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By Kelly Teagle — November 24, 2011

Image from WebMD

Following on from my previous post about Gardasil for guys we’re heading back to the heartland of women’s health: the Pap smear.

I’m sure this is a subject as near and dear to your heart (well, perhaps a little lower) as it is to mine, and after our recent focus on Human Papillomavirus it is definitely worth a deeper look (no pun intended).

So here it is… the Ins and Outs of Pap smears.

What is a pap smear?

A Papanicolaou or ‘Pap’ smear is a sample of cells collected from the cervix with a specially-designed brush and then mounted on a microscope slide to look for abnormalities.

The cervix is located using a duck-billed device called a speculum to open and support the vagina. Within the cervix is an area where the surface cells gradually transition from inside-type (glandular) cells to outside-type (squamous) skin cells, an area known as the ‘transition zone’ for obvious reasons. In this region the cells are more likely to undergo unwanted changes called metaplasia.

Thanks to recent research breakthroughs, we now know that cervical metaplasia is triggered by infection with certain types of Human Papillomvirus (HPV), information which has led to the development of vaccines against many cervical and other cancers.

Why do we need one?

By identifying cervical metaplasia early we can easily treat the effected cells before they turn into a cancer. This is why they are done regularly; every two years if your tests are normal or sometimes sooner if early changes are spotted.

When do I have to start getting them? (And when can I stop?)

Ideally, you should have your first pap about two years after your first penetrative sexual experience (which is not limited to penetration by a penis!) but smears are not usually done on girls under the age of 18.

Current Australian guidelines recommend pap smears every two years until the age of 70.

I’ve had the cervical cancer vaccine… do I still need them?

Sadly, yes. Whilst Gardasil reduces the risk of cervical cancer by a whopping 70% in women vaccinated before their sexual debut this still leaves a 30% residual risk ongoing.

Low risk is not the same as no risk, so until we have a vaccine against all the HPV types responsible for cervical cancer, given to all women, the pap smear will remain an important part of our screening regimen.

Meanwhile… has your daughter had all three shots? (Sorry, had to slip that in!)

I’ve only ever had female partners… do I need paps?

Again, sadly yes. HPV is transmitted between partners by intimate sexual contact, so if you’ve had penetrative sex involving another person (including penetration by fingers, toys or other penis facsimiles) then you’ve potentially been exposed and need to have regular paps.

What happens if my smear is “abnormal”?

Better Health Channel has an excellent fact sheet outlining the different types of pap abnormalities.

We know that the vast majority of minor abnormalities will return to normal as the body’s immune system suppresses and eradicates the HPV. That is why your doctor may simply advise a repeat smear in 6 to 12 months initially to confirm that the abnormality has gone.

For more advanced changes, or changes which persist over several smears, you would normally be referred for a colposcopy. This is a special microscope used by a doctor to identify visual characteristics of more significant cervical abnormalities, and if necessary they can take tissue samples (biopsies) for examination by pathologists in a lab.

[box] Pap tips

Know your pap history and keep details or copies of abnormal results; it’s unlikely that you’ll have all your paps done by the same doctor over your lifetime.

Relax! It sounds impossible, relaxing while someone’s poking about “down there”, but if your pelvic floor is relaxed it will definitely boost the comfort rating.

Avoid clenching your buttocks or lifting your pelvis off the bed. Try focusing on your breath with techniques like this one.

Find a clinician you’re happy with, which may be a nurse, doctor or other trained health professional. The important thing is feeling comfortable and trusting in their expertise.[/box]

[author] [author_image timthumb='on'][/author_image] [author_info]Dr Kelly Teagle lives in Canberra with her daughter Bella (5) and son Alex (2). She graduated from UQ Med School in 2001, is a Fellow of the Royal Australian College of General Practitioners and holds postgraduate qualifications in Women’s Health. Dr Teagle is the Principal of WellFemme Women’s Health Services; for private consultations phone the Annie Lim Group Family Practice in Deakin on 6162 0463 or Sexual Health and Family Planning ACT (SHPACT) on 6247 3077. You can email Kelly at [email protected]. Watch this space for the WellFemme website and Facebook page coming soon![/author_info] [/author]



About Author

Dr Kelly Teagle lives in Canberra with her daughter Bella and son Alex. She graduated from UQ Med School in 2001, is a Fellow of the Royal Australian College of General Practitioners and holds postgraduate qualifications in Women’s Health. For private consultations phone the Annie Lim Group Family Practice in Deakin on 6162 0463 or Sexual Health and Family Planning ACT (SHPACT) on 6247 3077. You can email Kelly at [email protected]

View all Kelly Teagle posts.

(15) Readers Comments

  1. Shell
    November 24, 2011 at 9:53 am

    I am new to Canberra, are there any free health clinics that do pap tests in Canberra?

    • Kelly Teagle
      November 24, 2011 at 6:09 pm

      Hi Shell, welcome to Canberra!
      You could try the Womens Health Service on 6205 1078, however they are mainly geared up to provide a free service to disadvantaged women and have limited resources. Their blurb on the ACT Health website says they “give priority to women who experience significant barriers to health service access. These barriers may include, but are not limited to, the impact of violence, social or economic disadvantage, disability, language, culture, sexuality or isolation”. This may be of some help if you meet these criteria.

