Obstetrics & Gynecology:
Pap Testing and Sexual Activity Among Young Women in the United States
Saraiya, Mona MD, MPH; Martinez, Gladys PhD; Glaser, Katherine MD, MPH; Kulasingam, Shalini PhD
From the Centers for Disease Control and Prevention, 1National Coordinating Center for Health Promotion, Division of Cancer Prevention and Control, Epidemiology and Applied Research Branch, and 2National Coordinating Center for Health Marketing, National Center for Health Statistics, Division of Vital Statistics, Reproductive Statistics Branch, Atlanta, Georgia; and the 3Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota. *Dr. Glaser is currently at the University of Arizona College of Medicine, Tucson, Arizona.
The authors thank Mary White, PhD, Stephanie Ventura, MA, Julia Holmes, PhD, and Jami Leichliter, PhD, for sharing their knowledge of the survey and providing input on the manuscript.
Presented in part at the Society of Gynecologic Oncologists Cervical Cancer Forum, September 12, 2008, Chicago, Illinois, and at the Practice Improvement in Cervical Screening and Management Committee’s Symposium on Cervical Cancer Screening and Management of Cervical Abnormalities in Adolescents and Young Women, June 19, 2009, Bethesda, Maryland.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Corresponding author: Mona Saraiya, MD, MPH, CDC, 4770 Buford Highway NE, MS K-55, Atlanta, GA 30341; e-mail: firstname.lastname@example.org.
Financial Disclosure The authors did not report any potential conflicts of interest.
OBJECTIVE: To understand whether and how recency of sexual activity is associated with Pap testing rates among young women.
METHODS: We analyzed data on self-reported receipt of Pap testing and initiation of sexual activity among young women and girls aged 15 to 24 years using the 2002 National Survey of Family Growth, an in-person, population-based survey of reproductive-aged men and women in the United States. The primary outcome was receiving a Pap test and its relationship to initiation of sexual activity. A multivariable model was used to predict the probability of having had a Pap test in the previous 12 months.
RESULTS: Thirty-three percent of the 2,513 women had never had sex. Of these, 13.9% had had a Pap test in the previous year. Sixty-seven percent of sexually-active women aged 15-24 reported receiving a Pap test (corresponding to 13.1 million tests). Approximately 59% women aged 15–20 years old who reported having initiated sexual activity in the previous 3 years also reported a Pap test in the previous year.
CONCLUSION: The current guidelines recommend screening 3 years after initiation of vaginal intercourse or at age 21, whichever is earlier. Contrary to the current guidelines, many young women who have not had sex or who initiated sex within the previous 3 years reported having had a Pap test. Assuming that the patterns observed in this study persist, there is an urgent need for education regarding the need to adhere to guidelines to reduce the burden of potentially unnecessary Pap tests in young women.
LEVEL OF EVIDENCE: III
The initiation of sexual activity has been used as a sentinel event to start cervical cancer screening in the United States. Previous guidelines in the 1990s advised women and their physicians to begin screening at age 18 or on initiation of sexual activity.1–3 Recent advances in cervical cancer screening and an improved understanding of the natural history of human papillomavirus (HPV) and cervical cancer have resulted in revised screening guidelines, including raising the age at which to start screening. In general, these newer guidelines recommend that a woman’s first Pap test be delayed to either 3 years after first vaginal intercourse (one guideline says within 3 years) or to age 21, whichever comes first.4–6 Therefore, it is important to study the linkage between age, first sex, and receipt of Pap testing to inform current and future cervical cancer screening guidelines. We examined the only national data source that has information on both Pap testing and age at first sex to understand whether and how recency of sexual activity is associated with Pap testing rates among young women.
MATERIALS AND METHODS
This study was approved by the National Center for Health Statistics’ institutional review board. The 2002 National Survey of Family Growth (NSFG) is an in-person, population-based survey of both males and females of reproductive age within households in the United States. The survey is designed to be nationally representative of females and males aged 15–44 years living in the United States.7 The response rate was 80% among women and girls. Survey participants are queried on a range of behaviors and attitudes related to sexual intercourse, family planning, and family growth. Women and girls aged 15–24 years as well as Hispanic and African-American women were oversampled in the 2002 NSFG. Between March 2002 and March 2003, a total of 2,513 women and girls aged 15–24 years representing 19.7 million females in the United States, completed the interview.
