Routine pap at first prenatal appt? Why?

[DoomaYula]

A friend of mine just refused a "routine" pap at her first prenatal appt. The provider told her that if she doesn't have one soon, she will have to find another provider for this pregnancy (not a big loss, imo). She is a grand multip with fairly closely spaced kids who has had a pap with every pregnancy and all have been normal. Anyway, I have breastmilk brain and can't recall why or why not a pap is necessary. Any takers? :

[Charmie981]

IMO, it's not necessary and I hate the idea of a provider forcing a mother into it.

The question to ask is always "what am I going to do with the information." I don't know what she would do with the information from an abnormal pap, but I have to say that I would just worry about it the entire pregnancy and it would be completely counter-productive for me.

I think the suggestion for a pap in early pregnancy stemmed from a larger number of abnormal paps in the pp period, so they have started doing them in early pregnancy, but that still doesn't answer the question of WHY they do them at all, sorry.

[doctorjen]

I offer my pregnant clients a pap in early pregnancy if they are due. I don't really care if they decline, though. For what it's worth, I don't actually see a higher rate of abnormals during pregnancy (I know that's something that people worry about, but in my experience, it hasn't been true with modern liquid pap technology.) I follow the same guidelines I do for non-pregnant women and talk to women about their individual risk for HPV and cervical cancer.

[3daughters]

Thanks for posting this question. I was thinking of asking it too.

I recently refused a pap at a prenatal visit. To my knowledge, I have never had a bad pap and I'm over 30 and its still been less than 3 years since my last one. The midwife acted like she was cool about it but then at the next visit she brought it up again and "strongly advised" me to have one done because it would be over 3 years till after the baby is born (like a month!). I asked her what she was looking for that was so important and she said STDs and HPV. I'm not high risk for either so I refused again.

I just wondered if it was standard to do a pap during prenatals.

[momileigh]

I HATE HATE HATE that women are treated like children when it comes to paps!

A pap is a cancer screening!

Are men REQUIRED to have a colonoscopy, OR ELSE they have to switch doctors?

"I'm sorry, sir, I won't treat you for your heart disease unless you let me do a rectal exam." Yeah, I can really see that happening.

Paps should be totally and completely optional at all times. Do you know women who decline paps will be denied birth control???

"I'm sorry, sir, you can't buy condoms unless you get your moles checked out."

It is the same thing. It is wrong and it disgusts me.

[kate3]

Pap smears are an important screening tool for cervical cancer and have been considered a part of "routine" PNC for ages. With that said, I will try to put this all into perspective.

Before we knew how much HPV had to do with cervical cancer, it was recommended that women have paps every year, regardless of age or sexual activity. The thinking was that if you did not have a pap at your 1st PNV it might more than a year until you had one at your post partum visit. It was a way to prevent women from "falling through the cracks" in regard to cervical cancer screening.

Well, now we have much more information about cervical cancer. It is casued by a sexually transmitted virus (HPV) and is slow growing. The current pap smear screening recommendations (ACOG, ACS) have been modified to reflect this new information. For women over 30 (the age group most affected by cervical cancer) who have had 3 normal paps in a row, paps can be reduced to every 3 years.

So, in this incredibly long explanation to a simple question, if you have had a recent normal pap, there is really no reason to do one at a PNV. But as we all know, change is hard and slow, and many practitioners are so accustomed to reflexively doing a pap out of habit that their practice has not changed based on the evidence.

[DoulaLMT]

FWIW, there are MWs out there who don't push them. Mine never even offered (I would have declined anyway) and of course I didn't ask. I'm almost 34 weeks and she's never done any type of pelvic exam.

[doctorjen]

I hate the blackmail aspect of paps in many settings, too - including planned parenthood. A PP said it well - it's cancer screening and it is not fair to withhold other care because someone doesn't want one.

