Women's Bodies, Women's Wisdom (64 page)

How Reliable Is the Pap Smear?

No test is 100 percent reliable, and the Pap smear is no different. Studies have shown that the false negative rate of the test runs from 5 to 50 percent, depending upon the practi tioner and the lab used. Occasionally a Pap smear will come back negative even though abnormal cells are present. About two-thirds of these false negative smears are the result of errors made by the health care practitioner in the collecting of the cells (known as sampling errors). About one-third of false negatives are due to laboratory error. There are also times when the abnormal cervical cells are located in areas of the cervix that simply can’t be reached by a Pap smear. So even under ideal circumstances, when everything is done perfectly, some cervical cancers will not be picked up early with a routine Pap smear.

What If My Pap Smear Isn’t Negative?

Sometimes you’ll get a Pap smear result that is scary or confusing. Here are the basic categories of Pap smear results and how to deal with them.

Sometimes a Pap smear will come back labeled “unsatisfactory for interpretation” or “limited.” This is not a cause for alarm. It just means that there were not enough cells present on the slide to interpret the smear adequately. An “unsatisfactory” reading doesn’t necessarily mean that your practitioner took a bad Pap smear or did it wrong. It just means that you need to get it repeated.

Another designation used on Pap smear reports is “limited interpretation secondary to inflammation.” Sometimes a yeast, trichomonal, or bacterial infection will result in inflammation being present in the cells taken on a Pap smear. Inflammation is also sometimes associated with thinned cervical and vaginal tissue (called
atrophy
) that occurs after pregnancy, after menopause, or during other times of low estrogen. Inflamed cells on a Pap smear are almost never a cause for alarm. Just get your Pap smear repeated after getting the infection or atrophic tissue treated. In many cases, the inflammation simply clears up by itself without treatment, especially if you improve your diet and lifestyle when necessary.

A Pap smear category that is often very confusing for practitioners and patients alike is known as ASCUS (atypical squamous cells of undetermined significance), present in 10 percent of Pap smears. Most of the time when the Pap smear comes back with this designation, it means that the cells of the cervix are atypical-looking because of some kind of reaction—healing, inflammation, atrophy, and so on. In 75 percent of cases of ASCUS, no actual cervical disease is present. This is when an HPV DNA test is helpful. If it’s negative, the cellular abnormality is pretty much guaranteed not to be because of precancerous changes. If it’s positive, current guidelines recommend getting a colposcopy and having a biopsy done on any areas of abnormality that the test finds; the abnormal tissue can often be removed immediately. I’d also recommend antioxidant supplements.

If you have inflammation present and your practitioner can find a cause, get it treated and then have your Pap repeated. ASCUS associated with atrophic changes in a postmenopausal woman will disappear with topical estrogen treatment or treatment that nourishes and replenishes vaginal mucosa. Remifemin, a standardized extract of black cohosh, has been shown to thicken vaginal tissues after four to six weeks, so this is a good choice for women who need to avoid estrogen. Estriol is another good choice. (See
chapter 14
.)

Sometimes ASCUS Pap smears are associated with what is called LGSIL (low-grade squamous intraepithelial lesion). When LGSIL is suspected, you’ll want to be sure to get close follow-up, with repeat Pap smears and HPV DNA testing every four to six months until your results come back normal. Statistics have shown that up to 50 percent of these abnormalities go away on their own—which is very good news. In some cases, your health care practitioner may recommend (or you may prefer) further investigation of your cervix through a colposcopy.

inally, if your Pap comes back as HGSIL (high-grade squamous intraepithelial lesion), your health care provider will schedule a col poscopy and directed biopsies of your cervix and possibly even a LEEP (loop electro-surgical excision procedure) to be absolutely certain about the extent of your abnormality. LEEP removes abnormal tissue from the cervix for diagnostic and treatment purposes while preserving normal cervical function. It can be done in the office and often can be used instead of surgical cone biopsy, a treatment for precancerous changes in the cervix that must be done in the operating room under anesthesia. Be aware, though, that, as explained above, there are some risks with LEEP because it can weaken the cervix and increase the chances of having a subsequent premature birth.

