Test for Chlamydia, Pap or No Pap

By Kait Scalisi, MPH

In the continuing saga of patients and healthcare providers communicating poorly about sexual health, a new study shows that chlamydia screening rates dropped after Pap tests became less common.

For decades, Pap smears and chlamydia screening were paired. Once you became sexually active, or in some cases when you wanted birth control, your healthcare provider performed both tests during a pelvic exam. In 2009, the American College of Obstetricians and Gynecologists changed its recommendations around the Pap. As the recommendation still stands, all people with cervices should have a Pap test at age 21, regardless of sexual activity.

At the same time, the CDC recommends yearly chlamydia testing for all sexually active women 25 and under, along with older women with risk factors such as multiple sexual partners.

These recommendations appear to leave a gap: What about the folks who were younger than 25 but having sex? When would they get tested for chlamydia if they didn’t have a Pap done?

The technical answer to this question is simple: there are other ways to test for STDs without a pelvic exam. For example, a healthcare provider use a urine sample or vaginal swab to screen for chlamydia.

The realistic answer is that they aren’t getting tested.

In the study, researchers at the University of Michigan Medical School looked at rates of cervical cancer and/or chlamydia screenings among two groups of female patients: those who made visits before the 2009 change in Pap guidelines, and those who made visits after.

Over 3,000 patients (aged 15-21) visited five family planning clinics in Michigan. Of those who visited before the guidelines changed, about 30% got tested for chlamydia. Afterwards, that number dropped to less than 1%. As expected, the percentage of patients getting Pap smears dropped dramatically too, from 24% to less than 1%.

It’s not that girls and young women were going to the doctor less. No, in fact the number of visits between the two groups was about the same. The opportunity was there, but not taken.

Chlamydia is curable if detected. So what can clinics and healthcare providers do to close the gap of testing without doing unnecessary Pap exams? An interview with the study’s lead author provides a few ideas.

First, healthcare providers need to shift their mindset and separate out STD testing and cancer screening. They don’t need to happen together and as mentioned above, no pelvic exam is even needed for chlamydia testing. Closely related to this is the need for knowledge about these non-invasive testing methods. If healthcare providers do not know about these options, it is hard to offer them.

Secondly, taking advantage of modern technology. Electronic health records can be formatted to remind healthcare providers when a patient needs a chlamydia testing, maybe even providing information about the noninvasive testing methods.

Lastly, STD testing need not be relegated only to preventative care visits. Here, prompts from electronic health records are particularly helpful. If a patient comes in for a sick or emergency visit, the prompt will pop up no matter what, encouraging the provider to administer the testing along with any procedures relevant to the reason for their visit.

Regardless of whether electronic health record alerts are an option, but especially if they aren’t, this study speaks to the need to better train healthcare providers in talking about sexual health issues. Missed opportunities for testing are not the only reason that STDs continue to spread an go untreated, but they undoubtedly are one factor. And they’re perhaps the easiest to change. After all, people will continue having sex, some of which may be unprotected, and changing the health behaviors of an entire population through community outreach and sex education will take more time and effort than shifting the practices of one group of people who are already dedicated to keeping us healthy.