Annals of Internal Medicine

Summaries for Patients

The Value of Continuing Regular Papanicolaou (Pap) Smears in
Postmenopausal Women

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The full report is titled The
Positive Predictive Value of
Cervical Smears in Previously
Screened Postmenopausal
Women: The Heart and
Estrogen/progestin Replacement
Study (HERS). It is in the 19
December 2000 issue of Annals of
Internal Medicine (volume 133,
pages 942-950). The authors
are GF Sawaya, D Grady,
K Kerlikowske, J La Valleur,
VM Barnabei, K Bass, TE Snyder,
JH Pickar, SK Agarwal, and
J Mandelblatt, for the Heart and
Estrogen/progestin Replacement
Study (HERS) Research Group.

What is the problem and what is known about it so far?

The recommended method of screening for cervical cancer in women before menopause is
to do a Pap smear every 1 to 3 years. It is unclear whether continuing regular Pap smears
in women after menopause is of value. Professional organizations recommendations vary
from continuing Pap smears throughout life to stopping them at age 65 in women whose
Pap smears were previously normal. False-positive Pap smears are frequent in women
after menopause; this means the test appears abnormal, but the woman does not have an
important cervical problem. It makes sense to minimize the chances of false-positive test
results because they lead to needless worry and follow-up testing. To complicate the issue,
little is known about whether taking postmenopausal hormones influences Pap smear
results.
Why did the researchers do this particular study?
To study the value of continuing to perform regular Pap smears after menopause for
women with a recent normal test and to find out whether taking postmenopausal
hormones influences the Pap smear results.
Who was studied?
The study included 2561 women with a uterus and normal Pap smears at the start of the
study. These women were participants in a larger study of heart disease and
postmenopausal hormones.
How was the study done?
Women in the study had Pap smears yearly during the study, and the researchers collected
information about the results. They then determined what additional diagnostic tests were
done to follow up on abnormal smears, and they determined the final outcome of the
diagnostic evaluation; this allowed them to decide whether each abnormal result was a
true- or false-positive one. Since all women were participating in a study of hormones, they
received either hormone replacement (estrogen and progesterone) or placebo pills that
looked like the hormones but contained no active ingredient.
What did the researchers find?
Of the 4895 Pap smears done in the study, 110 were abnormal. Only 1 of these was true
positive, however. Women taking hormones did not have a significantly higher frequency
of abnormal Pap smears than women not taking hormones.
What were the limitations of the study?
This study included women who were at low risk for cervical cancer and who had normal
Pap smears at baseline. These findings do not apply to women at high risk for cervical
cancer, those who have a history of abnormal Pap smears, or those who have never had
Pap smears.
What are the implications of the study?
Regardless of whether women are taking postmenopausal hormones, continuing Pap
smears after menopause for women who have a history of normal Pap smears appears to be
of limited value. Most abnormal results in this group of women will prove to be false
positive.
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2000 American College of PhysiciansAmerican Society of Internal Medicine S-61