Abnormal Pap Test

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Abnormal Pap Test

Topic Overview

What is an abnormal Pap test?

A Pap test, or Pap smear, is part of a woman's routine physical exam. It is the best way to prevent cervical cancer, because it can find cells on your cervix that could turn into cancer. The cervix is the lower part of the uterus that opens into the vagina.

When your doctor says that your Pap test was "abnormal," it means that the test found some cells on your cervix that do not look normal. It does not mean that you have cancer. In fact, the chances that you have cancer are very small.

What causes an abnormal Pap test?

Most of the time, abnormal cell changes on the cervix are caused by certain types of human papillomavirus, or HPV. HPV is a sexually transmitted infection. Usually these cell changes go away on their own. But certain types of HPV have been linked to cervical cancer. That’s why it’s important for women to have regular Pap tests. It usually takes many years for cell changes in the cervix to turn into cancer.

Sometimes cell changes in the cervix are due to other types of infection, such as infections caused by bacteria or yeast. These types of cell changes can be treated. In women who have been through menopause, a Pap test may find cell changes that are just the result of getting older.

What increases your risk for an abnormal Pap test?

High-risk sex raises your chances of getting HPV and having an abnormal Pap test. High-risk sex includes having sex without condoms and having more than one sex partner (or having a sex partner who has other partners).

HPV can stay in your body for many years without your knowing it. So even if you now have just one partner and practice safe sex, you could still have an abnormal Pap test if you were exposed to HPV in the past.

Smoking or having an impaired immune system also may raise your chances of having cell changes in your cervix.

Do abnormal cell changes cause symptoms?

The cell changes themselves don't cause symptoms. HPV, which causes most abnormal Pap tests, usually doesn't cause symptoms either. This is why regular Pap tests are so important.

If a different sexually transmitted infection is the cause of your abnormal Pap test, you may have symptoms, including:

  • A discharge from the vagina that isn't normal for you, such as a change in the amount, color, odor, or texture.
  • Pain, burning, or itching in your pelvic or genital area when you urinate or have sex.
  • Sores, lumps, blisters, rashes, or warts on or around your genitals.

What will you need to do if you have an abnormal Pap test?

You will need more tests to find out if you have an infection or to find out how severe the cell changes are. These tests may include:

  • Colposcopy, a test to look at the vagina and cervix through a lighted magnifying tool.
  • An HPV test. Like a Pap test, an HPV test is done on a sample of cells taken from the cervix.
  • Another Pap test in 4 to 6 months.

A colposcopy is usually done before any treatment is given. During a colposcopy, the doctor also takes a small sample of tissue from the cervix so that it can be looked at under a microscope. This is called a biopsy.

Treatment, if any, will depend on whether your abnormal cell changes are mild, moderate, or severe. In moderate to severe cases, you may have treatment to destroy or remove the abnormal cells.

Frequently Asked Questions

Learning about abnormal Pap tests:

Being diagnosed:

Getting treatment:

Ongoing concerns:

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Decision Points focus on key medical care decisions that are important to many health problems. Decision Points focus on key medical care decisions that are important to many health problems.
  HPV: Should My Daughter Get the Vaccine?
  Pap Test: Should I Have Colposcopy if My Pap Test Shows Minor Cell Changes?

Cause

Most abnormal Pap tests are caused by human papillomavirus (HPV) infections. Other types of infection—such as those caused by bacteria, fungi (yeast), or protozoa (Trichomonas)—sometimes lead to minor changes on a Pap test called atypical squamous cells of undetermined significance (ASC-US). The most common cause is HPV infection. Natural cervical cell changes (atrophic vaginitis) related to menopause can also cause an abnormal Pap test.

Symptoms

Because cervical cell changes that can cause an abnormal Pap test rarely cause symptoms, regular Pap test screening to monitor cell changes is important.

Human papillomavirus (HPV) infection, which is the most common cause of abnormal cervical cell changes, usually does not cause any symptoms.

