by Sanaz Majd, MD
A reader recently asked me to write about the female pap exam, and I thought it was a great idea for two reasons:
I often see young women in my office for their first exam, in a state of great fear and anxiety, who perhaps wouldn’t feel that way if they knew what the process really entailed.
I also see women of all ages and backgrounds who still don’t really know what a pap smear is and what they are being tested for.
So I thought I’d devote this entire episode to shedding light on the pap smear exam.
When and How Often Should You Get Your Pap Exams?
Newer national guidelines recommend getting your first pap smear starting at age 21, whether or not you’ve been sexually active. Once you have at least three normal pap smears in a row, most patients can move on to a three-year schedule. We no longer call the pap smear exam “annuals,” because they are no longer done annually for many patients who are low risk.
How to Prepare for the Pap Exam
After performing so many pap exam, here are two Quick and Dirty Tips that I recommend in order to prepare you for your pap exam:
If you had your previous pap done at a different clinic, be prepared to bring in the name and phone number of that clinic. Your doctor may want to have a copy of those records, especially if you’ve had an abnormal pap result before.
If you need refills of any hormonal contraceptives, bring them to your visit as well. Very often I get a new patient who comes in requesting a refill of a birth control pill she was prescribed by another provider. But she is unable to remember the name of the medication! Bringing your pills with you will help prevent delays in getting your refills.
The History: What Your Doctor Will Ask You During Your Pap Visit
Whether you are there for a headache, high blood pressure follow-up, or your pap smear exam, every doctor will start the visit with what we refer to as the patient’s “history.” Most doctors will ask a combination of the following questions, either directly or via a form you’ll have to fill out. So have the following information at hand:
How many times have you been pregnant, and how many children did you deliver?
Are you married or single?
How many sexual partners do you currently have, or have had in your lifetime?
What type of birth control (if any) do you currently use?
Have you ever had an abnormal pap result, what did it show, and when? Did you have any treatments for your previously abnormal pap smear?
Have you ever been tested for sexually transmitted infections (STI’s), and have you ever been diagnosed and/or treated for an STI?
Are your periods regular? When was the first day of your last cycle?
Is there any family history of breast, ovarian, or uterine cancer? If so, who in your family and at what age were they diagnosed?
If you are interested in birth control, and/or getting tested for STI’s, please make sure you bring this up to your doctor during your visit, preferably in the very beginning.
After the history part of the pap visit is the actual exam. The nurse who first takes your vital signs and places you in the exam room will likely give you a gown and tell you to undress from head to toe – that means everything, including undergarments. You can then think of the gynecologic female exam in three parts:
Part 1: The Breast Exam
Your doctor will have you lie flat on the exam table and place your arm above your head in order to stretch the breast tissue; this will make it easier to feel lumps and bumps.
If you don’t know how to do self-breast exams, this is a good time to ask your doctor to show you how to do them on your own once a month.
Part 2: The Pap Smear
You will be asked to bend your knees, place your feet on the stirrups (the loops hanging off the edge of each side of the exam table), and slide all the way down the table edge. I always joke with my patients that when you feel like you are about to fall off the edge, that’s the right spot to be in! I also recommend wearing socks so that your feet are protected from the stirrups.
Your doctor will then slowly insert what is called a “speculum” into the vagina. This is a disposable plastic or sterilized metal device that is used to “open up” the normally collapsed vagina walls so that we can find and take an unobstructed view of the cervix, the nodular structure that is the opening to the deeper uterus that sits at the end of the vagina.
The cervix has a very small opening in the center of it, called an “os,” that can carry abnormal cells that lead to cervical cancer. Your doctor will then scrape some cells off the cervical os with a couple of small instruments—one is a typically a wooden stick with a smooth surface, and the other is a very small plastic stick with a soft brush at the end. These instruments are then either placed on a slide or in a special container with liquid in it, and sent to the lab to be examined under a microscope. This scraping of the cervical os is the part of the exam that is referred to as the “pap smear.”
The doctor may also use an extra swab to test for HPV (the Human Papilloma Virus) in conjunction with your pap smear swabs. To learn more about HPV, check out my podcast on this topic. If you are under the age of 26, most doctors automatically swab you for gonorrhea and Chlamydia, two of the most common STI’s.
Part 3: The Pelvic Exam
Your doctor will close and remove the speculum and next perform the “pelvic exam,” where two fingers are inserted into the vaginal opening. Your doctor will be feeling for any nodule, mass, or abnormalities around your ovaries and cervix that can’t always be viewed but can be felt on exam.
Is the Pap Smear Exam Painful?
If you’ve never had a pap smear before, you are likely worried about it and wondering if it’s painful. Most women say that even though it may be uncomfortable, it is not painful. If you are small-framed, ask your doctor to use the smallest sized speculum available. She will also place lots of jelly surrounding the speculum, which will help it glide through. You may have a little bit of pressure, but I cannot remember the last time I had a woman complain of severe pain during this exam. Also, the exam takes only a few minutes, so your time of any discomfort is minimal.
And a for the “embarrassment factor,” all you have to remember is that your doctor does this exam over and over, all day every day. For doctors, this is our job, and we see it as physiological and medical. There is no reason you should ever feel embarrassed – we certainly don’t.
Just be honest with your doctor, and voice your concerns and questions about the exam, so that they can reassure you and take extra precautions to make you feel comfortable.
Hopefully, I’ve eased your fears and given you enough information to make your next (or first) pap exam less stressful.
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Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.