The outcomes of interest in our analysis were initiation of sexual activity and its relationship to having a Pap test. Each female participant was asked, “In the past 12 months, have you received a Pap test?” Each female participant was asked if she had ever had sexual intercourse using the question, “At any time in your life, have you ever had sexual intercourse with a man, that is, made love, had sex, or gone all the way?” For the purposes of this part of the survey, intercourse was defined as heterosexual vaginal intercourse. Respondents who reported that they had ever had heterosexual vaginal intercourse were defined as having had sex. Additionally, each participant was asked her age of first vaginal intercourse (age at first sex) with the question “That very first time that you had sexual intercourse with a man, how old were you?” More than 99% of these respondents provided the specific month and year at which first sexual intercourse occurred. Our analysis was limited to younger women, aged 15–24 years at the time of the interview, to allow for recency of first sexual intercourse and to allow us to capture key time periods (eg, 3 years after first sexual intercourse).8 We examined age at time of interview using single age categories and various groups (younger than 18, younger than 21) based on various screening guidelines.
A multivariable model was used to predict the probability of having had a Pap test in the previous 12 months, with inclusion of the following potential factors that may increase a visit to the doctor and therefore increase likelihood of getting a Pap test: age (15–17, 18–19, 20–21, 22–24 years), time since first sex (no sex, within previous 12 months, within previous 24 months, and within previous 36 months, 37 months and over), race and Hispanic origin (white, African American, Hispanic), mother’s education (less than high school, high school, some college, bachelor’s degree or higher), pregnancy in the previous 12 months (yes, no), current use of hormonal contraceptives (yes, no), and receipt of public assistance in the previous 12 months (yes, no). All analyses were performed using SAS 9.1 (SAS Institute, Cary, NC). Additionally, SUDAAN 9.0 (RTI International, Research Triangle Park, NC) was used to take into account the complex sample design of the NSFG.
About 67% of the respondents aged 15–24 have ever had sex, corresponding to 13.1 million. The number of women and girls who reported having had sex increased with each additional year of life, and, by the age of 22, 90.3% of women reported having had sex (data not shown). Age-group differences by race and ethnicity are shown in Figure 1. Although differences among groups are not significant, there is a pattern of higher levels of sexual experience for non-Hispanic African-American compared with non-Hispanic white and Hispanic young women, especially among younger teens. At the age of 15 to 17 years, 30.0% of non-Hispanic white women reported having had sex, 41.4% of non-Hispanic African-American women, and 25.1% of Hispanic women. Although there were racial and ethnic differences in proportions ever having sex in younger age groups, by age 20–24, similar percentages of women had had sex (non-Hispanic whites 86.6%, non-Hispanic African Americans 88.7%, and Hispanics 89.5%) (Fig. 1). More than half of women aged 15–24 years had received a Pap test in the previous 12 months. Among young women who had never had sex, Pap-test receipt varied by age, ranging from 5.4% of 15-year-olds reporting a Pap test within the previous year to 34.4% among the 20-year-olds (Table 1). Among girls under age 18 who had not had sex, 6.8%, or 277,000, reported a Pap test in the previous year; among those under age 21 who had not had sex, 11.6% reported a Pap test in the previous year; among those under age 25 who have not had sex, 13.9% reported a Pap test in the previous year.
Differences by race and ethnicity were noted in the likelihood of receiving a Pap test in the previous 12 months (Fig. 2); most differences were not significant, except for Hispanics. Similar percentages of non-Hispanic white and African-American women and girls who had never had sex reported having had a Pap test in the previous year (16.7% and 14.6%, respectively), but the percentage was lower for comparable young Hispanic women (4.4%). Although not all differences were significant, there is a clear pattern: Hispanic women were less likely to have had a Pap test in the previous year, regardless of time since first sex (50.3% within 3 years or 67.2% in 3 or more years), compared with non-Hispanic white women (62.8% and 80.0%, respectively) and non-Hispanic African-American women (66.6% and 79.0%, respectively).