In my own practice I explain the pap guidelines, explain what a pap shows and what it doesn't (many women mistakenly believe they've been tested for all STDs just because they've had a pap) and let women choose. I will not withhold birth control or other care, no matter what the situation, unless there is reason to believe the birth control will worsen the situation. (the only example of that I can come up with is working up a suspicious breat lump prior to giving the woman birth control because if it is an estrogen dependent cancer you could make things much worse.)

I hate that women can't make their own choices in many settings. I have caught babies for women I've never down a pelvic exam on, and I've prescribed plenty of birth control for women the same way. Based on the woman's individual history, I may well be recommending pap screening, STD testing, or whatever, and many choose to have those things done understanding their individual risk but if they don't, it is their risk to take.

[Stayathomemommy]

I am the friend that the OP was talking about. My midwife told me to get a new provider if i didnt agree to a pap in the near future. i told her i would come in ready to get one during the next appiontment or i would find someone else. The sad thing is she has been through 2 other pregnancies with me and knows me very well when it comes to how i labor and give birth. on the other hand this is not the only fight i will have when it comes to testing. I always get pushed to do the diabetes screening and GBS tests all of which i try to deny. I guess i just dont want to fight anymore. I want it to be up to me. I am going to interview another midwife but if she doesnt turn out to be any better i will be out of choices.

thanks for all your input. that support and reasurance was all i needed to be confident in my decision. After all the only reason she could give me that i should have a pap was because "we never know if our husbands are being faithful" ARE YOU SERIOUS!!! i was so mad. my husband and i have only ever been with eachother and well its up to me to risk it.

[DoomaYula]

Originally Posted by DoulaLMT

FWIW, there are MWs out there who don't push them.

Not here in Yuma

[Robinna]

Originally Posted by momileigh

I HATE HATE HATE that women are treated like children when it comes to paps!

A pap is a cancer screening!

Are men REQUIRED to have a colonoscopy, OR ELSE they have to switch doctors?

"I'm sorry, sir, I won't treat you for your heart disease unless you let me do a rectal exam." Yeah, I can really see that happening.

Paps should be totally and completely optional at all times. Do you know women who decline paps will be denied birth control???

"I'm sorry, sir, you can't buy condoms unless you get your moles checked out."

It is the same thing. It is wrong and it disgusts me.

Hi guys - not a birth professional, just lurking, but wanted to comment here -

It is EXACTLY this kind of messaging that caused me to develop a clinical phobia of all gynecological exams. As a late teenager (17) I had my 1st pelvic exam and pap because I thought I should be on the pill, I was not sexually active yet but it was becoming a distinct possibility, and I was taking care of myself in advance. Despite still being a virgin (and having told the Dr. so), I was treated like a promiscuous idiot and after I asked why she was taking so many swabs, she told me she was doing all the std tests. On a virgin. yeah anyway. A year later, time to renew my pills (and only very recently not a virgin, btw), and I was having panic attacks about going to have another exam, but had to, in order to renew my prescription. This escalated and escalated, I had a "hpv consistent" pap smear a couple of years later, was sent directly to the hospital for the coloposcopy round with an absolute a$$ of a gyn and had to be sedated in order to get through it.

I'd like to stress that I have NO history of sexual abuse whatsoever. I'm am an exceptionally confident and self-assured person. But the way I was treated and coerced consistently by any and every gyn Dr. that I encountered caused me to create a phobia to get myself out of going. I went off the pill so I wouldn't have to go, and checked myself into phobia counselling... which didn't cure it but made me realize I was only having the tests to please other people, so I relieved myself of that responsibility. Much later, in my first pregnancy, I used hypnosis to actually cure the phobia.

After a 10 year break between paps, I've now had 2, nearly 3 years apart, and don't really plan to ever have another. I really just did them to prove to myself that I could... for the 2nd one, when I asked my MW about why you'd do one in pg, she said that it was a high-cell-change period in a woman's life so that if there WAS anything going on with the cervix, pregnancy could escalate it, and that you COULD safely treat the cervix during pregnancy. So I opted "for". but I may never do it again.

