Pap Results and What to do Next
When it comes to women’s cervical health, the Pap test, also known as a Pap smear, is significantly important in reducing the incidence of cervical cancer.1 But with so many different stages of atypical or abnormal cells, even before the progression to cancer, it can be easily confusing for women to discern what their Pap results mean and what to do next to improve cervical health.
Back to Basics: What is a Pap Test?
A Pap test is used to sample the cells of the cervix. The cervix is composed of squamous, or flattened, cells with a border of columnar cells. Because of the difference in shape and overall morphology of these cells, it is at this border that cells are most vulnerable to premalignant changes.2 By sampling cells from this area, we are able to examine them microscopically to look for abnormalities.
Should you be Concerned?
You may have heard the words “ASCUS” or “LSIS” or “CIN,” but what do these all mean? Should you be concerned? Only about 5-10% of all Pap test results in the United States come back as abnormal1, but these abnormal results can leave women feeling anxious and worried.3
Cervical Dysplasia and HPV
Cervical cancer is the second most common cancer in women aged 20-39 years old.4,8 It is practically always proceeded by cervical dysplasia, therefore, in screening for cell abnormalities, we are looking to catch any form of cervical dysplasia early. This consists of any premalignant lesion or grouping of cells which can progress to cervical cancer, and is typically 100% treatable in its noninvasive stages.2
Almost all cases of cervical dysplasia are caused by a Human Papillomavirus (HPV) infection.2,4 HPV is a common sexually transmitted infection with virtually few to zero symptoms. It often clears on its own, however, some cases can progress causing the development of cervical dysplasia. Although there are more than 120 different types of HPV with 40 that affect the anogenital tract, testing for HPV type will not alter the course of treatment.3 That said, there are more aggressive subtypes such as HPV 16 and 18 which can cause changes in as little as 18 months, but typically it takes about 10 years for the full progression from atypical cells to cervical cancer.2
Understanding Your Pap Results
There are varying degrees of cell abnormalities with regards to cervical dysplasia. Starting with the most benign of the bunch, you may have heard the term “ASCUS”: atypical squamous cells of undetermined significance.
ASCUS
This indicates minor changes whereby cervical cells are not quite abnormal, but are also not completely normal. This is one of the earliest indications that these cells are starting to change, or that the cervical tissue is attempting to repair itself. In this case, the Pap is typically repeated sooner than the recommended screening schedule, but regression to normal cervical tissue is highly likely.
Colposcopy
In addition to a second Pap smear, your OB/GYN may wish to perform a colposcopy. This is a small biopsy of a few millimeters of cervical tissue to be examined by a pathologist.
Low-grade Squamous Intraepithelial Lesions (LSIL)
Beyond simple atypia of cells is the development of mild cervical dysplasia. Also known as Low-grade squamous intraepithelial lesions (LSIL), this represents our lowest grading of cervical intraepithelial neoplasia (CIN): CIN 1. Imagine your cervix as being composed of multiple layers of cells all squished down. LSIS or CIN 1 is diagnosed when we find that the basal cell later – the most bottom layer of squamous cells – is thicker than it should be. It is here that we find early changes in the size, shape, and number of abnormal cells. As cervical dysplasia progresses, the layers of cells that are affected extends further to the surface of the cervix.
High-grade Squamous Intraepithelial Lesion (HSIL)
A high-grade squamous intraepithelial lesion (HSIL) represents a moderate to severe form of dysplasia where 2/3 to 3/3 of the layers of cervical cells are affected. Also known as CIN 2 and CIN 3, this stage of dysplasia leads to a higher risk of further progression to cervical cancer.
Risk Factors
Although our understanding is that cervical dysplasia is caused by an HPV infection, there are many carcinogens which can contribute to the development of abnormal cervical cells. Remember that progression to cervical cancer is a very slow process, often taking 10-15 years in most untreated women. A warning sign of an abnormal Pap is a great indicator to review your personal and sexual risk factors and to make any lifestyle changes you can to promote tissue healing and prevention of further cell abnormalities.
Risk factors for the development and progression of cervical dysplasia include:
- Early age of first intercourse (younger than 18 years old). Biological changes in the cervix occurring in adolescence through puberty and into early adulthood cause a greater susceptibility to HPV infection and cervical dysplasia1,2.
- Cigarette smoking1,2
- High number of lifetime partners5
- Fear of having a Pap test and the stress associated with Pap findings5
- History of sexually transmitted infections5, and avoidance of condom use2
- Deficient dietary Vitamin C (<30mg per day)2
- Deficient dietary B-carotene2
- Abnormal serum B12 and folic acid levels6
Prevention and Treatment
Reviewing our list of risk factors, there are many areas that women, and their partners, can help prevent an HPV infection and subsequent dysplasia. Being mindful of sexual practices is a great first step. Eliminating risky sexual behaviour, including a reduction in the number of sexual partners, can help reduce the risk of developing cervical dysplasia. Additionally, ensuring proper condom use also decreases this risk.
There is also a significant correlation between cigarette smoking and incidence of cervical dysplasia. This is no surprise as cigarette smoke contains over 60 known carcinogens7, which can lead to cancer development in a multiple different organ systems and tissues throughout the entire body.