      I will assume here that you have a Medicare Card… generally, unless you can find a bulk-billing GP clinic (and I can’t think of one) a standard GP appointment would leave you around $35 out of pocket after your medicare rebate, plus the cost of the test itself which would be about $32 after the rebate, a total of just under $70. Most GP’s however (myself included) are happy to bulk bill you for such an important service if you let them know you’re having financial difficulties. The pathology labs will also bulk-bill for the test fee on Dr’s request. If you book an appointment for a pap at SHFPACT (Sexual Health and Family Planning ACT on 6247 3077) and tell them you need a pap but can’t afford one they will definitely bulk-bill you, and the pap test will also be bulk-billed). Hope this helps!

  2. Elizabeth
    December 1, 2011 at 12:14 am

    Unfortunately, women are being misled and risking their health if they follow our program – it is about a decade behind the evidence and was always excessive. No woman needs 26 or more pap tests, it’s OVER-screening and greatly increases the risk of a false positive and potentially harmful biopsies and over-treatment for NO additional benefit over 3 yearly and only marginal benefits over 5 yearly.
    Our program worries and harms FAR more than necessary, because they simply don’t care about the more than 99% who can never benefit from this program.
    Lifetime risk of cc – 0.65% – take out false positives and consider other factors had this rare cancer in natural decline before testing started and fewer than 0.45% can possibly be helped – while our referral rates are MASSIVE – 77% is the lifetime risk for colposcopy and usually some sort of biopsy.
    Much of this over-detection and over-treatment is completely avoidable….you stop over-screening.

    More doctors are putting their patients first and warning them about this outdated program, while others carry on urging women to risk their health unnecessarily. Even putting women through this invasive test more than absolutely necessary shows a cavalier disregard for the bodily privacy of women.
    A review of this program has just commenced, but the report is not due until 2014, and then how long before the Govt makes changes. 2016, 2020? No one is pressuring them to change this program, no one is protecting women – our legal rights, health and well-being.

    Other countries have no more cc or less with FAR less testing – Finland and the Dutch have 5 to 7 pap test program, 5 yearly from age 30 – the Finns have the lowest rates of cc in the world and send the fewest women for colposcopy/biopsies – almost all referrals after “abnormal” pap tests are unnecessary/false positives.
    The Dutch are about to move to 5 hrHPV “primary” tests at ages 30, 35, 40, 50 and 60 and only those positive will be offered the 7 pap test program. Self-test pap and HPV kits are also available.

    Those negative and monogamous or no longer sexually active might choose to forget all testing and revisit the subject should there risk profile change in the future. This program will identify those women “at risk” who have some chance of benefiting from pap testing and GREATLY reduces the amount of testing and over-treatment/unnecessary biopsies.

    I disagree with paying GPs to reach screening targets, it creates a potential conflict of interest – tell women or stop these payments. Women have never received honest and complete information about this testing and our legal right to make an informed decision has been dismissed…men are not treated in this way. There is no respect for informed consent in women’s cancer screening.

    I’d urge all women to walk away from this program and if you want to test, consider a program that provides you with better protection from false positives – over-treatment can damage the cervix and lead to cervical incompetence, premature babies, the need for c-sections, cervical stenosis, psych issues etc…these risks have always been hidden from women.

    The UK has lots of amazing doctors fighting for our right to make informed decisions about screening – Prof Michael Baum, Dr Angela Raffle, Dr Margaret McCartney and the Nordic Cochrane Institute is also a source of balanced information – they look at ALL of the evidence.

    If you’re considering mammograms – same thing, we haven’t been told the truth – throw the Breast Screen brochure in the bin and go to the NCI website and read, “The risks and benefits of mammograms” and anything by Prof Baum.
    If I had my way I’d hand a copy to every woman considering mammograms – over-diagnosis is a serious concern and also the benefits are controversial – more research suggests the fall in the death rate is about better treatments and not screening.

    IMO, our programs serve vested and political interests and are much more likely to harm us – it reflects poorly on our doctors that so few are prepared to warn women of the risks, “actual” benefits and are even collecting undisclosed target payments for pap testing/over-screening and risking their patients health.

