1/15/04

**New guidelines for Pap test screening.**

Alan G. Waxman, MD, MPH

**Questions for discussion:**

1.  How will we teach our patients to differentiate the pelvic exam from
    the Pap test?

2.  If a woman is put on an every 2-3 year cytology regimen, how will we
    keep track of when her next Pap should be or conversely, when her
    last was?

3.  Does a 24 year old who has never had vaginal intercourse need a Pap?

4.  Why does ACS set different intervals for conventional and
    liquid-based Paps for women in their 20s?

5.  Is there a role for the Pap plus HPV in Indian Country?

**\>\>\> <tracy.williams@TSAILE.IHS.GOV>**

**12/01/03 01:53PM**

1\. It is very difficult to explain to women the difference between a

PAP and a pelvic exam. I am not sure how to differentiate this except by
using the C word. It just has to be repeated over and over.

2\. This is a big problem at our clinic even for the annual exams. We do
have a health summary page that notes the last PAP, but the information
that the patient needs another one is generically noted as yearly. I do
make notes in my reviews (I tend to the see the larger number of the
women and do quarterly and yearly reviews on a percentage of charts) but
I still have women coming in for annuals that do not need PAP smears.
Since we use the "state of the art" RPMS, this will be a real challenge
to overcome.

3\. This is a very good question which I hope someone will respond to,
since I had a 30 year old virgin, NA, whom I could not get a PAP smear
collected.

4\. NO response.

6.  Yes. This helps guide our colpo testing.

**Alan Waxman <%5Bmailto:AWaxman@SALUD.UNM.EDU%5D>**

**Monday, December 01, 2003 2:40 PM**

Thanks, Tracy for starting off the discussion.

I'm going to address a few of the issues you raised.

Teaching patients, especially traditional women the difference between a
Pap and the rest of the gynecologic exam requires a bit of discussion. I
tell my patients that there are several tests we can do on the female
organs and that the Pap test is just one. "While you may not need a Pap
test every year, it is important to have the other tests." Also, it is
OK to use the C word with your Navajo patients. It's all in how you
phrase it. Instead of saying "We're doing this to see if you have
cancer" - a definite no-no with traditional Navajo women, try the third
person: e.g. "Some women can get cancer in their cervix. We do this test
on all women to see if they have changes that could turn into cancer."

The thirty-year-old virgin doesn't need cervical cancer screening.

I think you might have misread the Pap plus HPV question. It deals with
using cytology plus HPV DNA testing instead of Pap alone in women over
30 - not to be confused with follow-up of ASCUS with HPV testing.

**Perry, Donna <%5Bmailto:Donna.Perry@CHINLE.IHS.GOV%5D>**

**Monday, December 01, 2003 3:22 PM**

#2 With the PCC+ in use at Chinle, there is a little box on the adult
forms that lists the date of the last screening test (PAP, Hemacult,
Mammogram, etc). If the program works correctly, that field is self
populated and can give the provider an idea of the dates.

#5 The only way to know if the PAP/HPV testing is useful for AI/AN
populations is to do some sort of longitudinal study. With our current
marked increase in Syphilis and increasing HIV rates, HPV can't be far
behind.

**Knoki-Wilson, Ursula
<%5Bmailto:Ursula.Knoki-Wilson@CHINLE.IHS.GOV%5D>**

**Monday, December 01, 2003 5:38 PM**

Another way to explain the value of Pap smear to Navajo women is to say,
"We do this test to look for healthy cells. If we see a cell that is not
healthy, we check to see if cancer cells are growing in the cervix".

**Johnson, Erik \[Erik.Johnson@MAIL.IHS.GOV\]**

**Tue 12/2/2003 9:52 AM**

We need to do a lot more prevention, as this is really an STD, and
educate people about this, not just pretend it appears out of the
blue\...

**Lawrence Leeman \[lleeman@SALUD.UNM.EDU\]**

**Tue 12/2/2003 11:11 AM**

"Native American women should have reproductive health exams including
breast and pelvic exams annually."

To be heretical is there really a justification for an annual pelvic in
a monogamous 38-year-old NA woman?