A number of infections and sexually transmitted infections (STIs) can cause an abnormal Pap test. STIs can have a variety of symptoms, including:

  • A change in vaginal discharge (thicker, discolored, or bad-smelling) over a period of several days to 2 weeks.
  • Pain, burning, or itching while urinating that lasts more than 24 hours.
  • Pain during sexual intercourse.
  • Pain in the pelvic or lower abdominal area.
  • Itching, tingling, burning, or pain on the genitals.
  • Sores, lumps, blisters, rashes, or warts on or around the genitals.

Only a small percentage of abnormal Pap tests indicate cervical cell changes that may progress to cervical cancer.

Symptoms of cervical cancer may include:

  • Abnormal vaginal bleeding or a significant unexplained change in your menstrual cycle.
  • Bleeding when something comes in contact with the cervix (such as during sexual intercourse or insertion of a diaphragm).
  • Abnormal vaginal discharge containing mucus that may be tinged with blood.
  • Pain during intercourse.

What Happens

The cervix contains two kinds of cells: rectangular-shaped columnar cells on the surface of the cervix and in the cervical canal; and flat, scalelike squamous cells on the surface of the cervix. Columnar cells are constantly changing into squamous cells in an area of the cervix called the transformation zone.

Abnormal Pap test results can be caused by infection, which leads to cell changes in the transformation zone of the cervix. Pap test results often return to normal when the cells have returned to healthy growth or after an infection has been treated or has resolved on its own.

In some cases, untreated cervical cell changes that cause abnormal Pap tests may progress to precancerous or cancerous stages. Certain high-risk types of the human papillomavirus (HPV) have been linked to the development of cervical cancer. But changes in cervical cells usually progress slowly and take many years to become cancer cells. Treatment can remove or destroy these cells before they become cancerous.

Regular Pap test screening can detect cervical cell changes early.

  • Minor cell changes often go away without treatment.
  • Early detection of precancerous cell changes or cervical cancer usually makes a complete cure possible.
  • If a high-risk type of HPV is diagnosed, more frequent Pap tests or other testing (such as colposcopy or cervical biopsy) may be needed for further evaluation.

Cervical polyps are unrelated to cervical cancer, but they may be found and removed at the time of a pelvic exam and Pap test.

What Increases Your Risk

Most cervical cell changes that cause an abnormal Pap test are the result of sexual transmission of HPV disease. High-risk sexual behaviors by you or your partner at some time, possibly even many years ago, may lead to HPV infection. High-risk sexual behaviors increase your risk of infections and sexually transmitted infections (STIs).

Other risk factors that may also play a role in increasing your risk for cervical cell changes include:

If you have had one abnormal Pap test result, you may be at higher risk for having another abnormal Pap test in the future.

When To Call a Doctor

Most problems that cause abnormal Pap tests do not cause symptoms, so you won't know you have cervical cell changes. Regular Pap testing is needed to detect early cervical cell changes.

Call your doctor if:

  • You have unexpected bleeding between menstrual periods, especially if you are not using any hormonal contraceptives, such as birth control pills.
  • You have bleeding after douching or sexual intercourse.

If you think you may have symptoms of a sexually transmitted infection (STI), call your doctor for an appointment. Avoid sexual intercourse until you have been treated for your symptoms and can no longer infect your partner.

If your sex partner has symptoms of an STI, both of you should be evaluated by a doctor. If you have been diagnosed with an STI, such as genital warts, your sex partner(s) may want to be evaluated.

If you have had an abnormal Pap test, be certain to complete any additional testing or treatment that your doctor recommends. You and your doctor can decide how often Pap test screening should continue or whether other tests are needed.

Who To See

Your family doctor or any of the following health professionals can manage an abnormal Pap test:

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

You may have a Pap test as part of your routine gynecologic exam. A Pap test is used to identify abnormal cell changes on your cervix and to screen for cervical cancer. Pap test screening is the most effective way to detect early abnormal cervical cell changes.

Women older than age 30 may have a screening test for HPV infection at the same time they have their Pap test.1

Pap test screening schedule

The recommended Pap test schedule is based on your age and on things that increase your risk. For most women, it is best to have a Pap test every 1 to 3 years. Talk to your doctor about when to have your first Pap test and how often to have this test.