    NOTE: Not one country in the world has shown a benefit pap testing women under 30, but all have evidence of harm – these women produce the most false positives. I know some research is being conducted into the effectiveness of Gardasil – it’s possible to do the research here because we’re STILL performing pap tests on women under 30 – many other countries have excluded them for their own protection. It is considered unethical in the UK to screen women under 25. Pap testing women under 30 does not change the tiny death rate, but causes worry and harm.
    Have these young women provided informed consent for the testing or the research?
    Other doctors “get it” – see, “Doctors should not support unethical cancer screening programs” by Dr Margaret McCartney.
    As a low risk woman, my risk of cc is near zero – I made an informed decision almost 30 years ago not to screen and more recently declined breast screening. I did not get the information I needed to make informed decisions from our doctors or the Govt – in fact, that information was misleading, incomplete and inadequate.
    Many GPs simply tell women they must or should screen without providing information on the risks and actual benefits or giving the woman an opportunity to assess her risk profile. VERY few women are giving informed consent for cancer screening in this country and no one seems to care. A double standard exists – men were provided with risk information very quickly and doctors were reminded to get their informed consent – women are STILL waiting for this respectful and ethical treatment.
    Please, do your reading and protect your healthy body, make informed decisions about screening.
    Heads should roll that women are still being urged into a harmful and excessive program. (research into Gardasil) (self-test hrHPV kit being used in the Netherlands) (The new Dutch program) (Research by Dr Angela Raffle, et al “1000 women need regular smears for 35 years to save ONE woman from cc”)
    (“Why I’ll never have another smear test” by Anna Saybourn)
    “Time to change the Policy” by Dr James Dickinson (2002) – 9 years old now! (No delay – you MUST be joking!)

  3. Elizabeth
    December 1, 2011 at 10:40 am

    “Lifetime risk of cc – 0.65% – take out false positives and consider”

    Just noticed an error, that should read, “take out false NEGATIVES” – these women may be disadvantaged by the test – it may give them false reassurance and they delay seeing a doctor for symptoms.
    Women should be told to address persistent and unusual symptoms regardless of normal pap test results.
    Sadly, it’s an intrinsically unreliable test. There are no randomized controlled trials for pap testing either – I don’t believe we should ever introduce population screening without doing RCTs.
    It concerns me that a small problem has been turned into a massive industry in over-treatment, in the States one billion dollars is made every year from excess cervical biopsies. This testing should not be having such a negative impact on the more than 99% who can never benefit – they have rights as well, and their health, bodily privacy and quality of life should also matter.

    It’s worth noting this cancer occurs as frequently as mouth cancer – Dr Raffle and Dr Muir Gray make the point in “Screening” that few women had even heard of cervical cancer before the screening program started – the fear of cervical cancer is now far greater than for cancers that occur as often or in MUCH greater numbers like bowel and lung cancer. Many women don’t realize almost all of the referrals and treatments/biopsies are unnecessary and assume the test is catching cancer or women are being treated for cancer – this has skewed our perception of risk. It’s called the “popularity paradox”…
    Some women will say they had a “cancer scare” or had “pre-cancer” removed, when they had an abnormal pap test and normal biopsy or unnecessary treatment – the chance an abnormal pap test is for something that might become invasive cc – LESS than 1% – the chance it’s a false positive/over-treatment – more than 99%. It is therefore terribly important to do some research and do the right thing for your body and level of risk – it should be your decision.
    Anyone interested in this topic might enjoy the book by Raffle and Gray and books by Dr Gilbert Welch.
    We are some of the most over-screened and over-treated women in the world – and it continues….

  4. Kelly Teagle
    December 2, 2011 at 6:44 pm

    Thanks for contributing so much to this discussion, Elizabeth. One of the best things about the internet is that it helps empower people to seek out information, engage in robust debate and make informed choices about their health. As always, without challenging established ‘norms’ we cannot evolve.

    You make some very valid points about the Australian cervical cancer screening program. Its inadequacies are widely acknowledged amongst experts in the field who are also frustrated at the failure of protocols to keep pace with latest evidence (which is being continually updated at lightning pace). In one of the articles you cited these frustrations are echoed by the Chairman of the committee reviewing our current screening program, Prof Ian Hammond (who also chaired the last review). When approached to do the job again he replied that he “wasn’t prepared to chair the committee, to be honest, if it was going to be a really dragged-out process.” He obviously feels this will not be the case since he accepted the task. (must register to use this site)

    Even with motivated drivers like Prof Hammond and “no delay” the findings will take until 2014 to be handed down, due largely to the logistics of reviewing such a large body of ever-changing evidence and gaining nationwide expert consensus. The current screening program has been one of the most successful in the world so it is important to make sure that any changes made are improvements. Our cervical cancer rate is now amongst the lowest in the world: The Cancer Council quotes the following:

    “In 2005 estimates, cancer of the cervix accounted for 610 new cancers in Australian women (AIHW, AACR, NCSG & McDermid 2005). The lifetime risk of a woman developing cervical cancer before the age of 75 years is 1 in 233 (AIHW, AACR, NCSG & McDermid 2005). In Australia in 2004, cervical cancer accounted for 212 deaths (AIHW 2006). Between 1991 (when Australia’s National Cervical Screening Program commenced) and 2005, the incidence of cervical cancer among women aged 20 to 69 halved from 17.2 per 100,000 women to 7.3 in 2005 (AIHW, AACR, NCSG & McDermid 2005). The mortality rate has also declined from 4.0 in 1991 to 1.8 in 2004 (AIHW 2006), and is now among the lowest in the world (IARC 2002). Mortality data from 2001 to 2004 in Queensland, South Australia, Western Australia and the Northern Territory indicate that Indigenous women have a mortality rate attributable to cervical cancer of 9.9 per 100,000 women. This is more than four times the corresponding death rate of non-Indigenous women (2.1 per 100,000 women) (AIHW 2006).

