Most women have been there: Lying faceup on an exam table wearing a paper or cloth gown that makes a Snuggie seem flattering, feet positioned awkwardly in metal stirrups, butt scooted down to the very end of the table with a man or woman (sometimes two) who’s basically a stranger staring right at your vagina.
Ah, the Pap smear. Super important, yes, but insanely uncomfortable (not so much physically but certainly emotionally). And confusing. In 2012 the American College of Obstetrics and Gynecology (ACOG) and the U.S. Preventative Services Task Force (USPSTF) announced that women ages 21 to 29 who haven't had a prior abnormal Pap test should get one every three years, but not all doctors immediately adapted to the change, leaving patients confused about whether they still needed an annual test or if it was safe to skip the screening.
By now most gynecologists agree that once every three years is adequate (for women with normal results), and the American College of Physicians released a paper at the end of April 2015 with their guidelines, which basically parallel those from ACOG. But these are just recommendations: Every woman needs to do what is right for her body, so take the time to familiarize yourself with the Pap smear and other down-there tests so you can make the best decisions (with your doc’s input, of course).
The Pleasure of a Pap
Some of the best lifesaving practices (think Heimlich maneuver, colonoscopy, Pap) are also some of the most incredibly awkward ones. Before the Pap smear (or test, as some call it) was adopted as a standard screening test in women’s health in the 1950s, cervical cancer was the top cause of cancer death in women. But today’s rates are way lower, with deaths decreasing by more than 50 percent in the last three decades. Credit the screening, which catches abnormal cellular changes (called “dysplastic changes” in doc speak) before they become full-blown cancer, allowing doctors to stop the disease before it ever has a chance to start.
Your experience at the gynecologist is pretty much what your mother and grandmother went through, as the procedure hasn’t changed much in the last half century: After disrobing from at least the waist down (and waiting patiently with a big paper sheet over your bottom half as if this were normal), you’ll lay back on the exam table and place your feet in the stirrups at the end (spread ‘em!) and, if necessary, move down toward that end of the table.
Your doctor will insert a duckbill-shaped speculum into your vagina and prop it open (that’s the clicking noise and possibly uncomfortable pressure) to allow visual and physical access your cervix. (Note that speculums are not one-size-fits-all since vaginas come in all shapes and sizes. Your healthcare provider will select the right speculum for you.) They’ll use a small brush and spatula to collect cells from the cervix; you will feel some scraping down there for a few seconds, but it doesn’t hurt. The entire procedure from start to finish typically lasts no more than a few minutes. Afterward you may experience light spotting, so pack a panty liner in your purse.
Your doctor will let you know when to expect your results. Now, here’s the key thing: An abnormal result is usually not a diagnosis of cancer or even a present HPV infection. It means there was something unusual about the cervical cells, and your gynecologist will discuss having you come in for further testing to figure out what’s going on, which could be represent early positive changes caused by prior HPV that, based on your age, will generally return to normal on their own; changes caused by certain HPV types that can develop into cancer (and can be removed before that happens); or—in rare cases—it could be cancer. (Remember, that is in rare cases.)
When to Get a Pap Smear
Once you turn 21, you can legally drink, gamble in Vegas, and start getting Paps. (If that’s not a party, we don’t know what is.) Since invasive cervical cancer is rare in women younger than 21, even if you are sexually active before that age, you don’t need a Pap, according to ACOG. For average-risk women ages 21 to 29 with no history of abnormal Pap smears, it’s recommended to get the test every three years. From ages 30 to 65, you should either get a Pap every three years or have both a Pap and an HPV test (a.k.a. co-screening) every five years, per the guidelines. More frequent testing may lead to anxiety about both getting the exam and the need for follow up testing, which may prove unnecessary. And ain’t nobody got time for that.
For average-risk women ages 21 to 29 with no history of abnormal Pap smears, it’s recommended to get the test every three years.
But there are things the guidelines don’t tell you: “Anyone who is immuno-suppressed; has had an abnormal (positive) Pap smear, biopsy, or treatment for cervical dysplasia in the past three years; or has had a positive HPV test may require more frequent testing,” says Rebecca Jessel, M.D., a gynecologist in Denver. So—you guessed it—talk to your doctor if you're unsure.
When you go to schedule your appointment, ideally the test should not be done during your period, but there is no need to cancel your appointment if the two coincide. Many offices recommend that you avoid intercourse and douching for two days prior to having a Pap smear, and if you are using any vaginal medications, check with your doctor whether you should stop them prior to the exam.
The Other Tests You Need
Pap or not, sexually active women should be tested regularly for sexually transmitted infections (STIs) since most don’t cause symptoms, so you could have an STI without realizing it. How often you need to be tested depends on your lifestyle: People with a high number of partners or those who don’t use condoms may want to be tested more often than those in long-term relationships. No matter what, if you have any unusual changes or symptoms, see your doc stat.
If you want to have an IUD inserted, you'll need a pelvic exam, and if you need a prescription for hormonal birth control of any kind, you may also need a pelvic exam, although even this recommendation has recently changed. But if you are symptom-free, you may not require this part of the visit, during which your gynecologist evaluates the health of your ovaries, cervix, vagina, and uterus through external and internal examinations.
The American College of Physicians says that the exams are costly to our health care system, don't reduce diagnoses of diseases or death in asymptomatic women, and may lead to anxiety, embarrassment, pain, unnecessary surgery, and other side effects that could cause women to forgo seeking medical care. So if you don't have any symptoms such as pelvic pain, vaginal discharge, or irregular or heavy periods, they say you may not need a pelvic exam.
ACOG agrees: They recommend that asymptomatic patients work with their doctors to figure out their best exam schedule. But if you do have symptoms, ACOG suggests having a pelvic exam is important.
Lastly, don't neglect physicals with your general practitioner each year, as a visit to the gynecologist does not replace that.
Caroline Weinberg, M.D., contributed to this article.