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Adolescent Pap Smear Screening: Yes or No
J Pediatr Adolesc Gynecol (1996) 9:93-97
Opinions in Pediatric and Adolescent Gynecology Edited by Robert T. Brown, M.D., Chief, Section of Adolescent Health, Professor of Clinical Pediatrics, Professor of Clinical Obstetrics & Gynecology, Ohio State University College of Medicine, Columbus, OH, and by Paula Hillard, M.D., Associate Professor, University of Cincinnati Medical Center, Department of Obstetrics & Gynecology, Department of Pediatrics, Cincinnati, OH
Adolescent Pap Smear Screening: Yes or No The format of this Opinions in Adolescent and Pediatric Gynecology section differs from previous issues. Both sides of the debate are written by Dr. Paula Hillard, and she intends it to be provocative. Should adolescents have Pap smear screening? In the past, Dr. Hillard has written about an increase in the frequency of abnormal Pap smears among adolescents and about the value of a clinic at which the focus is on the particular needs of adolescents with dysplasia. Those needs are primarily educational, although it should be noted that research is necessary to define what our educational messages should be to best effect behavioral changes. There are some basic questions which should be answered; for example, what is a Pap smear, what is human papilloma virus (HPV)-is it a sexually transmitted disease (STD), what is colposcopy, and how can STDs be prevented? Other questions-what does it mean to have an abnormal Pap smear, what are the implications or consequences of an abnormal Pap smear (for a relationship, sexual behavior, risk-taking behaviors), etc-are more complex. One of the issues which is not frequently discussed is the question of what it means to an adolescent to have an abnormal Pap smear. Our clinical experience suggests that for some adolescents is a "big deal"; for many the biggest event, medically, that they've ever had to confront. But again, research is needed to help us understand if there are differences between our patients' reactions to the diagnosis of HPV and the diagnoses of other STDs. In Dr. Hillard' s clinic, the finding of an abnormal Pap smear triggers a chain of events: it means a discussion with the primary caregiver about the need for further evaluation; it means a visit with the nurse practitioner who explains Pap smears, colposcopy, cervical biopsies, cryotherapy, laser, etc; it means having to undergo colposcopy, a procedure which is uncomfortable (even more so than a Pap smear), if not downright painful. For many adolescents, a cervical biopsy, often described as a "pinch and a cramp," is the most painful procedure that they have ever experienced. They usually don't have the perspective of other medical evaluations or treatments. So what is the effect? For some adolescents it all does
make an impression. We would hope that the diagnosis of such problems as chlamydial cervicitis as an STD would make an impression and might lead to behavioral changes such as more responsible sexual activity, abstinence, condom use, or a frank discussion with a partner about safer sex. Unfortunately, for many teens, we don't see consequent changes in behavior. But the diagnosis and evaluation of dysplasia may be different. The whole issue of HPV infection-latent, subclinical, infectious, potentially lifelong-is pretty complicated to understand. We don't always have the answers to the questions that are clinically important-how infectious is it, can my partner get warts if I have dysplasia, will my dysplasia progress? What sort of messages do our patients draw from the experience of an abnormal Pap smear? We need to understand these issues better to tailor our clinical messages in ways that will be more likely to effect behavioral changes. We have the impression that our intensive efforts around the issue of cervical dysplasia can have an impact on behavior. Can we prove this? No, not currently. Do we believe it? Yes. It is important for readers to know that some people are asking whether or not adolescents should have Pap smear screening. What are the costs? What are the outcomes? Is it appropriate to spend our limited health care dollars on this evaluation and treatment? The reader should listen to both sides, and we should all try to answer the resulting questions. Robert T. Brown, M.D.