But apart from reducing the factors that put us at risk, there are many things we can do to improve our cervical (and overall) health. For example, increasing consumption of vegetables and fruits containing antioxidants has been associated with lower risks of malignancies.2 One study in Brazil reported that an increased consumption of papayas was associated with a decreased risk of both LSIL and HSIL, as well an increase in orange consumption decreased the risk of LSIL.4
Other major vitamins and antioxidants that are protective with regards to cervical cancer include a high intake of: Vitamin B12, Vitamin C, Vitamin E, beta-carotene, folate, and lycopene8:
Folate/folic acid and Vitamin B12
Especially important in its 5-methyl tetrahydrofolate (5-MTHF) form, folic acid is required for DNA synthesis, repair, and in methylation. Having low serum folate may increase risk of incorporation of HPV into the host genome.8
Associated with the cellular uptake of folic acid, vitamin B12 plays an important role in reducing homocysteine levels. Hyperhomocysteinemia increases the risk of cancer development because of the associated effects on DNA damage.6
One study reported that women with both adequate serum folate and vitamin B12 levels were 70% less likely to be diagnosed with HSIL.6 Therefore, the combination of folic acid and vitamin B12 may be significant in reducing DNA damage and thus the progression of cervical dysplasia.
Antioxidants
Vitamin C, Vitamin E, beta-carotene, and lycopene are all potent antioxidants which prevent reactive oxygen species from causing oxidizing damaging to proteins and DNA within our cells.8 They are all considered to prevent neoplastic changes in the cervix, though doses need to be evaluated, and should be recommended by a licensed health care practitioner.
Epigallocatechin gallate (EGCG) is a polyphenolic compound found in green tea possessing many antioxidants, anti-mutagenic, and anti-inflammatory properties.9 Known to provide protection against various forms of cancer, EGCG has been shown to decrease the viability of cervical cancer cells.9 Although green tea extracts are not recommended in pregnancy or during breastfeeding, non-pregnant women may wish to speak to their naturopathic doctor about including EGCG or daily matcha tea as a means of cervical protection and/or treatment for dysplasia.
Conclusion
Although many women tend to find Pap tests uncomfortable, this screening tool is vital for early detection of dysplasia and the prevention of cervical cancer. In its non-invasive stages, dysplasia is treatable with a high likelihood of regression to normal healthy cervical cells. A great way to be proactive and help prevent abnormal cell changes is by including a healthy diet rich in vegetables and fruits high in antioxidants.
Sources
1. Marshall, K. (2003). Cervical dysplasia: early intervention. Altern Med Rev. 8(2): 156-70
2. Hudson, T., & Murray, M. T. (2013). Cervical Dysplasia. Textbook of Natural Medicine, 1285-1292. doi:10.1016/b978-1-4377-2333-5.00156-5
3. Cendejas, B. R., Smith-Mccune, K. K., & Khan, M. J. (2015). Does treatment for cervical and vulvar dysplasia impact women’s sexual health? Am J Obstet Gynecol. 212(3): 291-297.
4. Siegel, E. M., Salemi, J. L., Villa, L. L., Ferenczy, A., Franco, E. L., & Giuliano, A. R. (2010). Dietary consumption of antioxidant nutrients and risk of incident cervical intraepithelial neoplasia. Gynecol Oncology. 118(3): 289-294.
5. Antic, L. G., Vukovic, D. S., Vasiljevic, M. D., Antic, D. Z., & Aleksopulos, H. G. (2014). Differencies in Risk Factors for Cervical Dysplasia with the Applied Diagnostic Method in Serbia. Asian Pac J Cancer Prev. 15(16): 6697-6701
6. Piyathilake, C. J., Macaluso, M., Alvarez, R. D., Bell, W. C., Heimburger, D. C., & Partridge, E. E. (2009). Lower Risk of Cervical Intraepithelial Neoplasia in Women with High Plasma Folate and Sufficient Vitamin B12 in the Post-Folic Acid Fortification Era. Cancer Prev Res. 2(7): 658-664.
7. Pfeifer, G. P., Denissenko, M. F., Olivier, M., Tretyakova, N., Hecht, S. S., & Hainaut, P. (2002). Tobacco smoke carcinogens, DNA damage and p53 mutations in smoking-associated cancers. Oncogene, 21(48): 7435-7451
8. Myung, S., Ju, W., Kim, S., & Kim, H. (2011). Vitamin or antioxidant intake (or serum level) and risk of cervical neoplasm: a meta-analysis. BJOG. 118(11): 1285-1291.
9. Sharma, C., Nusri, Q. E., Begum, S., Javed, E., Rizvi, T. A., & Hussain, A. (2012). (-)-Epigallocatechin-3-Gallate Induces Apoptosis and Inhibits Invasion and Migration of Human Cervical Cancer Cells. Asian Pac J Cancer Prev. 13(9): 4815-4822
Dr. Sarah King is a licensed Naturopathic Doctor, graduating from the Canadian College of Naturopathic Medicine in 2014. Prior to completing her medical studies, she attended Nipissing University where she received her Honors Bachelor of Science in Biology. Sarah has a passion for women’s health and is a birth doula in Durham and Toronto Region. She treats a wide variety of health conditions including menstrual disorders and hormone balancing, fertility, prenatal care, digestive concerns, skincare and mental health/anxiety. Outside the office Sarah is an avid runner with a love of the GTA’s best forest trails. She also continues to improve her yoga practice and teaches breath work as part of stress management counselling to her patients.