What are we screening for? I am dubious that this is an effective screen
for ovarian cancer, especially in our heavier patients. Although we may
detect asymptomatic vulvar lesions we are not recommending total body
skin exams for other patients. There is no reason to do a rectal exam on
a 38-year-old woman.

Appreciate the excellent summary of the new recommendations. Thanks

**Johnson.Erik \[Erik.Johnson@mail.ihs.gov\]**

**Tue 12/2/03 12:25 pm**

You would also need to know if she was always monogamous, and that her
husband is always monogamous.

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Tue 12/2/2003 12:47 PM**

In response to Erik Johnson's comment, he is absolutely correct on both
counts. It is an STD and we do need more community education.

However, it is important when educating women with abnormal Paps to
separate the sexually transmitted nature of the virus from the cancer
prevention aspect of the abnormal Pap. The virus is extremely common in
younger (\<30) women, 60 -75% of women will have had some exposure to
HPV. Only 2-3% will develop dysplasia. When told they have an STD, the
first instinct is to blame the last person they had sex with. In fact, a
woman could have acquired HPV a decade before the Pap becomes abnormal.
So, while it is sexually acquired, HPV is more a marker of

having had intercourse.

Unfortunately, unlike other STDs, condoms provide much less protection,
since it's acquired by skin-to-skin contact and not mucosa-to-mucosa
contact. I tell my patients it's sexually transmitted, but try to
de-stigmatize it. I discuss how germs are transmitted when a couple
kisses, and similarly germs are transmitted when they have intercourse.
HPV just happens to be one of those germs.

**Burke, Thomas \[tburke@ANMC.ORG\]**

**Tue 12/2/2003 12:54 PM**

Question #1

Larry has a valid point. Though ACOG recommends continuing pelvics I am
not aware of any data supporting that. I think there is an important
point about routine health screening in general. The Pap has come to
function as the main driver of health maintenance for young women. If we
say three years for the pap we still want to see them to talk BC and
smoking and weight control ect. The under 30s are still yearly. I think
most people have enough real health problem or risks or behaviors or
educational needs to be seen annually with or without a pelvic.

Question #2

To me the pap history is every bit as important as the current pap
result, e.g., both for determining interval and for managing abnormal
results. (Though that's hard to write into a guideline). The Alaska
system keeps a computerized log of all Pap and colpo results. It's great
and I hope you have something like it. It's a lot of work and it can't
be delegated to inexperienced staff. The larger the system where your
patients get care the more important this is since it's so easy to loose
follow up on abnormal or to have an incorrect index of suspicion. I will
try to attach a copy.

\* \* \* Patient Profile \* \* \*

Patient Name: Tom Burke S (41y/o) Chart#: 11111111

Case Manager: STEIN,BONNIE J Facility: ANCH MED CTR

Cx Tx Need : Routine PAP (by 01/31/2005) Inact Date: NO DATE

PAP Regimen : Pq3y (every 3 years) (began 09/25/2003)Income Elig: NOT

DETERMINED

Br Tx Need : Clinical Breast Exam (by 01/31/2003)Income Date: NO DATE

============================================================================

====

DATE PROCEDURE RESULTS/DIAGNOSIS

STATUS

\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\--
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

\-\-\-\-\--

1\) 01/25/2002 CBE WNL/Normal

CLOSED

2\) 01/25/2002 PAP WNL/Normal

CLOSED

3\) 12/20/2000 CBE WNL/Normal

CLOSED

4\) 12/20/2000 PAP WNL/Normal

CLOSED

Press RETURN to continue or '\^'to exit, or Select a left column number
to display/print: (1-4):

This is what I could easily paste in and it only has 3 years but the
printed data goes back to 1990 on a single page.

Question #4

I am puzzled about the \<30 group.. Why do we have a decreasing pap
frequency with age while there is an increasing cervical cancer
incidence with age? I believe the average age of Dx it 54. I know better
screening in younger women skews this. And I know there is a lot of
dysplasia in the 20-30 yr olds but cancer is still uncommon. Sure these
patients get pregnant and get STDs and are probably getting exposed to
HPV. The ACS guidelines referenced unpublished data with this
recommendation. So what data is there that we are more likely to miss a
cancer in women in her 20s who has a low risk history and get's 3yr
paps?

