Notable Greek-American Dr. George Papanicolaou did not win a Nobel Prize in Medicine, though he was nominated several times. He got a 13 cent stamp and name recognition. Women the world over laud him or curse him and know him as the one behind that annual/bi-annual/whenever-I-get-around-to-it staple of women’s health care – the PAP test.
Sitting in an OB-GYN exam room, garbed in paper drapes, my toes like icicles, a cheery doctor enters the room and announces – “Good news!” She has not examined me yet and I wonder what she knows. I am here only because my HMO nagged me to get a PAP test according to their recommended schedule. They hijacked me on the way to pick up a prescription with the promise of an opening in 10 minutes. I acquiesced just to get it over with.
“Just to get it over with” is how most women think about fitting the PAP test into their busy lives. It’s been drilled into us since we were teenagers that every year we must allow this thing to be done to us. I hate using the passive voice here, but the most self-actualized moment of the PAP test is willing yourself to relax. So it really was GOOD NEWS to learn from the doctor that if this PAP test came out normal, it was very likely to be my last. “You mean this ends?” I was incredulous. It does, and my first thought was that there has got to be some kind of cake to celebrate this.
My lifespan bookends the routine use of the PAP test for early cervical cancer detection. From the very first one I had as a teen to the last one a few weeks ago, nothing else has worked better than Dr. Papanicolaou’s test to reduce the incidence of death from cervical cancer. Only half a century ago, cervical cancer killed more women in the United States than any other cancer. Deaths by cervical cancer are now reduced to about 4,000 a year for American women. In stark contrast, there are about 250,000 deaths a year due to cervical cancer in the less developed countries of the world. That used to be us too. Routine screening with the PAP test has made all the difference.
Back in the day, the PAP test was often a young lass’s first introduction to interest in her lady parts. The emotional stakes were high and it sometimes didn’t go well. The heat of the lamp in contrast to the chill of the metal duck-billed thing, the cramping sensation. A doctor that might have been brusque or rude. Confusion or feeling violated. These and other less sensitive encounters with the medical industry gave rise to an active women’s health movement. Warm up that speculum! Put a soft covering on those cold, hard stirrups! Can’t we get some lady docs? Do I have to do this every year?
Things got really interesting in the 1970s when feminist encounter groups, emboldened with instructions from “Our Bodies, Ourselves,” passed out plastic specula, flashlights and mirrors and women finally got a look at their own cervix. Young women now find this a little horrifying, but at the time it was an important exercise in women creating agency to advocate for what they needed from the health care system.
As the pelvic exam experience improved, and more women trained as OB-GYNs, Nurse Practitioners and Physician Assistants, the PAP test also evolved. The cell collection device morphed from a popsicle stick to the fuzzy thing used now that looks like a wee bottle scrubber. The “smear” slide prep gave way to the wet prep used today.
Get a look at this timeline to see all the milestones in research that led to this dramatic reduction of cervical cancer mortality. From the 1940s when doctors begin routine PAP tests, through the excellent 80s when the Human Papilloma virus (HPV) was found to be the cause of cervical cancer, to the early 2000s when a vaccine against it was approved—each decade added improvements in experience and outcomes.
Back in the exam room, I grill the physician about why she believed this could be my last PAP test ever. She cited chapter and verse not only of the new frequency guidelines, but everything we’ve learned about the HPV over the years. Would anything work better? Only eliminating HPV, that common cold of STIs. But until we do that, or a mandatory All Condoms All The Time rule goes into effect, the Pap test is the way to go.
I went home and did my research. She’s right. And this isn’t even controversial, the CDC, ACOG, American Cancer Society and others are all in alignment with their recommendations.
To make this easier to understand, the fine communications specialists at the CDC made this infographic for us. Our tax dollars at work – thank you.
This is a good moment to reflect on the success of this advancement in women’s health. Not only has there been an extraordinary reduction in cervical cancer deaths, this was achieved through smart research that reduced the frequency of testing. Now women don’t have to get their first PAP until age 21, then get it only every 2-3 years depending on whether they got the HPV vaccine, slow down even more until age 65, then a full stop if all has gone well. This is good news for those of us who remember a more intense schedule of tests and interventions back in our young adulthood. The bar was much lower then for what constituted an abnormal PAP test, when colposcopies, biopsies, cryosurgery and repeat PAPs sent us back to the stirrups every six months.
This is also the right time to stop and thank all the unsung heroes of medical research. Although Dr. Papanicolaou is practically a household name, and Dr. zur Hausen and his team won the Nobel Prize in 2008 for the discovery of HPV, they are only the most visible. So I want to thank every lab technician, statistician, IRB professional, pathologist, clinical research nurse—and their high school teachers—for their professionalism in medical and public health research as we all marched down this path together. This is a great example of how investments in medical education and public health research save money as well as lives. The success of the PAP test is an important public health victory.