    One thing I am sure of is that Governments will not to throw billions into screening programs that don’t work. One of the underpinning principles of a successful screening test is cost effectiveness. If the evidence shows (as it does) that a program can be equally successful by only doing a test every 3 years rather than 2 then the change will be made.
    Health professionals fully anticipate that after this review the interval for paps will be lengthened to at least 3 years, and that the test itself may well be different, perhaps an automated test rather than a human scientist actually looking at cells under a microscope. As cancer rates continue to fall due to vaccination, testing for the fewer and fewer remaining cancers will probably change dramatically; it is a very dynamic and interesting area of medicine right now. In the meantime I encourage women to consider all information available to them, ask questions of their doctors and make an informed choice about whether to take up screening. Yes, there is a small imposition and financial cost associated with screening, yes you may end up having unnecessary follow-up tests, and yes the statistics are largely reassuring. We are all free to opt out, but please consider: would you be comforted by having exercised the right of refusal if you or a family member were the “1” in 233 to develop this preventable cancer?

  5. Susan
    December 3, 2011 at 7:52 am

    Kelly, I find your final question “would you be comforted by having exercised the right of refusal if you or a family member were the “1” in 233 to develop this preventable cancer?”

    To be condescending and fear-mongering.

    How do you feel when 49%+ of women who have had regular ‘normal’ smears get cervical cancer?

    YOu mention that women should consider all information available to them – HOWEVER much of the information stated by Eliz above is NOT published or shared in the pro-pap brochures or told to women prior to testing.

    Ask nearly any woman what the lifetime risk of cervical cancer is… you will quickly find that nearly all women believe that this RARE cancer is extremely common.

    Women who forgo having flu vaccine because they are ‘low-risk’ are cowed into having Paps because the media makes it seem rampant. So these women think they are more at risk/more likely to get cervical cancer than they are the flu?!?! WTF is going on here? It is mis-information that is completely intentional to support a system that has been built around pap testing & the FACT that it generates huge amounts of false results that keep many providers in business.

    Here in the U.S. paps keep an over 6 billion dollar business on its feet. Without false positives, there would be no need for colposcopy clinics being nearly as common as BurgerKings and more than 1/3 of our adult women would not be choosing to be neutered (hysterectomy) as the only way to avoid further trauma.

    How about instead of trying to guilt women into testing – you consider this question: How do you feel KNOWING that even ONE baby is born prematurely or never conceived at all due to UNNECESSARY damage done to unsuspecting women all over a less than 1 in 233 LIFETIME risk??

  6. Jacqui
    December 3, 2011 at 8:02 am

    Hi Kelly, I have some questions about your article. Why is it you are writing your article as if pap tests are mandatory? The pap is an optional screening test, just like the prostate test is for men. I see no mention of this in your article. Also, why have you not included the risks versus benefits? Very, very high rate of false positives and false negatives. Then there is the issue of unnecessary follow up testing such as colposcopy, LEEP, biopsies etc. Since these procedures happen to a huge majority of the women who trot in to have their pap, why is no mention made of these follow up procedures and the damage they can cause. Cervical stenosis anyone. What about problems conceiving or carrying a baby to term. Is that tumbleweed I hear blowing down the silent street of denial? Please, don’t get me wrong, I am not some legume eating hippy freak opposed to all forms of testing, I am however an informed woman who is very, very curious as to why this test which helps so few to harm so many is surrounded in lies, half truths and paternalism. Why do doctors not inform women of the fact that the test is VOLUNTARY, there are many RISKS as well as benefits, and that the doctors receive PAYMENT/INCENTIVES for every pap test they perform. Why are women treated like naughty children – We MUST have this test, do we WANT to get cervical cancer and die, it’s FOR OUR OWN GOOD???? Why are we not told the truth like men are, and given ALL the options and left to make our own damn decisions about this? Thank you for your time.

  7. niki
    December 3, 2011 at 8:35 am

    Dr Teagle,
    Thank you for your article. I would like to bring up one point.You say that “We are all free to opt out”.That has not been my experience. Years ago when I wanted birth control I was told that I would have to have a pap smear before I was prescribed the pill. My friends also had the same experience.
    Also, I have had three children and at every booking visit I have been asked when my pap smear was and it is asked in a way that it is assumed that I will have one if I am due. Even our yellow cards that we carry around during pregnancy has a place printed to put the date of our last pap. Does that make women think we are free to opt out?

    Also I wonder about the success of this program. I have read the autobiography of Jan Murray “Sheer Madness”. She tell the story of having a pap after the birth of her 5th child in about 1970. They tell her that her that her pap is abnormal and she should not not get pregnant. She does get pregnant and her doctors tell her she must have an immediate hysterectomy or she will die. She reluctantly agrees. After the hysterectomy her uterus is sent to pathology- no signs of cancer. The pap test was wrong!
    So if we take into account all these “mistakes” ie false positives is the program really that successful?

  8. niki
    December 3, 2011 at 8:46 am

    I should add if I didn’t make it clear -she had the hysterectomy while she was pregnant. I have also heard back in those days of a virgin having a hysterectomy after being told she had cervical cancer – obviously another medical error of the pap. I think these blunders are unforgivable and if we take into account the babies that were never born either by miscarriage or because these women were never given the chance to be mothers in the first place the program is a disaster!