Half of the respondents aged 15–24 who had sex for the first time in the previous year had had a Pap test within the previous year (Table 2). The longer it had been since young women had had first sex, the higher the percentage of women reporting a Pap test in the previous 12 months. Among women aged 15–20 years who had first sex within previous 3 years, 58.5% reported a Pap test in the previous year, compared with 78% for this age group that had first sex 3 or more years previously.
Results from multivariable analysis predicting the likelihood of having received a Pap test in the previous 12 months among 15- to 24-year-olds are shown in Table 3. Controlling for the other factors in the model (age, race, Hispanic origin, pregnancy in previous 12 months, current use of hormonal contraceptive, receipt of public assistance, and mother’s education), time since first sex was strongly related to the likelihood of having had a Pap test in the previous year. Young women who did not have sex were less likely to have a Pap test than were those who had sex within the previous 3 years. Those who first had sex more than 3 years ago were even more likely than those who had first sex within 3 years to have received a Pap test. Currently using a hormonal contraceptive and being pregnant in the previous 12 months were the most strongly and significantly related to an increased likelihood of having received a Pap test. After controlling for the factors in the multivariable model, race and Hispanic origin were not related to the likelihood of receiving a Pap test among young women aged 15–24 years.
In 2002, 13.9% of young women and girls under age 25 who had never had sex reported having had a Pap test in the previous year; about 60% of the young women and girls who had their first vaginal intercourse within three years or less had had a Pap test within the previous year. Whether one examines our findings by the earlier screening guidelines on when to start screening or by the current screening guidelines,9 the number of potentially unnecessary Pap tests among young women and girls is important to document. In 2002, when most respondents completed the interview, the 1995 guidelines for performing cervical cancer screening stated that women and girls should be screened after initiating sexual intercourse or at age 18, whichever is earlier. Given the sample and design of this survey, we can extrapolate our findings to the number of U.S. women. This means that approximately 277,000 potentially unnecessary Pap tests were performed on the 4 million girls under the age of 18 years who had not had sex. The results also can be examined using the 2002/2003 the American College of Obstetricians and Gynecologists/American Cancer Society Guidelines, which recommend that screening begin approximately 3 years after onset of sexual activity but no later than age 21. One conservative estimate of the number of potentially unnecessary Pap tests approaches 659,000 of the 5.7 million women and girls younger than 21 years who have not had sex. In addition, among those women and girls younger than 21, 2.9 million of the 4.8 million who had first sex within the previous 3 years had a Pap test in the previous 12 months. Or, alternatively, if one considers age 21, regardless of sexual activity, there were approximately 4.7 million women and girls younger than 21 who had had a Pap test in the previous year.
Our analysis of current behaviors among women and girls is important in the context of recent developments in cervical cancer prevention, screening, and management. Cervical cancer is rare among young women and girls. Between 1998 and 2003, there were 14 cases diagnosed among girls and women aged 15–19 years and 123 cases among women aged 20–24 years.10 Many studies show that the prevalence of high-risk HPV infection is quite high among young women and girls in the United States: 19% among sexually active girls and women aged 14–19 years and 29% among women aged 20–24 years.11 The long latency period between initial HPV infection (which is common soon after initiating sexual intercourse) and the development of high-grade cervical disease such as cervical intraepithelial neoplasia (CIN) 3 and cancer provides strong rationale for delaying screening. A concern with screening sooner than 3 years after the onset of sexual activity is that screening is likely to identify low-grade disease or HPV infection that will be transient in nature.12 Recent changes to guidelines reflect this concern: in girls and women up to age 21, conservative management of lesions such as CIN 1, CIN 2, or even CIN 3 now is recommended because of the high rate of regression of these lesions in this population.13 In addition, early, frequent screening creates an unnecessary burden of cost to the health care system and anxiety for the women who learn of abnormal results and undergo repeated examinations. Additionally, treatment of transient HPV cervical dysplasia in younger women is associated with adverse pregnancy outcomes.14,15 A recent prospective study in the United Kingdom shows that screening women aged 20–24 years had no effect on cervical cancer rates in women younger than 30.16
This study is limited by the self-reported nature of survey data on sexual behavior and Pap tests. Studies confirm that women are significantly more likely to overreport Pap tests compared with documentation of Pap tests in the medical record and to confuse the Pap test with a pelvic examination.17–19 We found that the prevalence of pelvic exams in the previous year was slightly lower than the prevalence of Pap tests at each single-year age group, possibly indicating less familiarity with the pelvic examination terminology or confusion with the terms.