Adolescent Pap Smear Screening: Pro Position National data indicate that an increasing percentage of adolescents have had intercourse at a younger age. In 1970, 28.6% of all adolescents were experienced sexually; 48.6% had had intercourse by age 19. In 1988, 51.5% of all adolescents and 73.3% of 19-year-olds had become sexually active.' These individuals constitute a group at risk for STDs including cervical dysplasia. Cervical dysplasia is considered to be a sexually transmitted disease, and its prevalence on Pap smears in our adoles-
Opinions in Pediatric and Adolescent Gynecology Edited by Robert T. Brown, M.D., Chief, Section of Adolescent Health, Professor of Clinical Pediatrics, Professor of Clinical Obstetrics & Gynecology, Ohio State University College of Medicine, Columbus, OH, and by Paula Hillard, M.D., Associate Professor, University of Cincinnati Medical Center, Department of Obstetrics & Gynecology, Department of Pediatrics, Cincinnati, OH
Adolescent Pap Smear Screening: Yes or No The format of this Opinions in Adolescent and Pediatric Gynecology section differs from previous issues. Both sides of the debate are written by Dr. Paula Hillard, and she intends it to be provocative. Should adolescents have Pap smear screening? In the past, Dr. Hillard has written about an increase in the frequency of abnormal Pap smears among adolescents and about the value of a clinic at which the focus is on the particular needs of adolescents with dysplasia. Those needs are primarily educational, although it should be noted that research is necessary to define what our educational messages should be to best effect behavioral changes. There are some basic questions which should be answered; for example, what is a Pap smear, what is human papilloma virus (HPV)-is it a sexually transmitted disease (STD), what is colposcopy, and how can STDs be prevented? Other questions-what does it mean to have an abnormal Pap smear, what are the implications or consequences of an abnormal Pap smear (for a relationship, sexual behavior, risk-taking behaviors), etc-are more complex. One of the issues which is not frequently discussed is the question of what it means to an adolescent to have an abnormal Pap smear. Our clinical experience suggests that for some adolescents is a "big deal"; for many the biggest event, medically, that they've ever had to confront. But again, research is needed to help us understand if there are differences between our patients' reactions to the diagnosis of HPV and the diagnoses of other STDs. In Dr. Hillard' s clinic, the finding of an abnormal Pap smear triggers a chain of events: it means a discussion with the primary caregiver about the need for further evaluation; it means a visit with the nurse practitioner who explains Pap smears, colposcopy, cervical biopsies, cryotherapy, laser, etc; it means having to undergo colposcopy, a procedure which is uncomfortable (even more so than a Pap smear), if not downright painful. For many adolescents, a cervical biopsy, often described as a "pinch and a cramp," is the most painful procedure that they have ever experienced. They usually don't have the perspective of other medical evaluations or treatments. So what is the effect? For some adolescents it all does
make an impression. We would hope that the diagnosis of such problems as chlamydial cervicitis as an STD would make an impression and might lead to behavioral changes such as more responsible sexual activity, abstinence, condom use, or a frank discussion with a partner about safer sex. Unfortunately, for many teens, we don't see consequent changes in behavior. But the diagnosis and evaluation of dysplasia may be different. The whole issue of HPV infection-latent, subclinical, infectious, potentially lifelong-is pretty complicated to understand. We don't always have the answers to the questions that are clinically important-how infectious is it, can my partner get warts if I have dysplasia, will my dysplasia progress? What sort of messages do our patients draw from the experience of an abnormal Pap smear? We need to understand these issues better to tailor our clinical messages in ways that will be more likely to effect behavioral changes. We have the impression that our intensive efforts around the issue of cervical dysplasia can have an impact on behavior. Can we prove this? No, not currently. Do we believe it? Yes. It is important for readers to know that some people are asking whether or not adolescents should have Pap smear screening. What are the costs? What are the outcomes? Is it appropriate to spend our limited health care dollars on this evaluation and treatment? The reader should listen to both sides, and we should all try to answer the resulting questions. Robert T. Brown, M.D.
Adolescent Pap Smear Screening: Pro Position National data indicate that an increasing percentage of adolescents have had intercourse at a younger age. In 1970, 28.6% of all adolescents were experienced sexually; 48.6% had had intercourse by age 19. In 1988, 51.5% of all adolescents and 73.3% of 19-year-olds had become sexually active.' These individuals constitute a group at risk for STDs including cervical dysplasia. Cervical dysplasia is considered to be a sexually transmitted disease, and its prevalence on Pap smears in our adoles-