Abnormal Pap test result

If your Pap test result is abnormal, the lab will use the Bethesda system (TBS) to describe how severe the problem is. Your doctor will use these results to decide how to treat the problem.

Following an abnormal Pap test result, more tests may be needed to determine whether an infection is present or to determine the severity of cervical cell changes. These additional tests include:

  • Human papillomavirus (HPV) DNA test. HPV testing is done to identify high-risk types of HPV infection. If your abnormal Pap test is caused by HPV, knowing whether you have a high-risk type of HPV can help guide your evaluation and treatment decisions.
  • Colposcopy and cervical biopsy. A colposcopy uses a magnifying instrument called a colposcope to look at the vagina and the cervix. Cell abnormalities (dysplasia) that might be missed by the naked eye can be seen with the colposcope. A cervical biopsy removes a small piece of the cervix so the tissue can be examined under a microscope.
  • Cone biopsy. This is an extensive form of a cervical biopsy. It is called a cone biopsy because a cone-shaped wedge of tissue is removed from the cervix and examined under a microscope. A cone biopsy may also serve as treatment by removing the abnormal cervical cells.

For more information, see:

Click here to view a Decision Point. Pap Test: Should I Have Colposcopy if My Pap Test Shows Minor Cell Changes?

For information on tests to diagnose a specific infection, see the specific topic:

What to think about

Testing methods, such as liquid-based collection, are being used in many areas of the United States. Liquid-based collection methods allow testing for HPV at the same time as a Pap test, but these methods may not be available everywhere and may be more costly.

The terms used to report Pap test results vary depending on which classification system is used. The Bethesda system (TBS) is used by most labs in North America. Other classification systems are used around the world.

Treatment Overview

Even though most abnormal Pap tests are caused by an HPV infection that will go away or by an inflammation that can be treated, you will need a follow-up evaluation to make sure your abnormal cell changes have resolved. Your need for treatment will vary depending on whether your abnormal cell changes are mild, moderate, or severe. Abnormal Pap test results may show minor cell changes (most common), moderate to severe cell changes (less common), or cervical cancer (rare). Depending upon the cause and severity of the cervical cell changes, you may need treatment.

If your Pap test shows that a vaginal infection or a treatable sexually transmitted infection (STI) is present, you can be treated with medicine.

Human papillomavirus (HPV) infection is the most common cause of an abnormal Pap test. There are many types of HPV. High-risk types can cause cell changes that could develop into cancer.

Evaluation of minor cell changes (ASC-US and LSIL)

An abnormal Pap test result is not uncommon because HPV infection is very common. Most cell changes seen in abnormal Pap test results will not progress to cervical cancer. If your abnormal Pap test shows minor cell changes, you may have several choices of what to do next.

Based on your age and the type of cell changes found, your doctor may recommend:

  • Watchful waiting, which includes repeat Pap tests about every 6 months, or less often if you are under 21. Watchful waiting will not be harmful if the abnormal tissue is not visible on the cervix or a type that is not likely to progress to cancer and you do not have an impaired immune system.
  • A test for high-risk human papillomavirus (HPV) types. The natural course of most types of HPV is to resolve on their own within 18 months. HPV in women younger than 30 usually goes away on its own. HPV in women older than 30 is more likely to persist.
  • A colposcopy so your doctor can look at the abnormal cells. A cervical biopsy may be done at the same time to confirm the colposcopy findings. Women with HIV infection will most likely be evaluated with colposcopy and then treated for any abnormal cervical cells.

For more information, see:

Click here to view a Decision Point. Pap Test: Should I Have Colposcopy if My Pap Test Shows Minor Cell Changes?

Treatment for moderate to severe cell changes (HSIL, ASC-H, or AGC)

Treatment decisions for an abnormal Pap test that shows moderate to severe cell changes are based on the Pap test results, colposcopy, and cervical biopsy. A larger tissue sample may be removed by a cone biopsy. In some cases, this procedure may serve as treatment so you are cured. Follow-up to evaluate and treat moderate to severe cervical cell changes is recommended sooner than for minor cell changes.

