There are reports popping up in the medical literature regarding the use of the Papanicolaou smear (PAP test) and its uselessness in women who have had their cervices removed. This has been debated from time to time over the years, but is now at the forefront. The conclusion was that the PAP is not needed without the cervix risk and that is becoming a recommendation by many authoritative gynecologic organizations. In view of where we all stand in the politics of world medicine today, perhaps another view of the issue is worth a peek. There are two sides to the coin.
As to the science, there is definitely value in taking a vaginal PAP in women without cervices. I did them for my almost four decades in gynecologic practice.
There are indeed those rare but nonetheless existent cases of vaginal cancers that are PAP screened and diagnosed. Rare, yes, but extremely virulent as compared to cervical malignancies and essentially the only chance for survival being early detection. The number of false positives that can have cancers ruled out by modern, noninvasive techniques, such as vaginal colposcopy, short of a simply biopsy is equally as rare, especially as our techniques become more refined. And there are known cases of lingering cervical cancer cells that can become vaginally vibrant years later.
There is also the detection of certain strains of the papilloma virus (HPV), a known forerunner to cervical cancer and likely vaginal as well.
Then there are the common vaginal infections of lesser morbidity that are PAP-uncovered and handily treated. When early changes of a vaguely suspicious nature are PAP-detected, the local application of estrogen cream and repeat tests after a known interval often eliminate the problem and give the patient that needed added security.
I can think of many needlessly-performed tests by insecure and inexperienced physicians that are infrequent enough and are dealt with when the clinician gains that security and maturity. But the PAP smear does not fall into that category.
This is a case of not seeing the forest for the trees. The words “cost effective” have no place in the management of our health concerns. We are in an era of preventive diagnostic procedures such as colonoscopies, sputum tests, TB skin testing, cystocopy, laparoscopy and mammograms, for starters, which can be dismissed if finances are allowed to be the governing factors. And those others are far more expensive and invasive.
As we waste billions on wars, space-military adventures and $640 rolls of bath tissue in Halliburton’s non-contested budget, isn’t there a certain shame in contesting the relatively minutia expense of an occasional PAP smear? Aren’t we at all embarrassed by even debating the issue? I cannot think of a better way to overspend than on our health. Instead of shooting first and asking questions later, why not PAP first and be thankful when it is negative?
This also reflects the two-tier medicine practiced in just about all the world, exceptions noted. In the underserved world that includes billions of needy women, their female tract pathologies are often the results of years of neglect, poor nutrition and callous and abysmal prenatal and intrapartum care. Vaginal fistulas and inflammations become chronic so having something so simple and innocuous as a PAP smear visit is often the only link these women patients have to their doctors and clinics. More attention, not less, must become the rule of thumb.
As that billboard cried out at Woodstock an era ago, wouldn’t it be great to spend all we wanted on our health care but were forced to have a church Bingo game to raise funds for another B-1 bomber?
Don Sloan is an ob-gyn physician and author of “Choice: A Doctor’s Experience with the Abortion Dilemma.” He can be reached at donsloan @ nyc.rr.com.