Question #5

So who doesn't have HPV? I guess that means have we looked. In practical
terms I assume everybody who has ever been sexually active has been
exposed to HPV and there's fair data to back that up. Certainly a (-)
high risk HPV test is nice to have. Giving (+) results to patients when
it has so little predictive value seems to be looking for trouble. Since
my patients who seem to make wise personal choices and those that make
unwise personal choices both seem to have HPV I'm not sure where to go
with prevention. I don't think there's good data for condoms either.

**Andrew, Bridget \[bandrew@ABQ.IHS.GOV\]**

**Tue 12/2/2003 1:39 PM**

Hi Larry et al:

Can you be sure she is monogamous (your 38-year-old female
patient)\...?!:) I've learned that it's not uncommon for women to have
male friends with whom they have casual sexual relations, or serial
relationships, well into their 60's. There also appears to be a sizeable
population of women who may not be immediately open about their weekend
drinking social life, which often involves casual sexual contact while
intoxicated.

Which brings me to the topic of "why the annual women's health apt.?"
Forgive me if I digress a moment from the discussion regarding cervical
cancer screening guidelines\... Interestingly, what may have started out
as an initiative to reduce the incidence of cervical cancer via periodic
screening, appears to have evolved into the cross-cultural phenomena of
the (comprehensive) annual women's health appointment. My impression is
that the majority of women we care for look forward to this apt., as a
yearly opportunity to "get checked" and to talk in private with their
provider about any "female concerns." Getting checked can mean different
things, but generally is code for making sure women haven't acquired any
sexually transmitted infections from partners (there seems to be a
fairly even mix of period casual sexual contact for both males and
females!). Interestingly, I think women suspected long before research
identified HPV, that abnormal pap smears had something to do with being
sexually active. In Zuni, getting checked means also getting screened
for diabetes and high cholesterol!

Also, not infrequently, the annual women's health apt is one of the few
times that females can take time for themselves, and focus on their
health. I've had more than one mother, who also had responsibilities
caring for elders, tell me that it was actually relaxing to get some
time away and come in for an apt.

Yes, cervical cancer screening remains an important goal, and it's
likely that screening guidelines and methods will continue to evolve
over time. However, I think we are in the enviable position of tailoring
annual women's health appointments to incorporate health screening and
education of value (and interest) to the populations we serve. For
example, in the younger female populations, early initiation of sexual
activity without contraception or condom use---with multiple partners,
appear to be significant health issues. If we structured preventative
"women's" health screening appointments for this population based solely
on current pap smear screening guidelines, we'd be waiting until these
patients either presented pregnant or our dragnet started tracking them
down after they reached 21. Instead, we can make an effort to segue from
12 year-old well child appointments, to teen wellness "PEs" in early
teen years, and family planning and STD screening appointments in the
late teen and early 20's. It is our responsibility as providers to
incorporate current cervical and breast cancer screening recommendations
within the general paradigm of annual women's health or age-appropriate
health screening appointments. I agree that changes in screening
recommendations should be discussed with patients, and they should be
given the option of less frequent appointments based on recommendations.
However, in view of the multiple (potentially preventable) health issues
endemic in the populations we serve, I think it would be a mistake to
allow fluctuating cervical cancer screening recommendations determine
the periodicity of preventative health screening encounters.

On a completely different topic:

Kudos to our Women's Health Program Director, Anne Daniels, for bringing
Thin prep to Zuni. Much easier to sample, far simpler abnormal pap
management algorithm.

**Birnbaum, Bernard \[Bernard.Birnbaum@CHINLE.IHS.GOV\]**

**Tue 12/2/2003 2:18 PM**

Another important question is whether or not we can use urine screening
tests (despite their somewhat lower sensitivity) for GC / Chlamydia
rather than yearly pelvic exams on young women (\<21) who are completely
asymptomatic. I guess I wonder what the yield of doing a bimanual or
speculum exam is on that population and how it changes management.

**Daniels, Anne E \[adaniels@ABQ.IHS.GOV\]**

**Tue 12/2/2003 3:00 PM**

I totally agree with you, Alan, about the need to de-stigmatize the
whole HPV as an STD issue. The only way we're going to eradicate HPV is
by everyone remaining virgins for life or by developing a vaccine, which
may someday happen\... Anyway, I also stress the importance of not
blaming the last partner for the HPV diagnosis.

