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14. HPV and “Pap Smears” with Dr. Kimberly S. Gecsi
100 Plays10 months ago
HPV, or Human Papillomavirus, is a group of more than 200 related viruses. Some types of HPV can cause health problems like genital warts and cancers, while others do not cause any symptoms and go away on their own. Dr. Kimberly S. Gecsi joins me in this episode to discuss key points about HPV including; Transmission, Types of HPV, Symptoms, Prevention, Testing and Treatment.
Kimberly S. Gecsi, MD is Chief Medical Officer, Froedtert & MCW Specialty Practice and Professor and Vice Chair of Clinical Operations in the Department of Obstetrics and Gynecology. Clinically she focuses on minimally invasive gynecologic surgery and lower genital tract disease. She has worked on national guideline development for the CDC, ACOG and ASCCP. She is active nationally in several organizations including being a member of the SASGOG Board of Directors, an ABOG board examiner, and on the GYN clinical consensus committee for ACOG. Her current research is focused on improving screening and resources for victims of intimate partner violence.
Featured in this episode:
- How common is HPV?
- Difference between HPV screening and pap smear
- Is the HPV vaccine effective?
- Alternative HPV and papsmear screening
- Do women over the age of 65 still need screenings?
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Looking for practical advice for women in their 60’s who want to become sexually active or want to improve their current sex life? Check out Sex in Your Sixties: Who says the fun has to stop? Written by a multidisciplinary group of health professionals who address issues such as pain with sex, low desire for sex, orgasm difficulties, your bladder and sex, same sex partners, vulvar skin conditions, trauma and more.
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Transcript
Introduction of Dr. Kimberly Gaetzee
00:00:00
Speaker
Hello and welcome back to Arwell Manatee. I am so excited to introduce to you all Dr. Kimberly Gaetzee. She is a chief medical officer sir at Frater and Medical College of Wisconsin specialty practice. She's professor and vice chair of clinical operations in the department of OB-GYN. She is a gynecologist. She clinically focuses on minimally invasive gynecological surgery. she's a bad as in the o I can tell you about personal witnessing of that, and lower genital tract disease. She's worked on national guideline development for the CDC, ACOG, and ASCCP, and she's active nationally in several organizations, including being a member of SASGOG Board of Directors,
00:00:41
Speaker
an ABOG board examiner, and on the GYN Clinical Consensus Committee for ACOG. Her current research is focused on improving screening and resources for victims of intimate partner violence. So excited to have here Dr. Gacy. Welcome. Thank you so much, Rachel. That was so nice of you to give you that wonderful intro. Oh my gosh, of course.
00:01:02
Speaker
for inviting me. This is so fun. I've been looking forward to it all week. Oh, wonderful. I'm so glad.
Importance of Pap Smears and Guidelines
00:01:07
Speaker
So Dr. Gatesy, if it's okay if I call you cum, is the person that I think of if I do a Pap smear and I have a tricky result, or I'm trying to figure out, you know, what's the next step? Because as you heard, you know, she's been part of actually helping to figure out these guidelines for the whole country and the guidelines have changed. And She taught me not only how to follow up that, but also to do coposcopy. So she's my go-to woman for all things HPV and pap smears. And so trusted expert here, I wanted to start off by asking her, can she explain, you know, what is a pap smear? Just start from the very basics. What is a pap smear and why i do women need pap smears or paps?
00:01:45
Speaker
Yeah, so cervical cancer screening is what we're talking about. And that is the test that we use in order to determine a person's current and also future risk for cervix cancer. Traditionally, way back in the 1960s, they developed the Pap smear.
00:02:05
Speaker
And the pap smear was taking some cells off of the cervix, putting them on a slide, and then looking at them under the microscope to see if you can see certain cells that look abnormal. And as we've progressed in our knowledge of both cervical cancer, and cervical cancer pre-disease. We've learned a lot of things. Number one, we've learned that there are better ways to do that test, which is looking at the cells in the microscope. And so nowadays, most people in the United States get a Pap test, not a Pap smear. A smear is when you take the cells and directly put them on the slide, the test.
00:02:44
Speaker
that we do now is we actually put them in a little jar of solution that then gets spun down and the cells come out in a nice thin layer on the slide. And so those cytology tests are still done today and are good at identifying cervix cancer or cervix precancer so that we can identify it actually before it becomes cancer, which is really the goal of our screening.
