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Published: Tuesday, May 17 2011 - 16:30

By Dr J Kabyemela, MD

There is a big difference in the recommendation of the starting age for having cervical (Pap) smears among countries with these programs. In the United States,  the American College of Obstetrics & Gynecology (ACOG) recommends 21 as the starting age. In the UK, the starting age is 25. Now, a newly presented research has thrown another spanner in the works.

According to the researchers, young women who have multiple partners or Pap (cervical) smeara history of sexually transmitted disease would benefit from cervical cancer screening before age 21, The results of this study were presented at the annual meeting of the American College of Obstetrics & Gynecology early May 2011.

"The patient population that we looked at is of lower socioeconomic status, they have a much earlier onset of sexual activity, higher rates of pregnancy and higher rates of sexually transmitted disease and all of these we know are risk factors for developing cervical cancer or abnormal Pap smears”; according to one of the researchers, Dr. Amy M. Johnson from the University of Connecticut School of Medicine and Hartford in the United States.

Dr Johnson went on to stress that, while it's likely safe to delay the initiation of cervical cancer screening in the "vast majority" of young women until age 21, she added, the new findings suggest that gynecologists should ask their young patients about whether they are sexually active and if so how many partners they've had.

Pap smears at 21

Because cervical cancer rates are low among women under 21, the American College of Obstetricians and Gynecologists (ACOG) recommended in November 2009 that women begin having regular Pap (cervical) smears at 21, rather than at 18 or within three years of starting sexual activity as had been recommended previously.

To investigate whether young women with risk factors for cervical cancer should be tested earlier, Dr. Johnson and her colleagues performed a retrospective case-control study of 394 patients who received cervical cancer screening at an inner city clinic.

Nearly 81% of the patients were Hispanic, Dr. Johnson said this week at the meeting in Washington, D.C. Their average age at their first Pap smear was 17.

High rates of abnormal smears

Eighty-two had moderate dysplasia (CIN2) and 37 had severe dysplasia (CIN3) before age 21. Those who reported having at least two partners were 4.5 times likely to have moderate or severe dysplasia, while patients with five or more partners had a 51-fold greater risk.

Moderate to severe dysplasia was also more common among young women with a history of sexually transmitted disease, with 42.1% having CIN 2 or CIN 3, compared to 22.8% of the patients with no STD history. The risk was particularly high among women with a history of Chlamydia (47.2% had moderate to severe dysplasia, compared to 22.6% of women with no history of Chlamydia infection) or genital warts (95.5% vs 63.6%, respectively).

"The current recommendation is to screen all sexually active girls for gonorrhea or Chlamydia under the age of 25 as part of their routine exam," Dr. Johnson said. But if young patients test positive for either STD, or if they have a history of STDs, she added, "perhaps they should be someone that you start doing Pap smear screening on earlier."

History of sexual behaviour

In fact the recommendations contained in this study are not new in practise. In the UK where the recommended starting age for cervical smears is 25, it has long been the practise of many doctors to offer smears to younger women if their sexual history indicates that they may be at increased risk of early development of abnormal cervical changes. However, what is still a matter of lively debate is what to do with abnormal findings especially if they are mild or moderate. It is a recognised fact that many such changes can and do often resolve spontaneously. Because of this, a recommendation to lower the starting age for routine Pap (cervical) smears is unlikely to gain traction especially on this side of the Atlantic.

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Some girls should have smears “before reaching 21”