Re: Adolescent pap guidelines
From: Barbara Nicol (blnicol@ix.netcom.com)
Wed Oct 25 16:36:32 2006
Married, monogamous, both partners claim no other partners - actually I think she is quite low risk, although I see that the basis for that opinion wasn't in my original presentation. I grant you that we get lied to daily by most of our patients, and we therefore have to treat them all that way - yet I'm inclined to trust this situation.
Even if it weren't so, the ACOG opinion recommended against early pap screening not because HPV isn't common - it is - but because severe disease is so rare and overtreatment of HPV that will spontaneously clear is quite common.
My immediate reaction was of course to get out the pap materials; I have the same training you do, but I'm trying to think this through a bit more. Is there an actual benefit here?
- Barb Nicol, M.D.
-----Original Message-----
>From: Lynn Montgomery <apgar10@qwest.net>
>Sent: Oct 25, 2006 2:21 PM
>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>Subject: RE: Adolescent pap guidelines
>
>First of all, she is not at "quite low risk for HPV", she is at high risk
>given that she is sexually active - being recently postpartum. I have
>always adhered to the practice of doing the first pap at age 18 or when they
>become sexually active. Given the extremely high number of abnormal paps I
>see in 14 through 18, I would not want to wait until age 21, and I live in a
>"low risk" community. I don't think this has anything to do with lawyers,
>it has to do with the fact that the prevalence of HPV is very high and it is
>our role to apply appropriate screening to assure that cervical lesions
>don't go undetected.
>Lynn
>
>-----Original Message-----
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Barbara
>Nicol MD
>Sent: Wednesday, October 25, 2006 3:11 PM
>To: Multiple recipients of list OB-GYN-L
>Subject: Adolescent pap guidelines
>
>ACOG and ACS says not to do a pap smear until age 21 or 3 years after
>1st intercourse (ref Oct 2004 ACOG committee opinion on cervical cancer
>screening in adolescents). They give pretty good reasons for this, too,
>so I try to adhere to it, while doing lots of STD tests in this
>population.
>
>So I have a patient, age 20, less than 3 years since starting sexual
>intercourse, presenting for her 2 week postpartum visit. She has never
>had a pap smear, because we are following the guidelines. She desires
>an IUD for contraception and is a good IUD candidate in every other
>respect, quite low risk for STDs, normal uterus, etc.
>
>Do I do a pap smear just because she wants an IUD, and normal paps are
>considered a prerequisite for IUD use?
>
>Or do I say that she doesn't need a pap yet, and is quite low risk for
>HPV given her social situation, and can have the IUD anyway? "Abnormal
>pap" is a contraindication for IUD use, but I haven't experienced
>"doesn't need a pap yet" and "wants an IUD" at the same time. Until
>now.
>
>What to do? Is the pap smear in this context only wasting money to ward
>off lawyers, or is there actual patient benefit?
>
>--
>Barbara Nicol MD
>St. Luke's Health Care Center
>San Francisco CA USA
>