For moderate or severe precancerous cell changes confirmed by biopsy, treatment will focus on destroying or removing the abnormal tissue. Treatment choices include LEEP, a surgery that uses a thin wire loop to remove the abnormal tissue; cryotherapy, which destroys tissue by freezing it; laser therapy, which destroys tissue with a laser beam; or cone biopsy (conization), in which a cone-shaped piece of abnormal tissue is removed from the cervix.

For cervical cancer, treatment will focus on destroying or removing the cancerous tissue. For more information, see the topic Cervical Cancer.

Treatment for an abnormal Pap during pregnancy

A Pap test may be done during pregnancy if a woman is due for her regular screening test. A pregnant woman with an abnormal Pap test is monitored closely throughout her pregnancy. Monitoring may include evaluation by colposcopy. The goal of evaluation is to rule out cervical cancer, a rare diagnosis. Treatment for abnormalities other than cancer is done after delivery.

Prevention

You cannot prevent an abnormal Pap test, but you can reduce your risk factors.

Have regular Pap test screening

The Pap test is the most effective screening test to prevent the development of cervical cancer. Pap tests done at regular intervals almost always detect cervical cell changes before the changes become cancerous. Regular screening for and treatment of cervical cell abnormalities can prevent the abnormal cell changes from developing into cancer.

The recommended Pap test schedule is based on your age and on things that increase your risk. For most women, it is best to have a Pap test every 1 to 3 years. Talk to your doctor about when to have your first Pap test and how often to have this test.

Quit smoking

Women who smoke are at higher risk for developing cervical cell changes that cause an abnormal Pap test. The reason for this is not fully understood. Quitting smoking may decrease this risk. Not smoking has many other health benefits. For example, nonsmokers have a lower risk of other cancers and heart disease. For more information, see the topic Quitting Smoking.

Reduce your risk of a sexually transmitted infection (STI)

Sexually transmitted infections (STIs), especially HPV infection, often cause abnormal Pap tests and can lead to other serious health problems. Preventing an STI is easier than treating an infection after it occurs.

  • Talk with your partner about STIs before beginning a sexual relationship. Find out whether he or she is at risk for an STI. Remember that it is quite possible to be infected with an STI without knowing it. Some STIs, such as HIV, can take up to 6 months before they are detected in the blood. Consider HIV testing if you or your partner are at risk for HIV.
  • Be responsible.
    • Avoid sexual contact if you have symptoms of an STI or are being treated for an STI.
    • Avoid all intimate sexual contact with anyone who has symptoms of an STI or who may have been exposed to an STI.
  • Use male or female condoms to reduce the risk of getting an STI. Using male condoms when you have sex has been shown to reduce your risk of getting HPV.2 Female condoms may help also, although there has been less study of this type of protection.
  • Abstaining from sexual intercourse is the only way to completely prevent any exposure to STIs.

Your risk for an STI increases if you have several sex partners at the same time or if your sex partner has more than one partner.

If you are age 26 or younger, get the HPV shot. The vaccines Cervarix (What is a PDF document?) and Gardasil (What is a PDF document?) protect against two types of HPV that cause cervical cancer. Gardasil also protects against two types of HPV that cause genital warts. Three shots are given over 6 months. The series of shots is recommended for girls age 11 or 12 and can be given to females ages 9 to 26. You can get either vaccine. For more information, see the topic Immunizations.

For more information on getting your daughter vaccinated, see:

Click here to view a Decision Point. HPV: Should My Daughter Get the Vaccine?

Home Treatment

All abnormal Pap tests require follow-up. In some cases, you may need further testing or treatment. In other cases, your doctor may recommend a period of watchful waiting that includes repeat Pap tests.

  • Be certain to complete any further testing that your doctor recommends. This includes repeat Pap tests as well as any other tests.
  • If a vaginal infection or a treatable sexually transmitted infection (STI) caused your abnormal test results, you will probably need medicine. Take all the medicine as directed by your doctor. If you skip doses or do not take all your medicine, the problem may come back.