[momileigh]

Robin - a similar thing happened to me. I was "forced" into a pap when I was 18 and a virgin. I kept going back for them once a year for the birth control, but every time I would cry and scream and generally freak out everyone. It would take several days after a pap before I felt normal and could return to my activities again. Now I totally refuse them all the time. (dh and I have never been with others, so I feel that risk is low enough to take.) I have a really hard time w/ vaginal exams during pregnancy/birth and if I ever have another baby, I will refuse all vaginal exams that I don't expressly want. I had a hard time getting out of them at school when we were supposed to practice on each other. I submitted to the practice vaginal exams (I needed the practice and felt it was unfair if I didn't), but I freaked out my classmates so bad that the instructor exempted me after two. After that, she excused me from having a practice pap. I can DO paps without a problem, but when I'm on my own, I will certainly "allow" clients to refuse them, once they have been educated on the risks.

I think I experienced my first pap as a violation because it wasn't presented as a choice. It was presented as, "This is what we are going to do to you now." And I submitted to it... and I have felt vulnerable and powerless ever since when in a similar situation. Thank goodness it had no effect on my sex life or on giving birth. (Well, maybe a small effect on my sex life... I don't ever want fingers penetrating me.)

Oh, and btw, my midwife refuses to believe I have never been abused. She is positively certain that I was molested and I just don't remember it. I told her I was absolutely positive I had never been sexually abused in any way, and she said, "You don't know what someone might have done to you as a baby." Maybe she has to believe that to avoid thinking she might do something to someone (pressure them into a pap) that could have such a big negative effect.

[SublimeBirthGirl]

Originally Posted by momileigh

I HATE HATE HATE that women are treated like children when it comes to paps!

A pap is a cancer screening!

Are men REQUIRED to have a colonoscopy, OR ELSE they have to switch doctors?

"I'm sorry, sir, I won't treat you for your heart disease unless you let me do a rectal exam." Yeah, I can really see that happening.

Paps should be totally and completely optional at all times. Do you know women who decline paps will be denied birth control???

"I'm sorry, sir, you can't buy condoms unless you get your moles checked out."

It is the same thing. It is wrong and it disgusts me.

AMEN!!!
WHY do we put up with this crap???

[SublimeBirthGirl]

I have no history of sexual abuse either and can't seem to decide to go in for a pap. My last one was more than 3 years ago now (I'm 32, had an abnormal at 19 but none since). I have gotten to a place where I just really dislike doctors, their attitudes, their condescension, and their power trips. Eventually I'll probably find a midwife to do one, but the CNMs here all work for OBs in OB-like settings. I honestly have no desire to ever see a doctor again for any reason and am in the (long, hard) process of cleaning up my lifestyle (eating healthier, exercising more) to help me avoid them.

[cravenab00]

i havent had a pap in over 3 years. i'm not real concerned about it.

i had an abnormal pap at my first prenatal with my DD who is now 6. The doctor called me (at work!) to tell me that my pap was abnormal and started in about cancer, having to birth very premature to treat it, that it was because of an STD (which i dont have) I had a total all out panic attack (at work) needed to go home. i finally called back to the office to see if i could get in that day (since the dr made the situation sound so imminent) and i talked to a nurse practitioner who told me there was just some mild changes which were common in pregnancy, that i had no STD, and scheduled me a colposcopy. I went in terrified, i needed medication to get through it. And then the doctor got in there and said "there are no visible changes here. were done" turns out i had a yeast infection, and that can cause an abnormal pap. I have since learned that many things can cause a false abnormal reading.

i had several normal paps since then, that were all met with horrible anxiety. I had to schedule them no more than a day before, otherwise i would make myself sick with fear and worry.

i dont think i'll ever have another one, unless a situation warrants it.

i truly dont understand how women are taught that lying on a table with their legs in the air, their genitals being touched by a stranger and instruments invading their vaginas, and things stuck inside her, are "healthcare" its really scary.

