Cervical Cancer Screening

The basics:

The details:

About Cervical Cancer:

Cervical cancer is of the most preventable forms of cancer. The key to this is early detection through a test known as a “Pap Smear”. This test is able to detect pre-cancerous changes, and action can then be taken to prevent cancer from developing. Or, if cancer is detected, there are treatments that may be able to address the situation before the cancer becomes life threatening. Because early detection can save lives, current medical guidelines generally recommend that anyone with a cervix get screened regularly, starting in their 20s.

Cervical cancer, as the name implies, is cancer of the cervix. Only people with a cervix are at risk of getting cervical cancer. The cervix is located at the end of the vagina and is a gateway to the uterus. If that’s not the anatomy you were born with, you are not at risk. If you have had surgery that removed your cervix, including some forms of hysterectomy, you are not at risk. If you’ve had surgery that constructed a cervix, you are likely not at risk, as the constructed cervix is made of different tissue.

According to the American Cancer Society, about 14500 cases of invasive cervical cancer are diagnosed each year in the US, and 4300 people will die from it. The screening test detects many cases and often successfully prevents them from turning into invasive, life threatening cancer.

Most cervical cancer is caused by HPV (Human Papilloma Virus), which is a very common sexually transmitted infection. Some estimates claim that most people who are sexually active will get infected at some point. Most HPV infections clear up without causing significant issues, some may cause things such as genital warts, and very few will cause cervical cancer. There is a vaccine for HPV, and using barriers such as condoms or dams during sex can help prevent its spread, but neither case is 100% effective. HPV can be spread by any kind of sexual interaction, including penis-in-vagina intercourse, manual sex/fingering (with or without penetration), anal sex, oral sex, or vulva-to-vulva contact, and contact with fluids is not required. To a lesser extent, HPV may be spread through any skin-to-skin contact, and there have been reports of cases where a person with an HPV infection in one area of the body has transmitted it to another part by simply touching both areas.

About the Test:

The most common screening test is known as a pap smear. This test involves taking cells from the cervix and examining them for signs of cancer or precancerous cells. The test only takes a few minutes, is performed without anesthesia, and is generally done in a doctor’s office. Often, it can be part of a larger exam.

The exact procedure may vary, but general goes something like this:

1. The doctor will ask you to remove your clothing and put on a gown.
2. The doctor will ask you to lie back and place your legs into what are called “stirrups”, which are designed to hold your legs apart for the pelvic examination.
3. The doctor will insert a speculum into your vagina. A speculum is a duck bill like device that is inserted closed, then opened and locked into place. It is designed to hold the walls of the vagina apart so that the doctor can access your cervix. They come in different sizes, so if the one the doctor uses seems to big or is unbearably uncomfortable, ask that they try a smaller size.
4. The doctor will scrape, brush, or swab the cervix in order to collect cells.
5. The doctor will remove the speculum and the test is complete.
6. Later, the cells will be examined and your results will be reported.

Commentary:

The pap smear is widely regarded as an uncomfortable, unpleasant, awkward, and invasive test, even among non-asexual people. But it’s also an important test, because it is highly effective at detecting and even preventing cancer while it is early enough to treat and eliminate.

It is common for asexual people, especially if they are penetration averse or uncomfortable with their genitals, to dread the thought of this test, and even avoid regular medical checkups out of fear that it will come up. This is a serious issue with serious implications that does not get enough attention. Fear of one procedure should not stop people from seeking other treatment, but the medical community is not doing enough to address this issue. Instead, doctors and nurses will often double down and insist and remind and cajole that you really oughta have this test. They’re expecting a patient who uses tampons and regularly engages in penetrative sexual activities. A patient who doesn’t want to deal with the time, expense, and hassle of the test. A patient who find the test embarrassing, but knows that a few minutes of embarrassment could save their life. They’re not expecting a patient who’s never had anything inserted in their vagina. They’re not expecting a patient with trauma. They’re not expecting a patient who’s dysphoric. They’re not expecting a patient with vaginismus. They’re not expecting a patient who is intensely uncomfortable with anyone doing anything in that area. They’re not expecting a patient who sees the exam as a violation. They’re not expecting a patient for whom the thought of the test causes paralyzing horror. And so they don’t respond properly to that situation, which means they don’t properly care for that patient.

First and foremost: You have a right to refuse any test or treatment. You can say no to a cervical cancer screening. Before you do, you should fully understand the risks that come with that decision and weigh them against the unpleasantness of the test itself. But you can say no, if that’s what you decide.

You can also talk to your doctor about ways to make the test less awful. Is there an alternative that can be done instead? Would a smaller speculum help? Would one made of a different material help? Would one that’s been warmed up a bit help? Would you be more comfortable inserting and removing the speculum yourself? Would it help if the doctor said more and explained what they were about to do at every step or said less and got it done with? Can they use lube on the speculum? Can you have someone you trust with you in the room or on the phone? Can it be done less frequently? Can they explain in advance and in detail what constitutes a “normal” level of discomfort, and what is pain that should be a signal to stop? If you’re not sexually active or you’re not comfortable with penetration or if you’ve never experienced penetration or nothing’s been inserted in your vagina before, tell them that. Can you put on a blind fold and pop in some earbuds and zone out for a bit? Whatever it is, they’ve probably had someone do it before. They can also adjust what they’re doing if they know how you’re feeling.

Stepping back a bit, as was mentioned earlier, most cervical cancer is caused by HPV, and most HPV infections are sexually transmitted. So there’s a natural question that arises from that, which is, “Do people who are not sexually active and never have been need to be screened?” Some doctors say no, while others say yes. The doctors who say no believe that the risk is so low that it is not worth the effort to screen. The doctors who say yes will point out that while the risk is low, it is not zero: HPV can be transmitted through non-sexual contact, and some cervical cancer is not caused by HPV.

There is a spectrum of risk, and you should honestly assess where you are on that spectrum and discuss with your doctor before refusing. On one end of the spectrum would be non-sexual contacts like handshakes, which have a very very low risk of transmitting HPV. Near the upper end would be things like frequent, unprotected penis-in-vagina sex with many partners. But again, the final decision is up to you. If you’re not sexually active and barely even shake hands with people (who does that anymore, anyway?), you can still decide to get screened, just in case. And if you’re at the other end of the risk spectrum, you’re still within your rights to say no.

It should be noted that the reason screening is universally recommended for anyone with a cervix over a certain age is because of the assumption that people over a certain age are sexually active, but may not be willing or safely able to admit it, or may be unwilling to take a test for an STI, no matter how common it is. By recommending universal screening, it removes the stigma around it. Taking the test isn’t an admission that you’ve had sex, it’s simply expected because of your age. And in some cases, if you refuse the test on the grounds that you’ve never been sexually active, the doctor may continue to push for it because they don’t believe you.

Bottom line: Routine cervical cancer screening saves lives. If you have no particular qualms about getting the test, then you probably should be screened as often as the guidelines recommend. However, if the thought of the test is overwhelmingly unpleasant, you should assess your risk and explore your options.