  9. Phoenix
    December 3, 2011 at 9:10 am

    Kelly, your article doesn’t make any mention of the negative and harmful side of pap smear testing. I made a complaint to the NSW Cancer Institute about their current advertising campaign (not sure if it’s happening in all states!) where they are using lies and threats to get women to pop on in for ‘their’ pap smears.

    These type of campaigns appear every so often when the national figures for the percentage of women having a pap smears begins to drop. And over the last few years, the figures nationally have been steadily dropping. I put this down to Gardasil (that’s a whole other arguement, a vaccine that only works against 2 strains of HPV and has serious life-long side effects shouldn’t be used on the public!) and more women finding out that cervical cancer is very rare, the test is unreliable (32% according to some scientific papers, but mostly hovering near only 50%) and that they have every right to stand up to their demanding doctors and refuse to be bullied. Especially since doctors operate under the PIP – Pap smear Incentive Program – a program which encourages doctors to bully/ambush women into screening via financial incentives and kickbacks…

    The posters in womens toilets and the TV advertisement all say, ‘A pap test is nothing, compared to (insert wearing high heels, having your legs waxed, etc). I’ve spoken to sp many women (and read stories online) who have struggled with feelings similar to being raped, degraded, violated, not wanting their husbands/boyfriends to touch them for weeks after a smear, who’ve been sexually abused yet are FORCED into having a pap smear by over-bearing and emotionally ignorant doctors. The Sydney Morning Herald ran an article not so long ago ‘tut-tutting’ over women who have been sexually abused ‘avoiding’ having pap smears. Absoliutely no mention anywhere that pap smears are OPTIONAL CANCER SCREENING and not a legal requirement!!

    The NSW Cancer Institute posters threaten women that (quote) ‘most women diagnosed with cervical cancer haven’t had regular pap tests’. Knowing that this is a common lie used by pap smear campaigners, I asked them to provide me with which statistics/research they are using to make this wild statement? They have been in contact with me, but they cannot tell me which realworld figures they are relying upon to make such a grandiose statement.

    The posters also say in big letters down the bottom – ‘Every woman, every 2 years’. That statement takes my breath away!!! Only high risk women should be testing, not EVERY woman! Virgins, virgin women who have had only one partner who was also a virgin, women under the age of 30, and any woman who simply says ‘no’, don’t need pap smears!

    Pap smear campaigns run on lies and threats. For me, that is a huge factor in making my own decision to decline this optional cancer screening. Another big factor was reading the horrific and disturbing stories from other women on internet forums about their experiences with pap smears. Women who have had vital medical treatment withheld from them by sadistic doctors until they be ‘responsible’ and have ‘their’ paps mear. Need a script for the pill? Have a pap smear first or you’re not getting one. Pregnant and need pre-natal care? Have a pap smear first or go find yourself another doctor. Need a new script for your migraine meds? Have a pap smear first or you get no script. Have insomnia and need help? Have a pap smear first or be dumped as a patient because you’re non-compliant (and no, I am NOT making up that last one!!! A friend in america went through that – she was stunned, I was absolutely furious).

    Point is, women are intimidated, bullied, raped emotionally and physically by supposedly well-meaning doctors (I say that sarcastically) to force them to get pap smears. Any woman saying no is met with anger, threats, refused medical treatments, and generally treated like lepers.

    I used to speak with Papscreen Victoria about the mis-information in their pamphlets (I’ve never had an answer from Papscreen NSW), and they admitted to trolling the electoral records to cross check which women weren’t on the national pap smear register, and then sending them invites in the post to get their smears done. Yes, an incredibly breath-taking invasion of privacy. But who can stop them?? If I got an invite in the post out-of-the-blue like that, I’d be talking to my solictor.

    To sum up, pap smears are used as a tool AGAINST women. We are denied informed consent, refused the right to say no, had important information (rare cancer, unreliable test, smears can’t save your life in 10% to 20% of cancer cases) hidden from them, and all of this is acceptable to the medical profession, the government and the state/national cancer agencies.

    I’ve never had a pap smear. I’ve always declined. How many other women should be doing the same? Any woman who is low risk should, and I’m guessing that would be at least 70% of the female population. It’s a national disgrace that it doesn’t happen like that.

  10. Kelly Teagle
    December 3, 2011 at 3:11 pm

    Hello ladies, thank you all for your comments. I apologise for posting this single response; all your points are worthy of lengthy discussion but I’m afraid your collective passion overwhelms my somewhat limited capacity to reply.

    I am quite surprised at the controversy my local informational piece has generated interstate and overseas. It was purely intended to provide some key facts about how and why paps are done, as I find many women are unaware of this during pre-test counselling. I am also surprised that Susan found the reflective question at the end of my last post to be “condescending and fear-mongering”. This type of reflective questioning I find is very useful when guiding patients through the uncertain realm of screening tests. For example, when couples are deciding whether to proceed with a screening test during pregnancy for genetic abnormalities it is often helpful to ask them beforehand to reflect on how they will feel about a certain result. To me this seems respectful and inclusive, not condescending. As for fear-mongering, well I happen to believe that HerCanberrans are intelligent women who understand that bad stuff happens in life sometimes so I don’t think they’ll be too shocked to hear that they have a small chance of developing cancer.

