Pap smears or self-swabs?

At the gynecologist's office, we know the drill: don a disposable gown, lie on the exam table, place our feet wide apart in stirrups, and wait for the doctor to insert a speculum, a metal tool that separates the vaginal walls and allows the doctor to insert a long swab to scrape cells from the cervix.

It's all part of a Pap test, which is performed as part of a pelvic exam. This mainstay screening test detects cervical cancer, which is diagnosed in nearly 14,000 American women each year and kills about 4,400, according to the American Cancer Society (ACS). If those numbers seem low, it's because routine screening with Pap tests enables far more women to detect and treat precancerous changes and prevent cervical cancer from developing. Globally, cervical cancer is the fourth most common cancer in women, according to the WHO.

But for many, getting a Pap test is a fraught, sometimes painful encounter that leaves them feeling physically or emotionally vulnerable. This scenario is hardly optimal for such an important procedure: while the incidence of early-stage cervical cancer has dropped in most groups in recent years, advanced cervical cancer cases haven't declined in any racial, ethnic, or age group over nearly two decades, according to 2023 ACS data.

But now there's an alternative. A new self-swab test enables women to collect a cell sample in their doctor's office independent of a pelvic exam, without the need for stirrups or speculum. The cells are then sent to a lab to look for strains of human papillomavirus (HPV) implicated in the development of cervical cancer.

New technology

Approved by the FDA in mid-2024, the self-swab test was made possible by recent technological advances in HPV screening. The new technology can zero in on cells collected from the vaginal wall instead of just the cervix, sparing women much of the discomfort of a traditional Pap test during a pelvic exam, says Dr. Stephanie Alimena, a gynecologic oncology surgeon at Harvard-affiliated Brigham and Women's Hospital.

"Pelvic exams are uncomfortable for everyone," Dr. Alimena says. "It involves such a sensitive and private area that we're not used to showing many people, and it's particularly sensitive for patients who have had trauma in the past. It's tough to be a patient on the receiving end of that exam. The Pap test can certainly add to that discomfort."

How it's done

The self-swab test allows women more autonomy than a traditional Pap test, which is performed by a clinician as part of a pelvic exam. But it's not yet a private process, like collecting a urine sample in a doctor's office bathroom. Instead, a clinician coaches the woman through the procedure, guiding her to part the labia, insert a plastic swab (similar in size to a pen), rub it along the vaginal walls, and remove it. The swab is then immediately placed in a vial and sent to a lab.

The FDA hasn't weighed in on whether the clinician stays behind a curtain during this process or watches the woman insert the swab, Dr. Alimena notes. "I think most of us (gynecologists) assume this occurs in the restroom or a clinic room without the health care provider present," she says. "However, the patient has seen the health care provider immediately prior to the self-swab to discuss how to perform the testing."

The new test's development is part of a shifting model of cervical cancer testing in the United States, Dr. Alimena noted. In use for 80 years, the Pap test looks for abnormal cells from the cervix. In recent years, the same cell sample has also been used to check for HPV. It turns out that the latter test is better at predicting future cervical cancer.

"Right now, labs run both tests at the same time. But in the last 10 years we've realized that detecting HPV is much more predictive of a problem than looking at cells from the cervix alone, because HPV causes more than 95% of cervical cancers," Dr. Alimena says. "So we're moving to a new paradigm of doing an HPV test first. If it's positive, only then will a woman need to return for a Pap smear to determine if cells on the cervix are abnormal." Testing positive for HPV is not unusual, so the follow-up test is needed to truly figure out whether an abnormality is present, and what treatment if any is needed.

When caught early through routine screening, cervical cancer is curable. In the United States, about 92% of women with early-stage cervical cancer survive five years or longer, compared with only 17% of women with late-stage disease.

Pros and cons

Self-swab tests boast several key benefits:

They're more palatable. Women may find self-swabbing more comfortable if they've had prior difficulty with pelvic exams, find a speculum painful, underwent radiation to their pelvic region, or suffer from a condition such as vaginal atrophy, which makes vaginal tissue thinner and less elastic. "Having the option to do things on their own terms might be attractive to a lot of women," Dr. Alimena says.

They're accurate. Pap and HPV tests, completed with a pelvic exam, have helped to dramatically reduce overall deaths from cervical cancer. But research findings so far suggests the self-swab method can meet the same objective. "Self-swabbing can be just as accurate in terms of HPV testing and help us decide who needs cervical testing," she says. "We're awaiting the results of more national research to verify the accuracy of self-swabbing."

They may boost access to screening. More women may seek cervical cancer screening if they don't need a pelvic exam to get it. In this way, the self-swab test may combat disparities in cervical cancer detection and treatment. For example, Black women have a 30% higher risk of the disease than other groups and are 60% more likely to die, she says. And nearly a quarter of women eligible for cervical cancer screening are overdue to get it, according to the National Cancer Institute. "If we can take away some of the barriers, I hope the disparities can roll away," she says.

Any cons to self-swabbing are hard to discern, Dr. Alimena says. The method doesn't come with any apparent risks. "The plastic swab should not be sharp, thick, or firm enough to cause any damage" inside the vagina, she says.

That said, some women may not wish to administer their own test and want to leave the task to a clinician. They can always opt for a traditional Pap test. Other women may have been advised to continue Pap testing due to previous abnormal findings.

Home testing on the horizon

The in-office self-swabbing option will likely lead in the next few years to at home kits that accomplish the same thing. As with certain other home-based tests, the sample collected will need be sent to a lab — in this case, to look for HPV. Women who test positive would then be guided by their doctors on follow-up steps.

The FDA is still reviewing at-home tests, which Dr. Alimena believes will take a few more years to hit the market. But clear sets of instructions need to be developed to make home testing an accurate option, she says.

"I think it's the direction we're going, and I'm excited for it to come," Dr. Alimena says. "But we need systems in place to make sure people don't fall through the cracks. It's great to get more access to testing, but only beneficial if you get follow-up care to prevent cancers from forming."

Prevention strategies

With vigilance, women can significantly decrease their risk of developing cervical cancer. Dr. Alimena recommends taking these preventive steps:

Seek HPV vaccination for yourself or loved ones. The CDC recommends that all children should be vaccinated against HPV between the ages of 9 and 12, but some adults are eligible for the vaccine up to age 45.

Stick to the schedule. Women should begin screening tests for cervical cancer in their 20s and continue through at least age 65, regardless of vaccination status or whether they're sexually active. Certain women need to continue testing after age 65 if they have had prior Pap abnormalities. (See "Cervical cancer screening guidelines.")

Follow up on any abnormal results. "With abnormal findings, you'll need to be watched more closely and undergo more testing," she says.

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