Crossing this threshold and reaching the end of PAP tests is a milestone worth celebrating. It means I’ve likely escaped death from cervical cancer when it is still a major cause of mortality elsewhere in the world. I’m lucky I live here in a resource-rich country that did the research, developed the test, then made sure women like me got one as needed.
When an American woman reaches the age of 62, she can get a lifetime golden passport to our National Parks for only $10. At age 65, she can get a lifetime golden passport to no more PAP tests. I love my age. The advantages of less frequent PAP tests are shared with younger women too. Now a young woman needn’t have her first PAP test until she is 21, plenty of time for her to get comfortable with the interest in her lady parts before she meets the Chilly Willy (aka speculum).
If you’ve had your last PAP test, it means you’ve not only lived long enough to not die from cervical cancer, but you’ve escaped a lot of others things too. So why not celebrate?!
What started as an airy caprice to indulge in cake, has turned into a new sort of post-modern feminist encounter. No, I won’t be passing out plastic specula (though one might appear on a cake, or a cast of them in a puppet show), and one look at your own cervix is probably enough. Because this public health triumph demands a bigger gesture, it’s now a full blown party – like Nia Vardalos’ “Big Fat Greek Wedding,” and Amy Shumer’s “Last F*ckable Day.” A sororal celebration for all of us who’ve reached this threshold and those who longingly anticipate it—I present My Big Fat Greek Last PAP Test Party!
Whatever the emotional stakes of our first PAP test, the last one should have us dancing. Opa! A little Greek folk music, reggae, glam rock, punk and some oldies ought to put us in the right mood.
Here’s our playlist for the #MBFGLPTP evening:
The Final Countdown - Europe
Pap Test - Crystal Castles
It's Over - Roy Orbison
You're Gonna Miss Me - The 13th Floor Elevators
The Last Time - The Rolling Stones
Stir It Up - Bob Marley and the Wailers
I'm So Glad - Cream
You Won't See Me - The Beatles
Bad Case of Loving You (Doctor, Doctor) - Robert Palmer
Paptest – PAP Test
Greek folk music
Bob Marley and the Wailers’ “Stir It Up” is the PAP test anthem. Not only does it sound like “Stirrup”—which could be what the examiner sings to the patient to assume the position—but its reggae beat may be the best way to relax into the experience.
We will be hungry and thirsty after all that dancing. Our menu:
Greek food in general
Crab-cakes (No, not those crabs. The Greek word for crab—karkinos—was used to describe a spreading growth. Onkos—another Greek word, the root word for oncology—describes a burden or tragic mask.)
Frosted doughnuts (those in the know understand why)
Pomegranate, raspberries, plums, cherries, strawberries – any red fruit you can think of
There is an old school cocktail out there called the Stirrup Cup, and it sounds awful. Most of us gave up cherry brandy after the first sip when we were, well, probably right around the time of our first PAP test. Ladies, let’s invent a more mature drink! #StirrupCupCocktail, or pass the Retsina.
And we must have a cake!—one to celebrate that cervical cancer, and nothing else, has killed us yet—a cake that anticipates all the birthdays yet to come. Red Velvet cake; Strawberry Shortcake; Raspberry chocolate ganache cake; any cake you want as long as it has a little red ooze to it.
Reaching the final PAP test of one’s life feels a lot like that big sigh of relief after the doctor takes the sample and removes the duck-billed instrument of anxiety. It feels great. I can relax. One less thing to worry about, even if different threats are making their way onto the list.
My MBFGLPTP is a lark, a fantasy of what-the-hell joy. There are still 4,000 cervical cancer deaths each year in the US and it is worse in less advantaged countries. Cancer, especially of the lady parts, still scares us. We all know someone who didn’t make it, who died too soon, and that it could have been ourselves. But it wasn’t. We got to live. And I believe the dead would tell us to celebrate the little joys of our lives with abandon equal to the large ones. From “Our Bodies, Ourselves” to “Lean In” for parity in medical research, there’s a lot to celebrate.
So I feel fine about this small triumph in personal health care, I feel great about a threshold of aging that subtracts a medical test and worry. Best of all is that so many more of us get to live because of Dr. Papanicolaou’s test.
But back in the exam room. After convincing me that I really did not ever need another PAP test if this one comes out well, the doctor added a caveat. “It’s the last one,” she said looking me straight in the eye, “unless you have 20 new sexual partners.”