In the postpartum chapter of Pregnancy, Childbirth, and the Newborn, we briefly address what reproductive health care a woman might need long-term, after her childbearing year is complete. There have been big changes recently in pap smear and breast screening guidelines. I will summarize them here, then put up an additional post with all the details about breast screening.
Pap smears: In the past, Pap smears were recommended every year. That has changed. The CDC website has a chart here comparing recommendations from 1) American Cancer Society and others, 2) US Preventive Services Task Force, and 3) ACOG.
General summary: Under 21 years, none are recommended, no matter what the woman’s sexual history. From 21 – 29, pap every 3 years, no HPV co-testing. From 30 – 65, pap every 3 years and/or pap and HPV co-testing every 5 years. (Note: For women who have had the HPV vaccine, HPV co-testing is still recommended.) After age 65, stop screening for women with adequate screening history – either 3 consecutive negative results or two negative tests in the past ten years with the most recent performed within past 5 years. Pap smears should also be stopped after hysterectomy, unless the hysterectomy was performed because of cervical cancer or pre-cancer.
On a related note: no evidence supports or refutes speculum or bimanual pelvic examination. The decision whether or not to perform the exam should be made after a discussion between the woman and her care provider. Examination of the external genitalia is still recommended.
Breast Cancer Screening: In 2009, the US Preventive Services Task Force (USPSTF) came out with new recommendations based on a review of the research. The Susan Komen Foundation, American Cancer Society, and ACOG have adapted their guidelines somewhat since that time, but differ from USPSTF on what age to begin screening and how frequently to screen. Summary of recommendations:
- Breast Self Examination (BSE): A monthly routine of standardized BSE is no longer recommended. However, breast self-awareness is recommended: looking at and feeling the breasts on occasion to screen for changes. If concerning and unexplained changes are found, the woman should speak with her care provider.
- Clinical Breast Examination (CBE): USPSTF says there’s not much evidence of benefit to CBE if the woman is having mammograms. Other organizations recommend CBE every 3 years for women under 40, and every year over 40.
- MRI: Only for women at high risk of breast cancer and only in conjunction with mammogram.
- Under 50 years: USPSTF has said there’s not sufficient evidence that the benefit outweighs the risks for most women, but that the decision should be made after a shared decision-making process between the woman and her caregiver, based on a full understanding of the benefits and risks. Other organizations say annual exams starting at age 40.
- 50 – 75 years: USPSTF recommends mammograms every other year, as adequate to catch treatable cancers without over-diagnosis. Other organizations say yearly.
- Over 75: USPSTF says there is insufficient evidence about benefits and harms. American Cancer Society says to continue annual exams unless the woman has serious chronic health problems
One of the primary risks for screening (especially in younger women) is the chance of a false positive – the mammogram detects something which is either not cancer, or is a cancer that would not have spread or become life-threatening. These false positives can lead to more testing, biopsy, and sometimes cancer treatment which cause side effects, and anxiety, and may not have been necessary.
To learn lots more about breast cancer screening, including benefits and risks of screening, read this post.