HPV and Cervical Cancer
00:03:05
Speaker
Also learned that HPV is the cause of cervix cancer and the vast majority of cases, over 99% of cases are HPV caused cervix cancer. And so we've developed tests that actually can detect if HPV is present long before it ever becomes pre-cancer and even longer before it ever becomes cancer. And so much of the technology today is actually aimed at doing HPV tests and using those tests to help us determine people's risks currently
00:03:42
Speaker
but then like I said, also in the future. Okay. So when people are coming in to see the gynecologist, first of all, we start this at age 21.
Screening Guidelines and Evolving Practices
00:03:50
Speaker
If anyone is telling you that to do a Pap test earlier than that, run away. Doesn't matter when you started having sex, right? That's a common misconception that I hear women tell me about all the time. The age 21 is when we start, but how often should they be having this test? Because I have women who come to see me in their 60s and they say, I always get a Pap every year. You need to do my Pap every year too. And then I have women in their mid to late 20s who say, do I really need that again? What is the general guideline at this point?
00:04:22
Speaker
Yeah, this is an active area of current change. We have two main agencies that tell us how often and what type of tests we should be doing on women and for how long, for how many years and during what ages.
00:04:38
Speaker
And so the American Cancer Society, they actually recommend not starting until 25 and then only using that HPV test. Yeah. So they recommend starting at age 25 and HPV test every five years until age 65. So that's really actually an easy screening paradigm. The US Preventative Services Task Force recommends doing the cytology. So the PAP test between age 21 and 29.
00:05:07
Speaker
and then switching to an HPV test every five years between 30 and 65. Now those guidelines are getting updated this summer. So there might be big changes coming this summer as to when we start to screen, how often we screen, which tests to use.
00:05:24
Speaker
My suspicion is they'll be moving more towards the American Cancer Society guidelines, but I don't know that for sure yet. Okay. Well, even in my time from medical school to practice, the guidelines have changed. Can you tell our listeners, like why did things start to change? Why are they constantly changing? Why are we still trying to figure out with cervical cancer? So I think what we're, you know, whenever you think about screening, you want to waive the risks of screening with the benefits of screening. So obviously the benefits of screening are to pick up disease.
00:05:58
Speaker
before it becomes cancer in the case of cervical cancer screening. We're not looking for cancer, we're actually looking for pre-cancer so that we can treat that so it doesn't become cancer. So the harms of screening would be doing extra procedures and extra tests that are not necessary. You know, if your risk is going to be the same whether we do the test or not, then doing the test isn't adding anything but extra Discomfort or potentially extra cost or extra testing and be painful and uncomfortable if there's no purpose to it then it's a waste I think the other risk with cervix cancer screening is
00:06:36
Speaker
there's a lot of anxiety around it. You know, if you get an abnormal test or if you're told you have HPV, there's lots of questions and concerns that that raises. And is that extra added worry and anxiety adding to any benefit? In a lot of instances it's not.
Advancements in HPV Testing
00:06:52
Speaker
And so when we weigh all of those things and look at the, you know, decades worth of data we have,
00:06:59
Speaker
We know that there are certain tests that are better than than other tests. So big hint here, HPV test is way more sensitive. So it's a better test than cytology. You're much more likely to pick up disease. So a negative test that's an HPV test is way more predictive than a pap smear. A pap test, we used to do it every year or every three years. So really a negative HPV test is just as good.
00:07:26
Speaker
as a negative Pap test after one year, it's just as good for five years. that's so name So that's what I meant by we're not only looking at your risk now, but also in the future because we can sort of predict if you've been HPV negative all along, that is doubly and extra protective for you as you get further and further down the road. So that's a lot of the reason why these guidelines are changing is because we're trying to pick up as much disease as we can. So get the most sensitive and best tests.
00:07:56
Speaker
but also not doing a lot of extra stuff that people don't need and potentially can be harmful or painful. Okay, that makes sense. Thank you. Can you speak to a little bit more about HPV itself? And if a person has HPV, do they always have HPV? Can we dive into that a little bit?
