Gynecological pelvic exams & Pap tests 101

What you can expect at the gynecologist’s office

Top things to know

  • A pelvic exam is an inspection of your external and internal genital areas, and an assessment of the health of your reproductive system and organs
  • Pap tests are used to screen for cancerous changes on your cervix
  • Routine Pap tests greatly reduce the number of new cases of cervical cancer diagnosed each year and deaths from the disease

What happens during a gynecological exam?

A gynecological pelvic exam is an inspection of your external and internal genital area, and an assessment of the health of your reproductive system and organs. It’s usually performed by your primary healthcare provider (like your family doctor, or nurse practitioner) or by a specialist like a gynecologist.

A pelvic exam usually involves three parts.

1. A visual and physical inspection of the external genitalia (your entire vulva, including your labia, pubic hair, and the opening of your vagina).

2. A speculum exam, when a speculum (a medical tool that is used to gently widen the vagina) is inserted into your vagina to allow your healthcare provider to see and assess the health of your cervix and vagina. Sometimes a sample may be taken in and around your vagina and cervix and to check the acidity of your vagina, and assessed for the presence of infections or changes in your cervical cells.

3. A bimanual exam, in which your healthcare provider inserts two fingers into your vagina and places their other hand on your abdomen to assess the size and mobility of your uterus and ovaries. This may sound daunting at first, but shouldn’t be painful.

Sometimes additional information is required, and your healthcare provider may also order blood tests or ultrasounds.

What is a Pap test?

A Papanicolaou test/smear (Pap test) is one of the tests performed during a pelvic exam, during the speculum portion (step 2). It is used to screen for cervical cancer and precancerous changes.

To get the most accurate results, you should not be menstruating and should have avoided sexual intercourse, douches, or vaginal suppositories for 48 hours beforehand (1). This is because these fluids may alter the results of the lab tests. If you’re wondering whether you should reschedule your exam, call your healthcare provider before the appointment.

During the speculum portion of the exam, a very small spatula, brush, or broom is partially inserted into the opening of your cervix and rotated. This should not be painful, but some people may feel some discomfort. By rotating the brush, a small sample of cervical cells is removed. Then the brush is withdrawn, and is either smeared along a glass slide, or the top of the brush is removed and stored in a small liquid-filled container. The sample (slide or liquid) is then sent off to a lab. In the lab, cytology (an inspection of the cells) will be performed to see if there are any abnormal cells, which could indicate precancerous or cancerous changes.

HPV and the link to cervical cancer

It’s common for an HPV (human papillomavirus) test to be done at the same time as a Pap test. An HPV test uses the same sample of cells from the Pap test, and tests for the presence of HPV in the sample.

HPV is a very common virus that is often transmitted during sexual intercourse. Most people who are sexually active are infected at least once in their lifetime (2). The majority of HPV infections clear up within 2 years, and do not cause any diseases or symptoms (2,3).

There are over 100 strands of HPV. Two strands in particular, HPV 16 and HPV 18, are responsible for 7 in 10 cases of cervical cancers and precancerous changes (4,5). These strands of HPV have also been associated with cancers of the anogenital region and oropharynx (throat tissue) cancers (4,5). Other strands, such as HPV 6 and HPV 11, are responsible for genital warts (2).

There are available vaccines that specifically target these cancer-causing strains of HPV.

In developing areas with limited resources, other screening techniques are used, including visual inspections of the cervix with acetic acid (vinegar) or iodine staining (5,6). These techniques provide immediate results at a much lower cost, which can allow for more access and rapid treatment of any cervical pre-cancerous growths (6). However, these visual screening techniques are not as reliable as Pap tests (7). False positives are also common when there is inflammation, irritation, genital warts, or hyperkeratosis present on the cervix (8).

Why are Pap and HPV tests so important?

The invention of the Pap test in the 1940s has had a major public health impact (2). Before the invention of this screening tool, cervical cancer was one of the leading causes of death for women of childbearing age in the United States (2). Since this screening technique became the gold standard, deaths from cervical cancer in the US have decreased by 60% (2).

As of 2012, cervical cancer is the fourth most common cancer in women worldwide (2,5). In developing countries, many people still lack access to Pap test screenings (5). Most deaths from cervical cancer (17 in 20) happen in these countries (2).

Cervical cancer prevention

Avoiding infection of HPV is the best way to prevent cervical cancer. Using a barrier method like condoms is the best way to prevent the transmission of sexually transmitted infections like HPV. If you received the HPV vaccination before you became sexually active, this should also protect you against high-risk strains of HPV, like those that can cause cancer.