[Dia]

So much that has been already stated in this thread echoes exactly how I feel about this issue.

At 16 - a VIRGIN - my family doc said it was time to have a pelvic exam and pap. I asked why. Got an explanation that was essentially "because it's what girls need." (Again, I was not on BC, no desire to be, not sexually active, no gynecological issues whatsoever, etc.) I'm grateful that at such a young age I somehow sensed this was basically unnecessary, slightly condescending, and would have likely been really traumatic. Never made that appointment. Honestly I still kinda get the heebie jeebies when I think about that experience. (And no, I have not been sexually abused either.)

BTW - I love reading Doctor Jen's posts and really wish she was my Dr. or I could find someone exactly like her.

[Robinna]

I can't tell you guys how relieved I am to hear it's not just me. I have lots of friends who "don't like it either" but still go, but pretend they "get it" ("aren't you worried about cancer? I always feel better after, knowing everything is ok," etc etc)... and I'm like, nuh no, if you really had a similar feeling about it, you wouldn't still be going, and you wouldn't feel better afterwards, you'd feel worse. And Momileigh - yeah - I have yet to meet a caregiver who accepts that I was never sexually abused, that the violation of the exams is traumatic enough in and of itself. sigh.

[Meche]

Here's a new excuse to push pap -- you all are going to love this...

I'm currently pregnant (G6P2) and 21 weeks along. I am seeing both a licensed homebirth midwife and a homebirth-friendly OB/GYN for concurrent prenatal care (have had trouble sustaining pregnancy in the past). All signs are "go" for my first homebirth.

At my first prenatal with the OB, they asked to do a pap smear, since it was coming up on a year since my last (done a few weeks after a m/c). I declined. At the next prenatal, they asked for a pap again. I declined again. At the *next* prenatal, they asked AGAIN. I declined AGAIN. Then things started getting a little hairy. The doc said that they need to have a result on file for a gonorrhea/chlamydia test, or else the hospital "would want to keep the baby at least 48 hours for tests if you don't have a negative result on file." As a doula, I had never heard of this before! I explained that I wanted a very hands-off pregnancy--basically, no vag exams. She persisted, "It's just a swab." I stated that I find pap smears very uncomfortable and aggravating to my cervix, and I refuse it with this pregnancy. So she asked me to sign a records release so they could request my last result from the previous OB that did last year's test. I signed. Plus I got my lab results (with neg G/C test) from my even-previous OB (do you follow me? 3 OB/GYNs in 3 years. sigh).

Well, at this last appointment, the most recent records came in. They didn't do a G/C test with the last pap. The two-year old records weren't good enough. They still want a new result on file. I wanted to scream! I have been with dh since we were both in high school. One partner, ever. Prior negative test result. I just want to know why they are hassling me for a G/C test??? The newest excuse is that the insurance company might not pay for the birth if there is no test result on file. HUH?!

So the doc tells me, "We can get the result from a urine sample." WTH??? I wish I knew why didn't they offer this before, why they had to pester me for four months to get a pap smear when they could have just done the G/C test from the urine sample the FIRST TIME. So I consented to that--it's non-invasive and I don't have a problem with the idea of the test, just the manner. Next visit, I find out if they got their result and are finally satisfied.

My midwife doesn't care about getting a pap or a G/C test. I guess she believes me when I tell her that I've been monogamous for 19 years.

I can't wait to see the look on the OB's face when I decline gestational diabetes and GBS testing.

[Artichokie]

I'm not a birth professional, but...

I have been through three different sets of midwives during the course of this pregancy (first ones went off my insurance, I hated the second ones, love the third). NONE of them insisted on a pap or pelvic exam of any kind. The first suggested, and I declined. Nothing else was said about it. Same with the second m/w group. The third group noted that I hadn't had it done, but didn't ask me why or if I would change my mind.

[g&a]

Good for you for sticking to your guns!
g.