Analysis Science

Behind the Pap Smear: A Wife Whose Husband Scraped Her Cervix Daily (!)

Naomi Elster

That couldn't have been comfortable for Mary Papanicolaou, but their work gave us the best way of screening for cervical cancer.

If my husband asked me to let him take a swab from my vagina every day for 21 years for an experiment, I’d be reaching for divorce papers faster than President Trump can cause offense on Twitter.

But as we approach the end of Cervical Health Awareness Month, we should be thankful that Andromache “Mary” Papanicolaou was more tolerant than I would have been. Her husband, George—who was by all accounts eccentric—spent almost a decade developing a test that could tell the exact stage of a menstrual cycle based on the changing shape and size of cells scraped off the cervix.

In the late 1920s, there wasn’t exactly a lot of enthusiasm for his invention; the world’s women didn’t need a doctor and a diagnostic smear to tell them whether they were on their periods or not.

Papanicolaou went back to the drawing board (quite literally—one of his collaborators was a Japanese-American artist famous for wildlife paintings but who made color sketches of cells) to develop something more useful. Having realized that cervical cells weren’t static, he went on a tour of diseased cervixes, emerging more than two decades later with the “Pap smear” that is now routine care.

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The Pap smear or test examines under a microscope cells taken from the cervix and can find cervical pre-cancers, giving doctors the chance to stop cancer before it really starts. Cervical cancers develop over a long time, typically five to 20 years. During that time, cells in the cervix are hijacked, changing their appearance, entering a pre-cancerous phase. According to the American Cancer Society, most cervical cancers happen in women who have not had Pap tests, but Pap smears and subsequent treatments are estimated to have slashed U.S. cervical cancer rates by up to 80 percent in half a century.

According to Centers for Disease Control and Prevention (CDC) statistics, more than 70 percent of women 18 and older had had a Pap smear in the previous three years surveyed; this is actually a decline from the start of the new millennium, when this figure was at nearly 85 percent among women ages 18 to 44. Women with higher levels of education were more likely to access screenings, and screening uptake also varied by race. Another study showed women with a disability being less likely to have a Pap smear even after they have been recommended to do so by their doctors. Many women may face logistical and financial barriers to making appointments (inability to get time off work or arrange child care), and women from cultures that are particularly closed about sexuality may find it extremely difficult to have a Pap smear. Further, they require a considerable infrastructure, including trained personnel to both take and decipher the smears.

Even with the varying degrees of access to the Pap test, George Papanicolaou’s diagnostic invention is a scientific success story—and one related to another important advance for cervical health: the HPV vaccine.

It’s easy to forget how momentous the invention of vaccinations and antibiotics are because many of us haven’t lived in a world without them. But even when we developed vaccines for polio (once described as America’s biggest fear after the atomic bomb) and similar infectious diseases, vaccinating against cancer still seemed like an incredible dream for a long time.

In vaccinations, safe chemicals incapable of causing infection train our natural immune systems to recognize and destroy a real virus should we come into contact with it. It’s like a self-defense class, learning to block a punch from an instructor who only mimics hitting you and won’t do you any real harm. But, because you’ve been trained, if someone ever does try to punch you, you can deal with it and escape unscathed.

The HPV vaccine protects against most forms of cervical cancer, which has just a 57 percent five-year survival rate for Black women and 69 percent for white women. A huge amount of research was required to prove the vaccines (Gardasil and Cervarix) were safe before they were put on the market, and they have been monitored ever since, with large, thorough safety studies worldwide. In June 2017, the World Health Organization (WHO) called in some of the best researchers in the world to painstakingly review every single piece of safety data available. The evidence—and there’s a lot of it—all stacks up to the HPV vaccine being completely safe.

However, as the WHO stated, “despite the extensive safety data available for this vaccine, attention has continued to focus on spurious case reports and unsubstantiated allegations.” Anecdotes about girls suffering severe side effects are powerful in terms of emotional impact, but, as the WHO committee notes, most of these claims are unfounded and the actual evidence confirms there are no safety issues.

The other strand of anti-HPV campaigning focuses, obsessively, on the fact that HPV is spread through sex. The vaccine is given to girls at a young age, because this is when their immune systems respond best to it (the CDC also recommends it for boys, for whom it can protect against genital warts and other conditions). This, according to a certain worldview, makes teenagers more likely to have sex early though, as author Jill Filipovic writes, it’s hard to imagine “seeing ‘Hey baby, I’m vaccinated’ proliferating as an effective pick-up line in the middle-school cafeteria.”

Research studies have also given evidence that concluded that receiving the HPV vaccine does not lead to promiscuity or teenagers starting to have sex earlier. Perhaps these studies seem like a questionable use of research dollars, until you look at the backlash against the HPV vaccine, a backlash that has seen vaccination rates plummet and will claim lives.

Using misinformation to prevent young women from receiving the HPV vaccine might not be so bad were cervical cancer not such a serious disease. It strikes young, and it hits hard. Though there are differences across the world, most women will be diagnosed in their 30s or early 40s.

As these women will often be in the work force and sometimes mothers, the ripple effect of their illness on their communities and even the economy of the culture around them can be profound. There is a great need for more research on the socioeconomic impact of cancer, but one Argentine study of families affected by cervical cancer reported that almost 40 percent of families lost income, had to sell property or use savings, and perhaps not surprisingly, patients who suffered economically due to their illness were less likely to receive all the radiotherapy they needed. And surgical treatment, if the cancer is not caught early by Pap smears, is invasive, often involving removal of the cervix and the uterus, which will make the patient infertile. The tragedy of having to endure this treatment is only enhanced by the fact that almost all cases of cervical cancer can be avoided through a simple shot in the arm.

At the end of 2017, new research suggested that women who have received the HPV vaccine may need only two or three cervical cancer screenings in their lifetime, compared to seven for nonvaccinated women. Women typically undergo 12 screens over their lifetimes, but with vaccinated women much less likely to get cervical cancer, a less stringent regime could be used, freeing up health-care resources with obvious benefits for women. However, a complete cessation of cervical cancer screening isn’t recommended, and considering the burden of cervical cancer, it is worth screening to catch it before it becomes a cancer, even if the risk is smaller.

The HPV vaccine was approved just in time for me to get it. I’ve witnessed cancer and its toll in both my personal and professional lives, and I have often had cause to be grateful for being protected against at least one form of it. I can recommend the HPV vaccine both as a scientist who understands the safety data, and as a woman who can say, hand on heart, I had it and experienced no side effects whatsoever.

I finished drafting this piece the day I had my most recent Pap smear. It wasn’t agony. Yet, to put it mildly, it was not an enjoyable experience. As I rushed to get dressed, my final thought was of Mary Papanicolaou. I resolved never to marry a man whose interest in gynecology is anything more than recreational.

But I understand the importance of catching cancer early, and I subsequently described my mood to a friend as “SAST”: Sulking After Smear Test.

If I heard I’d only have to have one more of those in my lifetime, I would be neither sad nor sorry. But for now, I’d rather get screened than not.

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