Whether or not you have LEEP, I recommend that you follow the Master Program for Optimal Hormonal Balance and Pelvic Health outlined in chapter 5, with additional high doses of folic acid to support your immune system (see below).

Other Technologies for Testing Cervical Cells

Once a woman has two abnormal Pap smears in a row, it’s generally recommended that she have an HPV DNA test as well. The HPV DNA test (which is now routine in many places) lets her know if she has one of the higher-risk subtypes of HPV. The next step is to further delineate the extent of the problem by a test known as colposcopy. In this test, the doctor observes the cervix through a magnifying lens to check the blood vessels and tissue patterns, taking biopsies from areas that appear abnormal, and sending them to the lab. Special attention is paid to the SCJ, making sure that this entire region is seen. Sometimes the abnormal cervical cells extend up into the endocervix, where they cannot be seen or tested. In these cases, a cone biopsy (a biopsy of the internal cervix in the shape of a cone) or LEEP procedure (see page 272) is recommended to further test the tissue in the endo cervix. This procedure is not only diagnostic but also often curative. Local anesthetic is available that can be sprayed on the cervix (or vagina) before the biopsies are taken, making this procedure virtually painless. Ask your doctor about it.

Common Concerns About Cervical Dysplasia

How Did I Get It?

No one knows precisely why one woman develops cervical dysplasia and another doesn’t. Like HPV, cervical dysplasia is related to the functioning of the immune system. In one study, women who were on immunosuppressive drugs for kidney transplants had a seven-times-greater chance of an abnormal Pap smear than did a control group of nonimmuno-suppressed patients. Smoking is a definite risk factor for cervical abnormalities leading to cervical cancer. Women with cervical abnormalities have been found to have lower levels of an tioxidants and folic acid in their blood. There is a known link between birth control pills and certain kinds of cervical dysplasias.
⁴⁸
This may be in part because the pill decreases blood levels of nutrients such as the B vitamins.

Can Smoking Affect My Risk for Cervical Dysplasia?

Many studies have documented the link between smoking and cervical dysplasia. Cotinine, a toxic by-product of tobacco, has been found in the cervical mucus of cigarette smokers. If you smoke, your mucosal immunity will be adversely affected in the cervical and vaginal areas.

Treatment

Women need to know that up to 50 percent of mild cervical abnormalities return to normal without treatment. A smaller percentage of the more severe abnormalities also regress. Follow-up Pap smears can help determine whether or not you need treatment.

When dysplasias don’t regress on their own, the treatment goal is to eradicate all the abnormal tissue. Standard gynecological medicine has excellent tools to treat both cervical dysplasia and early cervical cancer. The cure rate by standard methods is over 90 percent. Everyone who has an abnormal Pap should follow the nutritional recommenda tions in chapter 17 and in the Master Program for Optimal Hormonal Balance and Pelvic Health in chapter 5.

Methods to destroy abnormal cervical tissue include laser, cryocautery, trichloroacetic acid, and LEEP. LEEP is used to diagnose and treat some cases of SIL that in the past required cone biopsy under anesthesia in the hospital. Some practitioners use laser in the same way. The cervix heals well after a LEEP procedure, but it does increase the risk for subsequent prematurity in pregnancy.

Regular follow-up with a Pap smear every three months for one year, and every six months thereafter, is necessary to be sure that the abnormality doesn’t return. After several years of normal Pap smears at six-month intervals, many women can be tested yearly. This decision is made on an individual basis. As one of my colleagues says, “No one ever died from close follow-up.” Women who have had moderate to severe cervical dysplasia are likely to get into trouble if the disease progresses, which is why more frequent screening seems appropriate.

Nutritional Approach

Numerous studies have linked low levels of vita mins A and the B vitamins with cervical dysplasia. Oral contraceptives can increase a woman’s chances of having an abnormal Pap smear, though the data supporting this are not well known by gynecologists; the pill lowers B vitamin levels in the blood. In women whose diets are already low in nutrients, the pill can set up a slight deficiency state. High doses of folic acid have been used to reverse cervical dysplasias in women who developed them while on the pill. That’s why every woman who is on the pill (or HRT) needs to take a good multivitamin rich in B vitamins, including folic acid.