccine, and get your pap smears. First pap at 21. After your first pap is normal, you can go every three years. Some women might want a pap and a test for the HPV virus when they are over 30. Both of these together, if they are negative, you can go to every five years before you're tested again. That's the good news. Not a pap smear every year, every three years, or if you co-test, every five years if you're negative. If you've never had an abnormal pap smear, you can stop getting them at 65. If you don't have a cervix anymore, if you had a hysterectomy that wasn't for cervical cancer, you don't need a pap anymore.
So, your cervix is amazing, it keeps sperms out until you need them in. It keeps babies in until you need them out. Take care of it. And thanks for joining us on The Scope.

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