Pap Tests Advised for Sexually Active Older Unmarried Women
By Judith Groch, MedPage Today Senior Writer
Review
SACRAMENTO, Calif., Aug. 3 -- Sexually active
postmenopausal women who are not married or living as married
may benefit from yearly screening for cervical cancer,
researchers here reported.
Unmarried older women or those not living as married who
are sexually active have an increased risk of high-grade
cervical abnormalities and cervical cancer compared with
married women or those not sexually active, according to a
report in the August issue of Obstetrics & Gynecology.
In the same study, estrogen-progestin therapy was found to
increase the risk of having an abnormal Pap test, but it was
not specifically linked to high-grade epithelial lesions or
actual cervical cancer, according to Shagufta Yasmeen, M.D, of
the University of California at Davis, and colleagues.
These results came from a six-year analysis of a
prospective cohort of 15,733 postmenopausal women (ages 50 to
79; all with a uterus) participating in the randomized
controlled Women's Health Initiative clinical trial.
In an analysis of risk factors other than hormone therapy,
the researchers singled out sexual activity. Over a six-year
follow-up, independent risk factors for high-grade squamous
intraepithelial lesions and cervical cancer (after stratifying
for baseline cytologic abnormalities) included sexual activity
in the past year while not being married or living as married
(hazard ratio 3.5, 95% confidence interval 1.5-8.3).
After further adjustment for significant covariates, the
statistically significant predictors of any abnormal cytology
after a normal baseline smear still included not being married
or living as married and being sexually active at baseline or
year one (HR 1.4, CI 1.1-1.8), the researchers reported.
The overall annual incidence of high-grade abnormalities or
cervical cancer was significantly higher (19.5 per 10,000
person years) among the sexually active neither married nor
living as married women compared with women not sexually
active or married (11.3 per 10,000 person-years.) The same
order of risk was seen among a subset of women with normal
cervical cytology at baseline, the researchers reported.
Turning to the study's hormone analysis, the researchers
reported that although hormone therapy with conjugated equine
estrogen and medroxyprogesterone was associated with an
increased incidence of any cytologic abnormality, it had no
impact on the incidence of high-grade squamous epithelial
lesions or cervical cancer.
Other findings for women on estrogen-progestin therapy:
The risk of hormone therapy as a significant predictor
of any abnormal cytology after a normal baseline smear was
significantly higher than that in the placebo group (HR
1.4, CI 1.2-1.6).
Hormone therapy over a six-year period did not affect
the incidence of high-grade abnormalities or cervical
cancer, although hormone therapy did increase overall
abnormalities among women with normal smears at baseline.
Post-menopausal women with normal baseline cervical
cytology had a relatively low risk of developing new
cytological abnormalities, and the cumulative incidence of
high-grade cytology in the hormone group over three to six
years was less than 0.01%
Postmenopausal women taking hormone therapy who were
normal at baseline had a significantly higher risk of
low-grade cytological abnormalities compared with women
assigned to placebo.
Postmenopausal women with normal baseline cytology had a
relatively low risk of developing new abnormalities, and the
cumulative incidence of high-grade lesions over a follow-up
period of three to six years was less than 0.01%. The estimate
of squamous cell cervical cancer after negative cytology (0.93
cases per 10,000 person-years) was generally consistent with
other estimates, the researchers said.
Nevertheless, Dr. Yasmeen added, although there is an
age-related decrease in cytological abnormalities, the
"incidence drops neither fast enough nor low enough to
ignore the risk of high-grade cytologic abnormalities and
cervical cancer in all women over the age of 70 years."
The main limitation of the study, Dr Yasmeen noted, is that
the women in the trial may have been at low risk for cervical
cancer, and the study may have been underpowered to estimate
the differences in risk of high-grade lesions and cervical
cancer. In general, the vast majority of cervical cancer cases
occur among women who have not been previously screened or who
have not had three consecutive normal results.
Current recommendations by the American Cancer Society to
discontinue screening for women at age 70 do not take into
account risk factors such as continuing sexual activity, which
may involve new partners and associated exposure to human
papillomavirus, the researchers said.
Cox analysis found that among the significant predictors of
any abnormal cytology after a normal baseline smear was having
a new sexual partner in the past year (HR 1.4, CI, 1.2-1.8).
For low-risk postmenopausal women (married or not sexually
active) with normal cytology screening, the investigators
agreed that triennial screening would be appropriate because
the absolute risk of undiagnosed cervical cancer within three
years of a normal smear is very low.
On the other hand, Dr. Yasmeen concluded, the study
suggests that sexually active unmarried elderly women may
benefit from continued cervical cancer screening, even if they
have previously had normal cervical cytology.
The researchers noted that Wyeth-Ayerst Research provided
the study medication (active and placebo) for this study.
Explain to interested patients that postmenopausal patients who are sexually active and not married or living in a "married" relationship, may benefit from a Pap smear.
Advise married postmenopausal patients or those who are not sexually active that a Pap test would still be a good idea every three years after a negative test.
Reassure older patients on hormone therapy that although they may have abnormal cell findings on a yearly Pap test, the risk of cervical cancer is low.
