A Scenic Guide to Your Abnormal Pap Smear

by Lola Pellegrino

Hey, did you know that January is Cervical Health Awareness Month? If your response was “oh Lola FUCK you, dude” I’m guessing you are one of the 2–3 million people in the US who found themselves on the freaking-out end of an abnormal pap smear result in the last year. Understandably! Hey APSC (Abnormal Pap Smear Crew), bring your HPV, cervixes, and questions about whether that HPV is cervixes’ cancer over here. And let’s talk.

First: what is HPV? HPV stands for Human Papillomavirus, the most common STI, transmitted through skin-to-skin contact with the genitals. This means that you can get it no matter who you are, who you’re having sex with or what kind of sex you’re having. Penetrative … or not! Oral, genital, anal! Cis or trans! We’re here, we’re queer, pap smear. Being equal-opportunity is why HPV is so popular — estimates are that about 50–80% of all adults will have it at some point in their lives. There are about 40 strains of genital HPV, divided into “high-risk” and “low-risk” according to their likelihood to cause certain kinds of cancer. So, the “high-risk” HPV strains are high-risk for causing cervical, anal, etc. cancers and the “low-risk” HPV strains are low-risk for causing cancer but are responsible for causing genital warts. The cancer-y strains don’t give you warts, and the wart-y strains don’t give you cancer. I know, fair in a weird way, right? Now we all feel weird. Weird-er!

Let’s get something out of the way. If you’ve been going to the gyno at least every couple years, you can give yourself a preliminary, reassuring pat (pap) on the back, because I’m not really that worried about your abnormal pap smear being cervical cancer. Why? Because “the majority of cervical cancers in the United States occur in women who have never been screened or who have not been screened within the past 5 years … additional cases occur in women who do not receive appropriate followup after an abnormal Pap smear.” So the people most at risk for having cervical cancer are not you; they’re people who haven’t gotten an abnormal pap smear result because they didn’t or couldn’t get a pap smear in the first place. The same principle is why 80% of new cervical cancers occur in developing nations, where cervical cancer is the #1 cause of cancer-related death in women and why in the US, although widespread screening has reduced new diagnoses and mortality 60% since being implemented in the 1950s, the rates of both are still so high for medically under-served people that a community’s mortality rate from cervical cancer can be used as “a marker for low access to health care.”

The underlying idea is that having HPV doesn’t matter nearly as much as how long you’ve had it. Seventy percent of healthy young people will clear an HPV infection in a year, and 90% will do it in two. That means two years from now almost all of you APSC will have wasted your time reading this rest of this article. Not sorry! In healthy people, it’s only “persistent infections,” which are high-risk HPV infections that do not clear after about two years, that have any possibility of progressing into cancer, and it takes an average of 13 years (!) to do so. There are a lot of steps between HPV infection and cancer, and at each step, there’s a chance that the process will clear, regress, or stall. Here’s a diagram to help explain all of this. I want to draw your attention to the fact that in this diagram there is no place in which you should shit yourself.

Click for full-size

Sorry that I’m not an artist like you but rather a nurse who saves lives with nothing but her bare hands and raw intuition. (Did you like the little bowties?) First, you have to get HPV, which is seriously so easy to do that almost everybody does it at least once, like dropping your cell phone in the toilet. Then, the HPV you get has to be a high-risk strain — especially either #16 or #18, the two strains responsible for 70% of cervical cancers. Ninety percent of infections clear at this point and never go any further. 90%!! The remaining 10% become persistent, which takes years. After this, the HPV has to get all pissed and cause more changes in your cervical cells (dysplasia). THEN the dysplasia has to progress further and further, but it’s still not cancer until it breaks through the bottom layer of the membrane in a process known as “invasion,” because the people who name things in medicine do so from deep within the irony-free zone. Only after invasion is the diagnosis of cervical cancer made. “CIN” stands not for “Cancer Impossibly Near” but “Cervical Intraepithelial Neoplasia,” the fancy name for the cell changes that HPV makes. The number after the “CIN” stages the proportion of cells affected. With all this said, as slow as it is, HPV turns into CIN3 faster than CIN3 turns into cancer. Seriously, do you see how the cancer part doesn’t happen until that very last cervix all the way on the right? At every step there is something we can do to manage or treat it. All of this is how an estimated one fourth of all women in the US age 14–59 have some strain of genital HPV, and 23% a high-risk strain, but there were only about 12,000 diagnoses of cervical cancer predicted in 2011.

One more thing. If you’re over 30, you most likely got two results: a (normal/abnormal) pap smear result and a (positive/negative) HPV genotype test result. There’s more on it here and here, but real quick, the HPV test detects a current high-risk HPV infection in your cervical cells whereas the pap smear detects cells after HPV has made them abnormal. That’s why you can have a positive HPV test (current infection) but a normal pap smear (hasn’t done anything) or! an abnormal pap smear (you’ve had an HPV infection that made cell changes) and a negative HPV test (but you cleared the virus). The reason we start using both (“co-testing”) at 30 and not earlier is because the younger you are, the more likely you are to both have HPV and to clear it. As you get older, both of those things become less likely, making it more important to find the people who are affected.