00:08:15
Speaker
and where do they get it? Where does it come from? Yeah, so HPV or human papillomavirus is a very, very common virus. And there's over 100 different subtypes of the human papillomavirus. And some of the subtypes affect different areas of our body. So some you know are are on our skin, some are on in our oropharynx, some are in our genital tract, and some of them can cause cancer in these different areas. So there are HPVs that are considered high risk, the ones that are high risk for cancer, and we know there's 14 of the subtypes that are high risk for cancer. And
00:08:58
Speaker
you know really that was first identified in cervix cancer. We now know that those high-risk subtypes can cause oropharynx cancer, they can cause anal cancer, vaginal cancer, and about half of our vulvar cancers. So there's been a lot of learning about HPV subtypes.
00:09:18
Speaker
you know, any kind of contact, anytime you have contact with another human,
Understanding HPV and Its Prevalence
00:09:22
Speaker
we're trading back our HPV's back and forth all the time. And so there's a lot we still don't know about whether our immune system completely clears that virus subtype and it never comes back or if we just keeps it under control long enough that it's dormant and not doing anything.
00:09:41
Speaker
We also don't know a lot about getting infected with different subtypes at different times because just because you were HPV positive say when you were 25 with one particular subtype at 30 you might be positive with yet another subtype and at 50 yet still another subtype. Hard to know. We do know that the younger we are and as you start to become sexually active you're going to get exposed to a lot of HPV subtypes. And that's okay. We know that. That's something that happens when we have contact with other humans. Our immune systems are designed to fight those off. And so we we really want to make sure our immune systems do what they're supposed to do, fight off those subtypes. And so we don't worry so much about transient infections. We worry about ones that carry on for
00:10:31
Speaker
years and years and years because those are the ones that are more likely to be associated with cervix pre-cancer and cancer. Okay, I usually tell my patients that if you've had sex with two people or more than you've got HPV. Like that's just most likely the statistics, but definitely not really great statistics about there was some really excellent studies in the early 2000s that looked at virginal college students.
00:11:01
Speaker
And they followed them and they said, okay, we're going to start testing you for HPV as soon as you become sexually active. And we're going to test you every four months for five years to see how long it takes you to become positive for HPV.
00:11:18
Speaker
And it happens pretty quick. By 12 months, about 40% of these previously original college students were now positive for HPV. Within three years, over 50% of them were positive for HPV. So it's very common if you're sexually active, you're gonna be exposed to HPV. But we all have immune systems and let them do their job. Right, it's like the common cold, or at the common cold of the cervix and vagina. maybe
00:11:49
Speaker
okay a back Okay. So let's talk about the screening because I was mentioning this to you earlier that a lot of patients will come to me and they say, Oh yeah, I had a
Pap Test vs. Pelvic Exam
00:12:00
Speaker
Pap test done last year. And then I realized, no, they had a pelvic exam. You know, someone used a speculum to look inside the vagina and look at the cervix, but what is, you know, the exam and the testing for a Pap smear? How does a person know that that's what they are having a Pap test and not just a speculum exam?
00:12:15
Speaker
Well, I think the easiest way to know is if your provider tells you that. that's what So, you know, whenever you're going in for a routine evaluation, so say it's with your PCP or, you know, your woman's health provider, maybe that is your your primary care provider, maybe it's a nurse practitioner, maybe it's at a Planned Parenthood or other federally qualified health center.
00:12:42
Speaker
or with your OB-GYN. If you're going in and you're not having any symptoms at all of any problems, you may even need a pelvic exam. And so I think if they say, oh, I need to do an exam today, a great question is, okay, why? Why are we doing this exam today? you know well and And they may say, oh, well, you're due for your cervix cancer screening or your Pap test or your HPV test, whatever it is that they're doing.