To reduce your risk of cervical problems:

  • Have regular Pap tests. Regular Pap tests almost always detect cervical cell changes before the changes become cancerous. Regular screening for and treatment of cervical cell abnormalities can prevent cancer. You and your doctor can decide how often you need to be tested.
  • Reduce your risk of exposure to sexually transmitted infections by practicing safer sex. Use condoms until you are certain that neither you nor your partner has an STI. To prevent STIs, condoms must be put on before beginning any sexual contact.
  • Quit smoking. Women who smoke are at higher risk of developing cervical cell changes that cause an abnormal Pap test. The reason for this is not fully understood.

Medications

Medicines may cure a bacterial, fungal, or protozoal infection and allow minor cell changes called atypical squamous cells of undetermined significance (ASC-US) that have caused an abnormal Pap test to return to normal. HPV infection cannot be treated with medicine. The infection or inflammation changes of cervical cells are monitored in the following sequence:

  • If an infection is identified, even though you may not have symptoms, nonprescription or prescription medicine may be recommended to eliminate the infection. The type of medicine used depends on the type of infection present. For more information on treatment for a specific infection, see the appropriate topic: Chlamydia, Gonorrhea, Syphilis, Trichomoniasis, Vaginal Yeast Infections, Bacterial Vaginosis, Genital Herpes, or Genital Warts (Human Papillomavirus).
  • The Pap test is repeated at regular intervals as recommended by your doctor. If the repeat Pap test results are normal after the treatment of an infection, you can return to your normal Pap test screening schedule.
  • If the Pap test remains abnormal after treatment, you and your doctor may choose watchful waiting. Or a colposcopy may be done to diagnose the cause of the abnormal test. Regular Pap testing allows you to monitor minor cervical cell changes.

Estrogen cream. Women near menopause may have abnormal Pap test results because of normal body changes during menopause, such as cervical cell atrophy and estrogen loss. These minor cell changes may improve with the use of estrogen cream.

Surgery

If you have had an abnormal Pap test, surgery may be an option. Surgical treatment may be recommended if:

Surgery may be done to destroy or remove the abnormal cells on your cervix, or confirm or rule out the possibility that you have cervical cancer.

Abnormal tissue that can be seen through the magnifying viewing instrument (colposcope) can often be destroyed or removed with cryotherapy, a cone biopsy, a carbon dioxide (CO2) laser, or the loop electrosurgical excision procedure (LEEP).

Abnormal cervical cells that are detected by a Pap test but cannot be seen by colposcopy may be high in the cervix (cervical canal). Before treatment is recommended, the location and type of cell change must be confirmed by a cervical biopsy. Depending on the results of the colposcopy and cervical biopsy, a cone biopsy may be done as the next step.

Surgery Choices

Surgical choices for abnormal cervical cell changes include the following:

Procedures that remove abnormal tissue

  • Cone biopsy (conization) removes a cone-shaped wedge of abnormal cells high in the cervical canal. A small amount of normal tissue around the cone-shaped wedge of abnormal tissue is also removed so that a margin free of abnormal cells is left in the cervix.
  • Loop electrosurgical excision procedure (LEEP) uses a thin, low-voltage electrified wire loop to cut out abnormal cervical cells. It can also be used to remove a cone-shaped wedge of tissue like a cone biopsy.

Procedures that destroy abnormal tissue

  • Cryotherapy destroys abnormal cervical cells by freezing them.
  • Carbon dioxide laser uses a laser beam to destroy (vaporize) abnormal cervical cells. It can also be used to remove a cone-shaped wedge of tissue like a cone biopsy.

If the results of a Pap test, colposcopy, and cervical or cone biopsy point to invasive cervical cancer, then surgery, radiation, chemotherapy, or a combination of treatments will be needed to destroy or remove the cancerous tissue.

For more information, see the topic Cervical Cancer.

What To Think About

Minor cell changes may not need to be treated with surgery. When deciding on treatment for minor cell changes, consider the following:

  • Infections may be cured with medicines for the specific cause of the infection.
  • Minor cell changes often go away without treatment. Your doctor may suggest a period of watchful waiting before further evaluation or a biopsy is recommended. Surgery may be needed if the cell changes are confirmed by biopsy to be progressing to more severe cell changes. Surgery may also be done if follow-up evaluation is not possible or immediate treatment is wanted.
  • Cell changes caused by human papillomavirus (HPV) infection may not progress beyond mild changes. The natural course of most types of HPV is for the cells to change back to normal within 18 months without treatment. Cervical cell changes caused by HPV may be treated because of their degree of abnormality, but treatment does not eliminate the virus. You may still have HPV inside your body's cells.