HPV infections may be less likely to clear up in a person who smokes cigarettes, has a compromised immune system, or has an HIV infection (2). There is also some evidence suggesting condom use may also help in clearing HPV and regressing precancerous changes, possibly by minimizing re-exposure to HPV during sexual encounters (9).

How often should you get a pelvic exam and Pap test?

The American Congress of Obstetricians and Gynecologists (ACOG) recommends having your first full pelvic exam (including a Pap test) at age 21 (10,11). But this doesn’t mean you should not see a gynecologist or healthcare provider before turning 21. If you are younger than 21 (and especially if you are sexually active), be sure to see your healthcare provider for information about your reproductive health, contraception options, and STI prevention (11).

After turning 21, ACOG recommends that you see your healthcare professional every year for an annual pelvic exam (10). So long as tests come back negative, cervical cancer screening tests should be performed every three years until age 29 (11). From ages 30 to 65, Pap tests and HPV screening should be done every five years (10). Once a person has reached 65 years old and their last three consecutive screenings have been negative, then Paps tests are no longer recommended by ACOG (11).

Perhaps these recommendations will change in the future, as new research shows that people who are over 65 account for 1 in 5 cases of cervical cancer, and a decline in rates of cervical cancer does not happen until age 85 (12,13).

Others countries have different guidelines for how often someone should get a pelvic exam and a Pap smear.

Download Clue to track your pelvic exams with the “Appointment” category and use the calendar to predict the timing of your menstrual period up to 3 months in advance.


References

1. Fiona R. Prabhu FR. Female Genitalia. In: Lynn S. Bickley editor. Bates’ Guide to Physical Examination and History Taking. 10th ed. New York: Lippincott Williams & Wilkins; 2008. p. 381–403.

2. Kitchen FL, Cox CM. Papanicolaou Smear. StatPearls [Internet]. In: NCIB Bookshelf. Treasure Island: StatPearls Publishing; 2017 Nov 25. [cited 03 Jan 2018]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470165/

3. Plummer M, Schiffman M, Castle PE, Maucort-Boulch D, Wheeler CM; ALTS Group. A 2-year prospective study of human papillomavirus persistence among women with a cytological diagnosis of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion. J Infect Dis. 2007 Jun 1;195(11):1582–9.

4. World Health Organization. Human papillomavirus (HPV) and cervical cancer fact sheet. World Health Organization: June 2016 [cited 03 Jan 2018]. Available from: http://www.who.int/mediacentre/factsheets/fs380/en/

5. Stewart BW, Wild CP. World Cancer Report 2014.Lyon: World Health Organization; 2104.

6. Khan M, Sultana SS, Jabeen N, Arain U, Khans S. Visual inspection of cervix with acetic acid: a good alternative to pap smear for cervical cancer screening in resource-limited setting. J Pak Med Assoc. 2015 Feb;65(2):192–5.

7. Longatto-Filho A, Naud P, Derchain SF, Roteli-Martins C, Tatti S, Hammes LS, et al. Performance characteristics of Pap test, VIA, VILI, HR-HPV testing, cervicography, and colposcopy in diagnosis of significant cervical pathology. Virchows Arch. 2012 Jun;460(6):577–85.

8. International Agency for Research on Cancer. A practical manual on visual screening for cervical neoplasia. Lyon, France: IARC; 2003

9. Hogewoning CJ, Bleeker MC, van den Brule AJ, Voorhorst FJ, Snijders PJ, Berkhof J, Westenend PJ, Meijer CJ. Condom use promotes regression of cervical intraepithelial neoplasia and clearance of human papillomavirus: a randomized clinical trial. Int J Cancer. 2003 Dec 10;107(5):811–6.

10. The American congress of obstetricians and gynecologists. Well-Women visit: number 534. ACOG Committee opinion.The American congress of obstetricians and gynecologists. August 2012 (reaffirmed 2016) [cited 03 Jan 2018]. Available from: https://www.acog.org/-/media/Committee-Opinions/Committee-on-Gynecologic-Practice/co534.pdf

11. The American congress of obstetricians and gynecologists. Cervical cancer screening infographics. The American congress of obstetricians and gynecologists February 2016 [cited 03 Jan 2018]. Available from: https://www.acog.org/Patients/FAQs/Cervical-Cancer-Screening-Infographic

12. White MC, Shoemaker ML, Benard VB. Cervical Cancer Screening and Incidence by Age: Unmet Needs Near and After the Stopping Age for Screening. Am J Prev Med. 2017 Sep;53(3):392–395.

13. Elsevier. Women Should Continue Cervical Cancer Screening As They Approach Age 65. Elsevier.com. 01 May 2017 [cited 03 Jan 2018]. Avilable from: https://www.elsevier.com/about/press-releases/research-and-journals/women-should-continue-cervical-cancer-screening-as-they-approach-age-65