    Screening programs are not mandatory, nor are they enforced. Non-participation is not punishable, at least not in any systematic sense. Unfortunately though (as in all areas of life) there are some paternalistic medicos out there who see it as their role to dictate to patients, or worse even intimidate or belittle them. I too have been a victim of such medical bullying at a vulnerable time in my life and I condemn their methods as strongly as you all do. My advice is to find a clinician you trust and feel comfortable with. Don’t accept that just because someone is a doctor that everything they do must be ok… if it doesn’t feel ok then object and/or leave. You also have the ability to lodge complaints through the Healthcare Complaints Commissioner in your home state (sorry, not sure about agencies in the U.S.) In the ACT:, or in NSW:

    It is true that there are incentive programs for doctors to meet screening targets. This is not limited to just the cervical cancer screening program but also other areas like diabetic care and immunisation. These programs only become cost-effective when the people at most risk are participating, so practice incentives are designed to encourage doctors to identify patients most at risk from certain conditions and offer interventions. Health consumers are often the recipients of incentives too, such as immunisation bonus payments. Paternalistic as this may seem it still does not negate the individual’s right to decline.

    It is also true that adverse outcomes do occur in medicine. We walk a tightrope trying to get the balance right always: we are tending towards disclosure of every possible risk now, no matter how minor, often terrifying patients half to death before procedures that they actually really want or need and making the whole experience far more traumatic than it needs to be. This is called ‘informed consent’, something that litigation lawyers love to argue about. To be balanced we need to be open about the possible outcomes of not proceeding also. To most people even the very small risk of a cancer, especially one that can be cured, outweighs the small risks associated with testing. However I do acknowledge your points about making information more readily available regarding possible negative outcomes; thank you for reminding me to think about the way I counsel women in this respect.

    Your comments imply a belief that doctors take some morbid delight in imposing unwanted pap smears on women. Personally I don’t find pap smears to be very professionally challenging or exciting, nor is it the highlight of my week when I’m due to have one. I will celebrate along with the rest of womankind when there is a more ‘dignified’ way of ruling out this disease. Until that time however I will continue to offer a compassionate, co-operative service which includes open discussion about women’s healthcare issues and supporting their decisions. One of my tasks as a doctor is to interpret medical evidence and make healthcare recommendations; I will continue to support pap screening based on the evidence we have, ie. it works. When expert consensus shows that something else works better I’ll support that too. I would be doing my clients a disservice (and be negligent in my ‘duty of care’, medico-legally speaking) if I were to do otherwise.

    I don’t expect my words to meet with your approval, or that they will be the last words in this discussion. The information presented here is as honest and evidence-based as I can make it but I respect your right to disagree and make your own health choices. I admire individuals and groups like yourselves for the passion of your beliefs and willingness to challenge conventions. But you won’t find any cavalry-charge of militant pro-Pappers here, just a humble GP supporting the rights of women who are trying to do the right thing for the health of themselves and their families.

  11. Elizabeth
    December 3, 2011 at 4:10 pm

    Dr, thank you for your response.
    “Its inadequacies are widely acknowledged amongst experts in the field”

    BUT Dr Teagle, NO ONE is speaking to women, NO ONE is warning women that they are over-screening and risking their health for no additional benefit.
    Why are women locked out of these discussions, when they are they ones taking the gamble? Why is testing promoted as safe, simple, reliable and essential? We know the chance of benefiting is remote at best and zero for almost all women, and the risk of worry and harm VERY high – yet the last time I looked, Papscreen did not even mention false positives in their brochure, yet they mention false negatives, which are nowhere near as common.
    Why? Because false negatives serve to scare women into regular testing – it is ALWAYS about protecting the over-screening program, not women. We get bad advice at every turn, even from our doctors – many women still trust their doctors and follow their advice, assuming it’s in THEIR best interests.

    We don’t see this sort of dishonesty in prostate screening, yet unethical tactics, dishonesty and lack of respect for informed consent is the norm in breast and cervical cancer screening.
    I’d hoped the arrival of female doctors on the scene might have changed things, but have been terribly disappointed – they are as paternalistic as their male colleagues.

    To give you one example, Dr…
    There is a war raging in the UK and elsewhere over breast screening and many very senior doctors are calling for the program to be scrapped or scaled back. (including the man who helped set up the first screening clinic in the UK, Prof Baum) Yet VERY little manages to get into the papers here – recently though, a brave doctor, Assoc Prof Robin Bell, decided women should hear about this discussion – especially when our brochures are grossly inadequate and everyone in the profession is silent – she featured in the “Age” and raised the issue of over-diagnosis.
    The so-called benefits are also doubtful, as more research shows the fall in the death rate is about better treatments, not screening. Assoc Prof Bell has my gratitude and I respect her enormously – while every other doctor and academic remained silent or engaged in discussion locked away in medical journals, she spoke TO women…that makes her unique in the Australian medical profession.
    It is a shameful reflection on the way the medical profession views women – and their rights, health and bodies.
    Assoc Prof Bell has not forgotten what medicine is about – first do no harm – your first responsibility is to women, not these programs. Doctors should not be making decisions for women and accepting risk on our behalf…yet that is the norm in this country. The Minister of Health has naturally remained silent, along with everyone else, hoping the issue will simply die and they can get on with screening and reaching their target – their political objective.