**Andrew, Bridget \[bandrew@ABQ.IHS.GOV\]**

**Wed 12/3/2003 6:53 AM**

Hello Dr. Birnbaum: Agreed that urine LRC for Chlamydia and GC provide a
convenient, sensitive, non-invasive option for STD screening. I believe
the sensitivity of urine

LCR is very close to or equal that of cervical LCR, depending on which
study

you look at. Two years ago we incorporated urine Chlamydia and GC
screening

as part of en-mass sports PEs at the teen center, and ended up with a

surprisingly high incidence of Chlamydia AND GC!

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Wed 12/3/2003 3:52 PM**

Larry\'s point about the necessity of the annual pelvic exam is an
excellent one and one that begs for some good \"evidence.\" The routine
reproductive health exam (formerly known as the annual Pap smear)
provides an opportunity for health promotion, education, disease
screening, i.e. mammograms, cholesterol, fecal occult blood tests,
diabetes and thyroid screening, STD screening, also screening for
domestic violence, elder abuse, depression, etc. So we still encourage
the visit even without the Pap test. Where does the pelvic exam fit in
here? There\'s not good data to support it in the asymptomatic woman.
Nor is there good data to refute it. Ovarian cancers are diagnosed -
though it\'s not a very sensitive or specific way to diagnose it; vulva
cancers are diagnosed -though there usually is some pruritis, which may
or may not bring the woman in. Fibroids may be diagnosed, but usually
they are not clinically important if there are no symptoms. So I\'d rate
the routine pelvic exam a level C. -Maybe it\'s a good idea. Some
\"experts\" think so.

**Schmitt, Kim (FDIH) \[Kim.Schmitt@FDIH.IHS.GOV\]**

**Tue 12/9/2003 9:10 AM**

I totally agree not to mention this is the only time my 40 + patients
answer yes to screening questions about urinary incontinence.

**Schmitt, Kim (FDIH) \[Kim.Schmitt@FDIH.IHS.GOV\]**

**Tue 12/9/2003 9:16 AM**

I just forwarded this to all who do our teen sports PE - any discreet
data?

**Perry, Donna \[Donna.Perry@CHINLE.IHS.GOV\]**

**Tue 12/9/2003 12:07 PM**

There have been some school screening programs that have been reported
in the literature. One of those was in Louisiana. They had surprisingly
high positive rates as well, with the peak around 10th grade.

**Johnson, Erik \[Erik.Johnson@MAIL.IHS.GOV\]**

**Wed 12/10/2003 6:28 AM**

I remember when the guidelines were FIRST made\... For the every three
years recommendations: there was an OBGYN conference and they voted on
the frequency, the range was from every 1 to every 10 years, and they
averaged out the votes and it came to every 3 years. Then it was
promoted as \"scientific\", but our OBGYN instructors made fun of that,
and said it was actually a \"consensus\" and was relevant only in so far
as who was at the meeting that day.

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Wed 12/10/2003 6:43 AM**

No, there actually is a lot of data supporting that Paps are as
efficacious in eliminating cancer at intervals of 1,2,or 3 years, but
not 5 years. See a couple of recent articles by Sawaya ET. Al. using the
national Breast and Cervical Cancer Program database New England Journal
of Medicine 2003. Vol 349 pp 1501-9. Obstetrics and Gynecology 2000 vol
96 pp219-223.

**N. Burton Attico, MD \[nbattico@POL.NET\]**

# Wed 12/10/2003 8:26 AM

But, doesn\'t the prerequisite of the consecutive negatives have to kick
in first before that patient can be put on the q3yr. schedule? And if
something \"new\" or different occurs, don\'t you then start all over
again?

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Wed 12/10/2003 11:43 AM**

Dr. Attico\'s point is good. The Q 2-3 yr screening starts at age 30
after at least 3 negative consecutive (ideally) annual Paps. If the Pap
is abnormal, then appropriate management and follow up should intervene
before spacing the Paps again.

**Holtz, Anita \[Anita.Holtz@CROWNPOINT.IHS.GOV\]**

**Fri 12/12/2003 9:27 AM**

I am jumping in late, but had a comment on the 30-year-old virgin
scenario. Several people have talked about patients having \"vaginal
intercourse\" as a criteria. My experience here is that many of the
women who have sex with other women do not report this to providers. And
even when they do sometimes do not get Pap smears.

