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IstockphotoTeens girls can skip Pap tests, according to new guidelines that say women should start cervical cancer screening at age 21. But some experts are concerned that rates of sexually transmitted diseases or unplanned pregnancies could increase without the Pap test to prompt a doctors visit.

As it stands, as many as 1 in 4 U.S. teenage girls has had an STD at some point in her life, often soon after she becomes sexually active, according to research published this week in Pediatrics.

“I am concerned that without the recommendation for young women to get Pap smears early on, they will lose important opportunities to seek advice and to learn about their health—particularly their sexual health—at a time in their lives when they need it most,” says Kimberly Spector, an adolescent health educator in Los Angeles. “Regardless of the tests performed during a gynecologist visit, the conversation regarding sexual health risks and preventative measures can be very informative and empowering for young patients."

In the past, women were told to start Pap tests, which can detect abnormal cells in the cervix, three years after becoming sexually active or at age 21—whichever came first. However, these abnormal cells often go away on their own, particularly in young women. If they dont, such cells grow so slowly that catching them at age 21 is still early enough to remove them before they become cancerous. And catching them sooner could lead to unnecessary tests and treatments that sometimes damage the cervix, increasing the risk for a premature birth later in life.

The new guidelines still recommend that girls who are under 21 see a gynecologist; they just dont need Pap tests, according to the American College of Obstetricians and Gynecologists.

Next Page: Will some teens misinterpret the guidelines? [ pagebreak ]
The fear, however, is that some teens may misinterpret the new rules and miss out on important discussions about contraception and protection against STDs such as gonorrhea, bacterial vaginosis, chlamydia, and human papillomavirus (HPV).

“If women hear that they no longer need Pap tests annually or until they are 21, perhaps they wouldnt seek any preventive health care, and whether this results in decreased screening and identification of chlamydia and other STDs remains to be determined, but it is concerning,” says Harold Wiesenfeld, MD, the director of the division of reproductive infectious diseases at the University of Pittsburgh School of Medicine.

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Many STDs, including chlamydia and gonorrhea, have no symptoms. “Unless screened, young women will remain undiagnosed, untreated, and at risk for complications, including pelvic inflammatory disease, which results in infertility,” says Dr. Wiesenfeld, who is also an associate investigator at Magee-Womens Research Institute, in Pittsburgh. "[Still] the Pap test is not the 100% trigger to do chlamydia screening,” he says. “We need to do a better job about STD screening overall.”

Teens who are sexually active should use contraception and take steps (such as using condoms) to prevent STDs, even if they dont need Pap tests, says Alina Salganicoff, PhD, the vice president and director of womens health policy for the Henry J. Kaiser Family Foundation, an advocacy group based in Menlo Park, Calif.

“We are going to have to pay special attention to how we educate our adolescent patients about contraception and STD prevention,” she says.

However, most experts agree that Pap tests are indeed unnecessary for younger women and that the new guidelines will not put them at risk. Most also agree that the new guidelines are not an effort to limit care.

“I do not fear the consequences because these guidelines are well thought out and give us a great opportunity to focus on who is at risk for cervical cancer,” says Bobbie Gostout, MD, the chair of the department of obstetrics and gynecology at the Mayo Clinic, in Rochester, Minn.

“Cervical cancer screening is very important, but we are getting smarter at screening,” she says. “We are backing off from screening those that have less to gain from it." The cervical guidelines, which recommend that sexually active teens still be counseled and tested for STDs (although a pelvic exam might not be necessary), “hit it right,” she says.

Teens who have received HPV vaccines, such as Gardasil, are protected against several HPV strains that are linked to many, but not all, cervical cancers and to genital warts. These types of vaccines may eventually reduce cervical cancer rates even further (rates have been dropping since the 1970s), although experts say the impact wont be seen for 10 to 15 years. Therefore, girls and women given the HPV shot need to have Pap tests starting at age 21 and every two years after that, just like those who havent had the shot.

Next Page: Experts recommend doctor's visit before sexual activity [ pagebreak ]
The Centers for Disease Control and Prevention, in Atlanta, added Gardasil to its routine childhood vaccine schedule. It recommends that Gardasil, which is administered in three doses, be given to all girls ages 11 and 12, and even for girls as young as 9, with catch-up doses for girls and women ages 13–26 who haven't been vaccinated.

“We know that the HPV types targeted by the new vaccine are linked to cervical cancers that tend to occur five years earlier than cervical cancers caused by other HPV types,” Dr. Gostout says. “So once adolescents are well vaccinated against HPV, we should have even more confidence in eliminating Pap tests in younger women."

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“We are now rolling out the vaccine, and clearly the first group that will experience broader protection is young women,” agrees the Kaiser Family Foundations Salganicoff. “The HPV vaccine is a really important step that young women can take in terms of protecting themselves against HPV and subsequent cervical cancer."

Ideally, teens should have an HPV shot and see a gynecologist for counseling about STDs before they become sexually active, experts say. HPV vaccines dont protect women who have already been infected with the virus.

“Ideally, women need to establish a relationship with a reproductive health provider before they become sexually active,” Dr. Wiesenfeld says.