00:13:10
Speaker
or you're due for STD screening or you know you answered positive to this question about what's going on with your pain or your menstrual cycles or whatever and I want to explore that okay great now I know why I'm having this exam if they say well I just always do an exam Well, maybe you don't need it. Number one, and most likely that means that they're not going to be doing any cervix cancer screening at that time. I also think it's really important at the patients to know, okay, when was my last cervix cancer screening? My last cervix cancer screening was in 2022 and I had an HPV test. So that means I'm due in five years for my next
Self-Testing and Screening Accessibility
00:13:50
Speaker
cervix cancer screening. So it's
00:13:51
Speaker
having some kind of knowledge and agency and knowing when your screening was and when your next due for screening, I think is really important for patients to take that empowerment over their health. I totally agree. And for anybody who might feel a little bit shy or nervous about asking your medical provider the question, why a phrase that I love to use and now everybody's going to know that I use this phrase. Help me understand follow up Right? Like I understand why we're doing this today because it's a very nice way to ask. Not confrontational. Literally help you understand why why this is happening. mean Not challenging or anything. You know, it's not going to put your provider on edge or think you're a difficult patient or you know. your body or
00:14:35
Speaker
to know what's being done to you and why. Exactly. No, that's very helpful. So tell me more about self-testing. This is an area that I don't really know much about at all and I think is a really cool move and a good direction. This is probably the most exciting thing I think that has happened with cervix cancer screening in forever. You know, we know that the vast majority of patients that get cervix cancer So over 50% of patients that get cervix cancer have either never been screened or have been inadequately screened. So meaning they've been too long between screenings or they are well behind in either their follow-up of their screening or whatever. So there are lots of reasons why patients haven't been screened or have been inadequately screened.
00:15:30
Speaker
Some of them have to do with they don't have easy access to a physician in order to do those screenings. Maybe they have a, you know, physician that says, Oh, well, I don't do public exams. I don't do pap smears. You have to go see somebody else and patients know they don't have the time or the resources in order to do that. There's a lot of patients out there that are unfortunately victims of sexual trauma and and for a public exam is in incredibly difficult. Some patients really just have a lot of anxiety or pain or fear with exams. And so they avoid these and many of these patients, you know, they will say, I know I'm supposed to be getting this, but I just can't do this. And so I think what this self testing really gives us an opportunity to give patients another way to get screening.
00:16:26
Speaker
and to meet these screening needs without having to see a provider, without having to have an exam, and also can be done in a wider array of places. The FDA just approved a self-test, and the self-test that they approved has to be given in a healthcare care environment.
00:16:46
Speaker
So what does that mean? It could mean a doctor's office, for sure. It could mean a pharmacy. It could mean a lab. So just like I would order blood work for you, I could order this HPV test. do You show up at the lab, they give you the kit.
00:17:02
Speaker
It has the instructions. Oh, the CDS Modern Clinic is going to be all over this. hey Exactly. And so this really gives you the opportunity to participate in screening without necessarily needing to have a pelvic exam. Now, that comes with the caveat that if the test is abnormal, you might need additional testing from there. But i that's a different conversation for a lot of patients. Right.
00:17:29
Speaker
Oh, that's very exciting. Okay. I like to see what happens. ends And, you know, just to kind of bounce off of that, we assume, I mean, depending on how things turn out, if the HPV test is positive or negative, then that will determine the next test. But if a person has had all negative PAPs, then, and negative HPV specifically, then by age 65,
Screening Exceptions for Older Women
00:17:52
Speaker
they're done, right? Do you think that's going to change? Or is that are still there? Oh, I still think that's going to continue as our recommendation. So I think there's a couple caveats with that. I think there's a lot of, you know, misunderstanding about stopping at age 65. And when is it okay to stop? It is not just a blank, Oh, I'm 65. I never need to be screened again. There's a couple important caveats.
00:18:18
Speaker
caveat number one is that person needs to have had regular screening at least over the last 10 years. So if they haven't been regularly screened, then guess what? You can't stop at 65. That regular screening needs to be negative.
00:18:35
Speaker
so If you've had three negative just Pap tests or two negative HPV tests, you're good. Okay. If you haven't had negative tests, even if you've had screening, but it hasn't been negative, you can't stop. Third caveat is you need to have not had either cancer or high grade abnormalities on your Pap smear that required treatments.
00:18:59
Speaker
at any time in the last 25 years. So if you've had, you know, some treatments, so you had high grade dysplasia, they did a procedure called the leap on you 10 years ago. Guess what? You got 15 more years of screening after age 65. That has to be negative in order for you to be able to discontinue. Okay. That makes sense. It's all about risk calculation.
00:19:23
Speaker
It's all about risk calculation. But then for the people, you know, my sweet patients at age 65 who are saying, well, don't you care about me getting cervical cancer anymore? am i Is my life over now at 65? Or if I have a new sexual partner, you know, how do you explain that to them? ah So the key there is the past history. So if you've been regularly screened and we have these negative HPV tests, you are at an incredibly low risk for cervix cancer.