Treatment choices for moderate to severe cell changes are more likely to include surgery to specifically destroy or remove the abnormal tissue.

Other Treatment

Removal of the uterus (hysterectomy) may be a treatment choice for some women who have had an abnormal Pap test if both of the following are true:

  • They are done having children.
  • They have other gynecological problems, such as heavy irregular bleeding that does not improve with medicine, that would also be treated with a hysterectomy.

Other Places To Get Help

Organizations

American Congress of Obstetricians and Gynecologists (ACOG)
409 12th Street SW
P.O. Box 96920
Washington, DC  20090-6920
Phone: (202) 638-5577
Email: resources@acog.org
Web Address: www.acog.org
 

American Congress of Obstetricians and Gynecologists (ACOG) is a nonprofit organization of professionals who provide health care for women, including teens. The ACOG Resource Center publishes manuals and patient education materials. The Web publications section of the site has patient education pamphlets on many women's health topics, including reproductive health, breast-feeding, violence, and quitting smoking.


Centers for Disease Control and Prevention (CDC): National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
1600 Clifton Road
Atlanta, GA  30333
Phone: 1-800-CDC-INFO (1-800-232-4636)
(404) 639-3534
TDD: 1-888-232-6348
Email: cdcinfo@cdc.gov
Web Address: www.cdc.gov/nchstp/od/nchstp.html
 

The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention is a branch of the Centers for Disease Control and Prevention (CDC). Their Web site provides information and updates on sexually transmitted diseases (STDs), human immunodeficiency virus (HIV), and tuberculosis (TB). You can also find fact sheets on these health topics.


References

Citations

  1. American College of Obstetricians and Gynecologists (2005, reaffirmed 2009). Human papillomavirus. ACOG Practice Bulletin No. 61. Obstetrics and Gynecology, 104(4): 905–918.
  2. Winer RL, et al. (2006). Condom use and the risk of genital human papillomavirus infection in young women. New England Journal of Medicine, 354(25): 2645–2654.

Other Works Consulted

  • American College of Obstetricians and Gynecologists (2009). Cervical cytology screening. ACOG Practice Bulletin No. 109. Obstetrics and Gynecology, 114: 1409–1420.
  • ASCUS–LSIL Triage Study (ALTS) Group (2003). A randomized trial on the management of low-grade squamous intraepithelial lesion cytology interpretations. American Journal of Obstetrics and Gynecology, 188(6): 1393–1400.
  • Cox JT, et al. (2003). Prospective follow-up suggests similar risk of subsequent cervical intraepithelial neoplasia grade 2 or 3 among women with cervical intraepithelial neoplasia grade 1 or negative colposcopy and directed biopsy. American Journal of Obstetrics and Gynecology, 188(6): 1406–1412.
  • Cuzick J, et al. (2003). Management of women who test positive for high-risk types of human papillomavirus: The HART study. Lancet, 362 (9399): 1871–1876.
  • Guido R, et al. (2003). Postcolposcopy management strategies for women referred with low-grade squamous intraepithelial lesions or human papillomavirus DNA–positive atypical squamous cells of undetermined significance: A two-year prospective study. American Journal of Obstetrics and Gynecology, 188(6): 1401–1405.
  • Wright TC, et al. (2003). 2001 consensus guidelines for the management of women with cervical intraepithelial neoplasia. American Journal of Obstetrics and Gynecology, 189(1): 295–304.
  • Wright TC, et al. (2007). 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. American Journal of Obstetrics and Gynecology, 197(4): 346–355.

Credits

By Healthwise Staff
Primary Medical Reviewer Sarah Marshall, MD - Family Medicine
Specialist Medical Reviewer Kirtly Jones, MD - Obstetrics and Gynecology
Last Revised October 17, 2011

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