    Helen Zorbas from Breast Screen recently appeared on TV, advising women a Swedish study showed 30% less mortality from breast cancer for screened women over the long term. She OMITTED to mention the later study that showed the fall in the death rate is about better treatments, not screening. This is my STRONG objection – it is unethical for those in positions of power to cherry-pick research that supports their cause and objectives – they are playing with women’s lives, this is NOT a game – if she wants to mention the Swedish program, she MUST also mention the later study.
    Of course, how many doctors have stepped forward to warn women of the omission and to challenge Ms Zorbas?
    Not ONE…
    Is that a fair, ethical and acceptable way to treat women?

    It is IMPOSSIBLE to make an informed decision about screening when risk information is deliberately suppressed, when misleading and incomplete/cherry-picked information is fed to us and psychological and other unethical tactics are used against women. This attitude does NOT exist in prostate or bowel cancer screening…the latter struggles for funding, even though it occurs far more often than rare cervical cancer, and we get nowhere near the pressure to test. Prostate screening has been handled ethically and respectfully…men don’t get orders or scare campaigns.

    Why this extraordinary and continuing pressure to screen for a rare cancer?
    Because it was known at the start that vast numbers would be needed if they were going to justify the vast sums spent on this program to screen for a RARE cancer, and one already in natural decline – an unreliable test meant many healthy women would get caught up and harmed by this testing, it was also known that very few women could benefit from the testing – they were looking for 15 in 100,000 women – a few needles in a huge haystack.
    Informed consent might jeopardize the target and the effectiveness of the program, and so this program started with the knowledge it would operate outside the law (informed consent) and proper ethical standards.

    Screening programs are “offers” because they expose healthy symptom-free people to risk and therefore we are legally entitled to, and you are ethically obliged to provide, a BALANCED overview of risk and “actual” benefit to enable us to make an informed decision, and that includes being free to decline….do you really think that is a description of what we have in cervical and even breast cancer screening?
    Not even close…

    IMO, this was never a suitable population screening test…it is unethical to operate without informed consent and to harm and worry vast numbers to “possibly” help a few women.
    If vested and political interests are preventing change, this needs to be dealt with swiftly and harshly and you immediately notify women that our program is excessive and harmful.

    It is ONLY possible for this abuse of rights, health and body to continue with YOUR co-operation and that of other doctors – you all remain silent and continue to urge women to over-screen and risk their health. YOU have deserted your patients and now serve the program, which is clearly not in the best interests of your patients.

    You say this is the most successful program in the world, I couldn’t disagree more…
    It is only successful if you don’t give a damn about the more than 99% who can never benefit, who not only endure this invasive test, but endure it far more than necessary, and when 77% end up being referred for colposcopy, biopsies and over-treatment. Some are left worse off…
    Not to mention all the women who get “abnormal” results and spend months worried sick, waiting to re-test…or end up on the abnormal pap test merry-go-round.

    These women have no voice, no one is really counting them or cares – there is little research on the number of excess cone biopsies and LEEP. I know my sister’s specialist told her more than 50 cone biopsies are performed for every one that turns out to be necessary. We have research that links these procedures, especially LEEP and cone biopsies, to cervical incompetence and high risk pregnancy/premature babies and the need for c-sections, we know some women end up with cervical stenosis and scar tissue that can cause issues with menstruation and lead to endometriosis and may require a procedure/surgery. We know some women develop psychological issues and psycho-sexual problems. All of this is ignored and dismissed with the entire focus on the small incidence and death rate. Many of these women never work out they were over-treated and that has provided the profession with some protection from legal action.

    We have young women pushing screening for the Cancer Council because their mothers “had cancer” when they were 23, when you can bet the mothers had a false positive and unnecessary treatment – we know pap testing every woman under 30 makes NO difference at all to the death rate, you just worry and harm the masses. We now have lots of women who “think” they have a “family history” of cervical cancer or “think” they had a cancer scare. It’s just cruel…Dr Raffle tells us that 1 in 3 pap tests will be “abnormal” in women under 25 and that it’s unethical to screen them. Yet many of our “doctors” persist, some even testing teenagers.

    Also, if you want to promote this as a contest, as a race to eradicate this rare cancer – Finland would clearly take the award – they have the lowest rates of cervical cancer in the world and the lowest referral rates. Their program has always shown some regard for the women who can never benefit and restricted testing to 5 yearly from age 30 to 50 or 60.
    Our program MAXIMIZES the harm for NO additional benefit – I’d say our program is one of the WORST in the world.

