Dear Dr Mitchell,
Can pap smear results show "normal" when it should be "abnormal"? I did a pap smear at the beginning of the year and I was told it's "normal". But then I recently saw signs of small warts close to the opening of my vagina and I was given a prescribed cream (Aldara) to use. It's been about two months and I'm still not seeing any changes or the warts disappearing. What could have caused the genital warts? I had to specifically ask the doctor if there's any treatment for it because I was told it wasn't anything to worry about.
I read your recent article about the importance of pap smears and knowing about cervical cancer treatment and its relation to HPV, and it was very informative and educational. However, I am still confused about why the pap result would show "normal" yet I have genital warts? Also, I would like to know which of the HPV injections would be best in my case, Cervarix or Gardasil? How does the doctor test for HPV?
The pap smear is a screening test that examines cells that are removed from the cervix in an attempt to pick up early abnormal changes in the cervix that can lead to cervical cancer if left untreated. It can sometimes detect inflammation of the cervix and also identify some specific bacteria and changes associated with viral infection such as the human papilloma virus (HPV) and the herpes simplex virus II (HSV II).
The pap smear does not always show up abnormal changes on the cervix and in as much as 30 per cent of cases, the pap smear may be reported as being normal and there are significant underlying abnormal changes (false negative). There are some conditions that result in an increase in the false negative rates. If infection or inflammatory changes are present, these can alter the pickup rate. The presence of blood and semen can also affect the result of the pap smear. If the cervix is not readily visualised and an improper sample is taken then the pap smear can miss abnormal changes.
Genital warts are usually caused by HPV. Genital warts may also be the result of syphilis. It is quite possible for you to have genital warts and for the cervix to be completely free of the infection and as a result the pap smear will be normal. Sometimes the abnormal cells are high up in the cervix and may be missed at the time of the pap smear.
Genital warts are usually caused by HPV types six and 11 and these are considered low risk types. This means that there is virtually very little chance of you developing cervical cancer or vulval cancer from these types. These two main types account for over 90 per cent of genital warts. These warts can cause itching and an unsightly appearance to the vulva and vagina and so should be treated. Treatment may be done by using Aldara cream or by burning off the warts. The HPV may be present in what appears to be normal appearing skin and mucosal surfaces in the vulva and vagina and warts may recur despite adequate treatment.
However, all women with genital warts should have a pap smear done and have a special examination called colposcopy where the cervix is examined in detail to look for changes in the cervix caused by the HPV that can lead to cervical cancer. Treatment of these abnormal changes can also be done at the time of the colposcopy.
HPV is extremely common and once you have ever been sexually active you can get this infection. Over 80 per cent of sexually active women have the virus. The body naturally clears the virus if you have a good immune system. As you get older, your ability to get rid of the virus decreases. Women over 30 are at increased risk of persistent infection.
HPV testing can be done by taking a sample of the secretion from the cervix and sending it off for testing. This can be done at the time of the pap smear. It is not recommended for women under 30 since HPV is very common in this age group and is probably of very little significance since most young women have a good immune system and will actively get rid of the virus. HPV testing aims at detecting the common high risk type HPV virus types that cause cervical cancer (types 16, 18, 31 and 45).
Prevention of the infection is difficult since condom use only gives about a 75 per cent reduction in HPV transmission. This is because the virus may be present in areas that the condom does not cover such as the scrotum and the inner thighs. Vaccination is the mainstay in primary prevention. Cervarix is the preferred vaccine in cervical cancer prevention since it offers effective coverage against the four main types of high risk HPV (16 18, 31 and 45). Gardasil is effective against genital warts but does not give effective coverage against HPV 18 and 45 which are important types that cause cervical cancer.
All women from age 10 to 55 years old should be vaccinated with Cervarix. This is so even if you have had the HPV virus or were treated for an abnormal pap smear. Vaccination will protect you against recurrence from re-exposure. A pap smear should still be done to pick up abnormal changes that may rarely occur due to HPV types not involved in the vaccine.
Your partner should also be tested to see if he has HPV or genital warts since treatment can reduce risk of re-exposure. Contact you gynaecologist who will advise you further.
Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions via e-mail to firstname.lastname@example.org; write to All Woman, 40-42 1/2 Beechwood Ave, Kingston 5; or fax to 968-2025. Dr Mitchell cannot provide personal responses.
The contents of this article are for informational purposes only and must not be relied upon as an alternative to medical advice or treatment from your own doctor.