**Murphy, Neil (nmurphy@anmc.org)**

**Sun 12/14/2003 6:58 AM**

I have two questions:

A lot of providers tell me that Liquid Pap Preps are really THE STANDARD
of care in 2003. Is that true?

Secondly, some folks have told me that certain micronutrients, e.g.,
folic acid, etc\... will alleviate cervical disease\....a milligram a
day to keep the colposcopists away, so to speak\....is that true?

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Mon 12/15/2003 7:25 AM**

NO and NO

Most studies show liquid Paps to be a bit more sensitive than
conventional Paps and some show them to be as specific. The liquid Paps
are a lot more expensive. The question your facility has to ask is
whether the small increase in sensitivity is worth the increased cost. I
know of no professional organization that considers the liquid the
standard of care. ACOG specifically does not. (See their technology
assessment bulletin in Obstetrics and Gynecology December 2002 also see
the ACOG Practice Bulletin Number 45, August 2003 "Cervical Cytology
Screening".) The federal government in its Breast and Cervical Cancer
Early Detection Program made a conscious decision not to pay for
liquid-based Paps for the reasons listed above. Having said all that, if
you use the Thin Prep liquid based product, reflex HPV testing is a cost
effective and convenient way to triage patients with ASC-US Paps.

The studies on micronutrients are not very conclusive. Folic acid has
been looked at, as have antioxidants and tocopherols with contradictory
results. Folic acid is good for other things though, especially in
reproductive age women.

**Johnson, Erik \[Erik.Johnson@MAIL.IHS.GOV\]**

**Mon 12/15/2003 8:47 AM**

"The thirty year old virgin doesn't need cervical cancer screening." But
they will be at high risk of breast cancer\...

**Majus, George (PIMC) \[george.majus@MAIL.IHS.GOV\]**

**Mon 12/15/2003 5:43 PM**

While many guidelines would support not having to do a pap on a
thirty-year-old virgin.  I know a young woman who at age 29 stated she
was a virgin, developed cervical CA, had a hysterectomy at her young
age.  Had she not had the PAP, it would not have been found until too
late.  She might be one in a million, but I wouldn\'t want to try to
defend that one in a million in court, on why the PAP wasn\'t done.

**Lindley Gifford \[lgifford@KICTRIBE.ORG\]**

**Tue 12/16/2003 5:58 PM**

I just wanted to thank everyone for the fascinating conversations on the
primary care list serve. It is like an IHS chat room! With a little
controversy to remind us that we are not identical in our beliefs and
practices.

It will be very interesting to see if we physicians/providers can change
our practices, patients willing to change routines and the IHS/RPMS
system able to accommodate change. Specifically spacing Paps to every 3
years when indicated, not requiring a pap to start contraception,
keeping track of who needs a pap and when.

The take-away message that I get from all of this, is that we cannot use
rigid templates for preventive healthcare, however easy they might be. A
14-year-old requesting contraception needs effective birth control,
counseling on condoms, GC/Chlamydia testing, and not a pap smear. An 85
year old woman needs BP control, diabetes and cholesterol screening, not
a Pap (unless a history of significant cervical dysplasia or cancer or
symptoms) or gonorrhea/Chlamydia. For everyone in between we providers
need to know risk of the disease that we are screening for, the risk and
implication of false (+) and false (-) and benefit of disease detection.

This reminds me of the controversy surrounding PSA screening in men.

There will be those patients who come in every year for everything,
because they are reassured, thinking that no disease found equals no
disease present.

**Friend, Terry \[tfriend@ABR.IHS.GOV\]**

**Thu 1/8/2004 8:38 PM**

Hello All, Back to the Pap smear issue\...

I work in the Aberdeen Area, at Pine Ridge.