00:19:52
Speaker
And so any screening we do after that point in time, because our probability of having cervix cancer is so low, We're only adding testing and it's only causing risks, not any benefits. So there's no benefit of testing after that age because you've demonstrated that you are this low risk person that's unlikely to get cervix cancer. I love your question of, oh, but what if I, you know, I'm now sexually active again and I'm worried that no I'm going to get new HPVs. Yes, you might get new HPVs.
00:20:25
Speaker
Absolutely. But what we know about the pathophysiology of cervix cancer, so meaning what happens with cervix cancer and how HPV causes cervix cancer, is that if you get HPV today, you're not going to get cervix cancer for 30 years.
00:20:42
Speaker
So, you know, at 95, you'll have the survey answers and the risk is so minuscule that you might already be, have been exposed to that HPV and already cleared it and already have antibodies. So the risks still remain so super low that it doesn't make sense to restart screening. Yeah.
00:21:01
Speaker
Okay, thank you. The other way to reduce your risks through HPV vaccination. Let's talk about that.
Benefits and Advocacy for HPV Vaccination
00:21:09
Speaker
Vaccination. yeah well What age, what gender?
00:21:12
Speaker
ah because there's All genders are able to receive the HPV vaccine and should receive the HPV vaccine. Because unfortunately HPV does not discriminate. It does not discriminate. The HPV vaccine prevents not only cervix cancer, but also anal, vaginal, vulvar, vulvar wards, as well as oropharynx cancer, which is really on the rise. And that's the bigger one that we worry about in men.
00:21:39
Speaker
So lots of cancers are prevented with this vaccine. The earlier we get it in to patients, the better it works. So we really want to get that kind of pre-adolescent stage. You're 10 to 12 years old or 11 to 13 year old, anything under the age of of really 15.
00:21:59
Speaker
is ideal starting at age nine is the earliest that you can give up. And both boys and girls, if we can get them vaccinated at that early phase, awesome. For those that didn't you know get vaccinated in their adolescent years,
00:22:16
Speaker
Catching up anytime up to age 27, also great. Get that vaccination in, going to have the best chance of success as far as reducing your risk for HPV because our immune systems respond better to vaccines when we're younger. And so that's the rationale for why younger is better. It is approved up to age 45 for both men and women and the vast majority of states and pairs are paying for this. The benefit isn't as strong as it is in younger people, but we do still recommend it for patients that are concerned about their risk for HPV based diseases, as well as for people that have had high grade disease.
00:22:59
Speaker
they really should be getting vaccinated as part of their treatment plan for their high grade disease. Okay. That makes sense. And we were talking briefly about this earlier, this study that came out of Europe that showed for. yeah but I mean, it's zero cancers, you know, like we've been vaccinated. Yeah. Well, zero cancer for the strains that are covered by the vaccine, zero cancers from those. And this is just amazing. So.
00:23:27
Speaker
It works. It works very, very well. It's a very safe vaccine. And not going to make your kids start having sex.
00:23:35
Speaker
And you know, I tell all of my patients about HPV vaccination because, yeah, they may be out of the age range for it, but they have daughters. They have friends that have daughters. They have, you know, nieces, nephews. They got sons. They got grandchildren. Like, definitely advocate as much as you can for vaccination. It's safe. It's good for you. It prevents cancer. I mean, come on. Yeah. Yeah. Right. Exactly. How many vaccines do we have that actually prevent cancer?
00:24:02
Speaker
I know. Not very money. So it's super exciting. I think that's all of my questions for you. This has been very informative. I think we covered a lot and answered a lot of the frequently asked questions that we get as you know to why and when and oh the last one was even if you don't need a pap test after 65, do you still need a gynecologist?
Healthcare Needs of Older Women
00:24:22
Speaker
So I would say it depends.
00:24:24
Speaker
It depends.
00:24:34
Speaker
do really well with just their primary care physician. However, patients that you know, are having any kind of symptoms from a sexual function standpoint, from a urology standpoint, and having issues with either urinary function or bowel function, or if they're noticing discomfort in their vaginas or vulvas, and certainly if they're having any vaginal bleeding. Yes, you should see a gynecologist for those types of concerns. Yeah. Okay, awesome. Well, thank you. Thank you so much for your time. It's been wonderful to catch up with you and to talk about HPV and preventing cervical cancer. Thank you so much. I really appreciate it.