Now that we’ve established that you’re going to be okay no matter what, I feel your focus turning to the next important matter: who fucking gave me this shit? Oof we can’t really know who or even when. This is because most HPV infections clear up on their own without any symptoms and are therefore never detected. So a new HPV diagnosis doesn’t necessarily mean that it was the last person you had sex with, or there were more people having sex with the people you were having sex with than you thought. There’s also no HPV test for dudes, even if they say “test me for everything.” And that’s probably the best we’re able to do until someone figures out how to make a cervix talk.

The only thing we can say definitively about how you got HPV is that it wasn’t because you were a slut because sluts don’t exist. That’s right: you are the same person you were 25 minutes ago in the waiting room. There is no reason why you should stop doing anything sexy that made you happy before you got diagnosed. There is no reason why you should not get close to another person again. There is no reason you should now regret something you didn’t regret before; I speak from a place of authority, because regretting sex was my undergraduate major. Having HPV doesn’t mean you did something “bad,” or “dirty,” or “slutty,” ever, at any point, period. It doesn’t mean anything except that you are infected with a strain of a virus which very rarely causes cancer, and that we’re going to monitor you so that doesn’t happen, and if it does we’ll be there with you treating it. If simply having had HPV makes you bad/dirty/slutty, then 80% of adult humans are bad/dirty/slutty, and I always swore that if there were that many bad/dirty/slutty people on this earth I was going to another earth and I’m still here, aren’t I.

The exchange for knowing that there is no reason to judge yourself because you got HPV is that you must also release the other person(s) involved from judgment, too. Again, almost all HPV infections come and go without ever being detected; the vast likelihood is that the person who gave it to you had no idea. But let’s say you got it from A Dude who transmitted it knowingly without disclosing or otherwise misrepresented himself to you. Even there, the incredibly shitty thing is that he lied to you, not fact that his body had germs on it. It’s not easy to do, but I promise if you accept the fact that 1 HPV infection does not equal 1 or more sluts you will feel so, so much better.

Accepting this also lets you maximize your opportunity to Real Talk Express all the honeys/handsomes that will be appearing between your legs. You’ll have read this fantastic Scarleteen article and be able to tell them in your best NPR (No Problem Really) voice how you have HPV and all the stuff you’ve learned about it and how it’s important to be up-front with other people about risks, but also that STIs are like any other illness. Then they’ll tell their friends and those friends will tell their friends and soon enough we’ll have destigmatized 80% of the world in one fragrant wave. I mean I know you were pretty upset about this before, but now you’re thinking, “Whoa, when can I get started?” I know!

Before we get too excited, APSC, let’s go back to where it all began — your abnormal pap smear results — and talk about what’s going to happen next. I totally didn’t even ask you, were you ASC-US? LSIL? HSIL? Check out this “Understanding Pap Results” chart from the ARHP or these tables from the CDC and then come back.

Thanks, ARHP/CDC, catch you guys later. So, you saw that depending on your results, there are three general options for follow-up: a repeat smear, a HPV test, or a colposcopy. We’ve covered the first two but not the last. The term “colposcopy” is defined as “visual examination of the cervix and surrounding structures,” but in practice we use the term to refer to both a “looking at things” part and a “taking a biopsy” part. A colposcopy begins just like a regular pelvic exam: stirrups, speculum. Then, we take a colposcope, which is enchantingly described by others as “a pair of binoculars mounted on a pole” and myself as “an enormous wheely microscope,” and use it to look for anything abnormal inside. We check out your cervix as-is, then we brush some vinegar on it like the most interesting salad and look, throw some colored filters on and look, and sometimes apply a liquid called Lugol’s solution and look. If at any point we do see something suspicious, we biopsy it. If we don’t, we don’t. This may be why some of your friends were like “colposcopy, more like a snoozeoscopy” and other friends were like “yo that shit hurts!” Clinicians err on the side of “let’s get a sample just in case,” because the side of “missed something important” sucks way more than the pinch of a biopsy for you and the pain of causing another person pain for us. I’ve noticed that having a good colposcopy experience has almost nothing to do with if you get biopsied and everything to do with anxiety level, so do what you need to do to relax. Since known > unknown fear-wise, beforehand you could read up on the procedure more. During, ask the provider questions or request that they narrate to you what they’re doing. Also, maybe bringing a cool friend to hold your hand? Gawwww, of course. Just let me know when your appointment is.

Okay, off to insert two IUDs at once blindfolded while getting blasted in the face with a Supersoaker.

and of course http://en.wikipedia.org/wiki/Human_papillomavirus (of course)

Diagram especially came together from:

P.S. Americans can get low-cost pap smears here and here and of course here (and here!)

P.P.S. I think I might have gotten “We’re here, we’re queer, pap smear” from somewhere but I couldn’t for the life of me find where so if you know please fill me in 4 attribution purposes!

Lola Pellegrino is deeply concerned about the care and feeding of your vagina business. Here is her tumblr.