The Pap tests reported are only those that occurred in the 12 months preceding a respondent’s interview, not necessarily their first Pap test. There is a possibility that many young women and girls might have had their first Pap test earlier, and we may be underestimating the number of women who might have had their first Pap test and its relationship to onset or recency of starting sex. We could not examine how many women were supposed to have a Pap test but did not get it because the NSFG does not ask women and girls whether they ever had a Pap test or how often they get a Pap test.
The most recent survey of the NSFG was conducted in 2002, during a time when screening guidelines were changing, so it may not be entirely fair to compare our findings with the current guidelines, but it gives us a sense of how onset and recency of sex are associated with Pap testing. However, recent provider surveys indicate that not much has changed since 2002. In a 2003 survey, 74% of obstetrician–gynecologists reported that they would screen 18-year-old women who had not had sex,20 and, in a 2006 survey, 72% of certified nurse midwives stated they would screen 18-year-old women within 1 month of starting sex.21 A 2007 primary care physician survey indicates that half of physicians are likely to screen 18-year-old sexually nonexperienced women and that more than 92% would screen an 18-year-old woman within 1 month of first sex (Yabroff KR, Saraiya M, Meissner HI, Haggstrom DA, Wideroff L, Yuan G, et al. Specialty differences in primary care physician reports of Papanicolaou test screening practices: a national survey, 2006 to 2007. Ann Intern Med. In press.). Many reasons may exist for (over)performing Pap tests in younger women and girls. Pap testing is common among young females who are receiving other reproductive health care.22 The practice of linking Pap tests with both receipt of hormonal contraception and prenatal care also has been documented in previous studies,23,24 and they continue to be strongly associated with getting a Pap test. In addition, concerns about litigation, the misconception that cervical cancer is common and 100% preventable in young women, and a lower awareness of the natural history of HPV and cervical cancer also may play a role.
If the patterns observed in this study have persisted, there may be a need for further education and stronger interventions (ie, reminders, lack of reimbursement) regarding current guidelines. Our current understanding of the course of HPV infection in the majority of girls and young women and the financial and clinical burden of screening them underscores the importance of providers’ understanding the need for an increased interval between the age at which patients report their first vaginal intercourse and the age at which they receive their first Pap test. Additionally, these findings can help inform cost-effectiveness studies on current screening practices among girls and young women, especially as HPV vaccination coverage increases. Because there are many unanswered questions related to the HPV vaccine, such as duration of protection, any change in screening recommendations as a result of the HPV vaccine is still years away. Currently, those who have received the vaccine should continue to be screened regularly for cervical cancer, according to guidelines.25 Recommendations for when to start screening among fully HPV-vaccinated girls and women (especially those who have been screened before having had sex) have not changed, but experts predict that they are likely to change in the future.26 Cost-effectiveness studies have suggested that both a change in the age to start screening (25 years) and how often to screen (every 3–5 years) would make the most epidemiological and economic sense.27,28 As the paradigm for cervical cancer screening and prevention changes, continuous monitoring of preventive behaviors, policies, and interventions about timing of first sex, timing of first Pap, HPV DNA testing, and HPV vaccines will be important to ensure that newer technologies are being accompanied by evidence-based practices.
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Figure. No caption available.
© 2009 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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