While I understand that cervical cancer is not common in teens, I have
had 7 16-year-old patients and 1 15-year-old with severe cervical
dysplasia. This does not count the multiple 17 + year-olds. This also
does not include other providers with the same patient profile here in
Pine Ridge. We had a patient with invasive cancer while pregnant at age
21; she died at age 22. I'm curious about the possibility of sexual
assault at a young age in some of these women. I hesitate to put off pap
smears until age 21. There may not be a history of sexual assault in
these women, but if there is, I do not want to delay testing this
population with the numbers of young women with high-grade disease.
Sexual assault may not be something a woman is willing to admit.

Is there any room for historical risk factors here? Earlier when
referring to HPV as an STD, it was stated that HPV may have been
acquired 10 years prior to onset of cervical change. If a woman acquired
an oncogenic strain of HPV at age 26, had negative Paps until age 30 and
is then spaced out for 3 years, is this wise? Should there be
consideration for women to continue yearly Paps if she has a high risk
history: sexual debut at a young age, multiple sex partners, partner who
has multiple sex partners, history of STD, smokes \> 10 cigs a
day\.....?

Earlier discussion asked about a woman's monogamy. I am very concerned
about spacing out pap smears in this population because I do not know
about the male partner's monogamy. It is not uncommon when taking a
sexual history to find that women often feel, for good reason, that
their partner is not monogamous. Or she admits that she has not been
monogamous. Another issue is that some providers are uncomfortable with
taking a sexual history. During a chart review a provider sees 3
negative Paps in 3 years so they plan to space the next pap out to 3
years, but was the patient asked about specific risk factors? Talking
about sexual risk factor scan be very uncomfortable in some, in the day
of HPV and HIV is there any excuse not to ask?

**Bolza, Rosemary (FDIH) \[Rosemary.Bolza@FDIH.IHS.GOV\]**

**Sat 1/10/2004 3:22 AM**

These are the same questions I have been wondering about. I also don\'t
know how to easily access many of the women\'s pap history especially if
they get care from different facilities.

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Sat 1/10/2004 7:41 PM**

Terry and Rosemary ask questions that have been of concern to all of us.
There was much debate among the practice bulletin committee of ACOG
about not basing screening frequency on risk factors.

The reason for setting a specific starting age for screening if there is
no history of earlier sexual debut was based on just the concerns Terry
raises, i.e. sexual abuse among young women who may not be willing or
able to reveal it to their providers. Also many providers are unwilling
or unable to elicit that kind of sexual history. The reason for setting
21, as that starting point is that invasive cancer is extremely rare
prior to age 21. Terry\'s seen one at 21. I recall one (25years ago) at
19. I don\'t know whether either had adenocarcinoma, which isn\'t picked
up well on Pap. I suspect both would have been picked up had Paps been
started 3 years after onset of intercourse, but they may not have had
earlier Paps, even though the recommended starting age when both were
diagnosed was 18 not 21. The risk of missing CIN 2/3 if screening isn\'t
started till 21 is a concern, though CIN 2/3 isn\'t cancer and again if
young women are screened 3 years after coitarche it will most likely be
picked up.

An important caveat is that even though cervical cancer screening isn\'t
recommended until 3 years after onset of intercourse, screening for STDs
is still recommended with the onset of intercourse, as is contraceptive
counseling and prescription.

What\'s the down side of doing Paps on adolescents? The exam is
embarrassing, intrusive, and uncomfortable and is likely to diagnose a
lot of ASC-US and LSIL requiring further interventions without really
preventing any cancers.

It\'s a tough trade-off. Epidemiology suggests that these new guidelines
won\'t miss cancers. On the other hand, an N of one is a powerful
influence on the practice of medicine.

The issue of risk factors is more easily dealt with. The various risk
factors for acquisition of HPV, multiple partners, etc. and for
dysplasia, i.e. smoking dictate who needs screening, but once screening
is started, risk factors other than immunocompromise don\'t predict the
rate of progression. Therefore, the guidelines should hold. A woman who
has negative Paps from 21-30 may encounter HPV at age 31, but the
chances of missing a dysplasia before it becomes cancer are small if she
is screened every 2-3 years.

Rosemary expressed concern about not having a reliable Pap history. In
that case, I\'d treat her as if she hadn\'t had a Pap.

After all this is said, however, the bottom line is that we\'re using
our clinical judgement and experience to care for patients. If we feel
that an individual patient has a good indication for a Pap even if the
guidelines say it isn\'t time, just do it.

Thanks for raising the questions.