DEAR DOCTOR K: I'm 48 years old. Twenty-six years ago, I had a cone biopsy after an abnormal Pap test. Since then, all my Pap tests have been normal. But recently my doctor says that scar tissue from my biopsy has made it difficult to get adequate cells. What do I do about Pap smears now?
DEAR READER: A Pap test is done to catch a cancer of the cervix that is just beginning to start -- and can be cured before it causes damage. Every type of cancer begins with a single cell. The cell starts to multiply uncontrollably. As it starts to do that, the cell changes its shape. Under the microscope, you can tell the precancerous and cancerous cells.
In a Pap test, the doctor scrapes cells from the surface of the uterus. Then the cells are examined under the microscope. A report of "inadequate cells" can mean a couple of things. One possibility is that there weren't enough total cells in the sample to interpret the Pap. Or it could mean that the sample does not have enough of the cells that line the channel leading to the inside of the uterus. These are called endocervical cells. Many doctors believe that a sample without enough endocervical cells is not as accurate: The Pap test could appear "normal" even in a woman with cancer.
A cone biopsy, like you had, can cause scarring of the endocervical canal. This can make it difficult to obtain endocervical cells for testing. The hormonal changes that occur with entering menopause also can reduce the number of endocervical cells. You are 48, an age at which many women begin to enter menopause.
If you were my patient, and your report said you did not have enough total cells, I would simply repeat the test in a few months. On the other hand, if your report said you didn't have enough endocervical cells, specifically, I would take extra steps to get an adequate sample.
As a first step, I might prescribe vaginal estrogen. This would help make your endocervical cells more available. Your Pap test would be repeated in a few months. If this failed, your cervix could be dilated to retrieve the cells. But this is uncomfortable and may be unnecessary if your cervical cancer risk is low.
These days, when doctors take samples for a Pap smear, we also often do tests for a virus that is now recognized to be a cause of cervical cancer -- human papilloma virus (HPV). People who have certain strains of HPV are at higher risk for getting cervical cancer. A Pap test can identify HPV even if the number of endocervical cells retrieved is inadequate.
I'd recommend that your clinician check for HPV. If the test is negative and you don't have other risk factors for cervical cancer, you can have routine Pap tests. As long as the cells aren't atypical, you don't need to worry about inadequate endocervical cells.
(Dr. Komaroff is a physician and professor at Harvard Medical School. Go to his website to send questions and get additional information: www.AskDoctorK.com.)