    You also accept that the fall in the incidence and death rate is all about screening – that is MOST unlikely.
    This cancer was already in decline before screening started and the very things that were having an impact are very likely to be having an even bigger impact today. It’s convenient to give all of the credit to the program, but most know that’s unlikely…more hysterectomies occur these days (it’s a safer procedure), fewer women smoke, thanks to the Quit campaign, better condoms and hygiene, less sexually transmitted disease etc (the last two mentioned by Dr Gilbert Welch in his latest book, “Over-diagnosed”)

    Stomach cancer has fallen by the same or a greater margin, with no screening – without randomized controlled trials you can never be sure, but we know if pap testing helps anyone, it’s fewer than 0.45%.
    “1000 women need regular screening for 35 years to save one woman from cervical cancer” (Dr Raffle et al) – how many women are worried and harmed over that period?

    This cancer is NOT preventable either – false negatives will always occur.
    There are FAR better ways to deal with this rare cancer and our doctors should have walked away from this program long ago, and should now demand hrHPV PRIMARY testing and self-sample HPV and pap kits for those women who make an informed decision to screen. We should also educate women on prevention – condoms can reduce the risk of HPV infection by 70%…(US study of college women – I have the reference if you’d like it)

    The continued over-screening and over-treating of women is inexcusable – doctors are knowingly risking their patients health – this is a very serious matter.
    I firmly believe this program remains unchanged because it is firmly controlled by vested and political interests – they benefit from it, we do not…

    The research into the effectiveness of Gardasil means they need young women to have pap tests – the delay is IMO, to enable them to also finish their research – they are deliberately violating the bodies of young women to further research – these women have been excluded for their own protection in many other countries.
    Who is protecting our young women? Are research egos of more importance than the legal rights and health of our young women? We all know they cannot benefit from pap testing.

    The facts: Our doctors are silent, our doctor promote over-screening and inappropriate screening, our doctors serve the program and collect target payments for their trouble. They have allowed Papscreen to corrupt the doctor-patient relationship.

    Your final statement is one promoted by pro-screeners and is rarely used in other screening programs.
    It denies women the protection of law and ethics that must accompany every screening program – the right to assess the evidence and their risk profile and to make an informed decision.
    I take responsibility for my screening decisions and they are based on facts, not scare campaigns, hype, misinformation or to make up numbers for Papscreen or help a doctor reach her screening target.
    It is inappropriate to make that statement about bowel cancer screening, which is much more common…and
    it’s an offensive and insulting way to try and sell screening to women. We want the facts and some respect for informed consent, not threats and scary predictions.
    Be careful accepting any facts or statistics from pro-screening groups, their capacity for fudging figures and the facts is well-known to informed women.

    There is an opportunity here: to put your patients first and to act in their best interests and stop working for the program.

  12. Elizabeth
    December 3, 2011 at 4:26 pm

    “Don’t accept that just because someone is a doctor that everything they do must be ok… if it doesn’t feel ok then object and/or leave.”

    That is difficult for some women, the consult room can be an intimidating place. We also have clinics flagging files to ambush women in unrelated consults and without the facts, many women are unable to defend themselves against doctors. In NZ there are clinics that display posters that say that unscreened women of the practice may receive a visit from a nurse to “assist” with their pap test. In the UK before the incentives program was changed (thanks to some amazing doctors who have tirelessly fought for women’s rights to be respected) women were often counselled (bullied) by two doctors if they refused to test, others were forced to sign a disclaimer or removed from patient records. Papscreen encourage doctors to screen opportunistically, to do their dirty work, yet research shows opportunistic screening can cause psychological harm. It should be the woman’s decision if and when she screens – and we should be free to see our GP, without fear of being pressured into an invasive and unreliable test.
    I know women who avoid all medical care because of the pressure to test…who buy the Pill and other meds on-line or overseas – that should not be necessary.
    It is shocking to think that far more common health problems may be ignored or neglected and that GPs are happy to waste our valuable consult time to work for Papscreen.

    “But you won’t find any cavalry-charge of militant pro-Pappers here, just a humble GP supporting the rights of women who are trying to do the right thing for the health of themselves and their families.”

    How can they make the right decision for their health when they don’t have all of the information and if you are promoting over-screening and inappropriate screening?

  13. Amanda Whitley
    December 3, 2011 at 6:43 pm

    Ladies, thanks for all your contributions to this post.

    It’s obvious that this is an issue that you feel passionately enough about to seek out commentary on pap smears across the web (I think this is the first time this website – designed as a resource for local women – has received a multitude of international and interstate visitors within a couple of hours of each other).

    I understand and respect your desire to give the issue of what you consider ‘unnecessary pap smears’ airtime…and I believe there has been adequate opportunity for all views to be aired.

    In this case, however, I think Kelly’s simple article on ‘basic pap facts’ (which, for those of us who do think pap smears are a good thing, was informative and interesting) really doesn’t deserve some of the personal comments directed at her. The fact that she’s a GP doesn’t necessarily mean she’s the enemy.

    Although Kelly has not requested any action be taken, in respect to her status as a purely voluntary contributor to this website – and my own personal view that there are far more appropriate forums in which to have this conversation – I have decided to close comments on this post. Many thanks for your contributions and best wishes in your campaign to educate people as to your point of view…

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