Everything You Need to Know About STI and Pap Tests

All the sexy stuff including the difference between a Pap and a pelvic exam, your chances of getting HPV and how often you should be getting tested

Let’s be honest: Talking about sexually transmitted infections isn’t super fun. Even less of a hoot? The thought of going for STI tests, like a Pap smear—especially when it’s your first time. From that scary-looking contraption to myths around pain, it can be pretty frightening. But regular STI testing, including a Pap test, is also essential to your health.

Speaking with doctors for this story, I was shocked when I discovered that most Canadians under the age of 30 will contract a strain of the HPV virus that can cause cervical cancer, often without knowledge. HPV, or the human papillomavirus, is the most commonly transmitted STI (and is common in both men and women). It was even more surprising to learn, thanks to a 2017 report from the Government of Canada, that some sexually transmitted infections, including chlamydia, gonorrhoea and syphilis, have been on the rise for over a decade. The good news is that most STIs are extremely treatable and most cases of HPV resolve without complication—but the key is knowing you have them in the first place. This is where regular STI testing comes in.

Knowledge is power, especially when it comes to your sexual and reproductive health. Here’s everything you need to know about Pap smears and STI tests, and why you should make them a regular part of your health agenda. (Seriously, you’ll thank us later).

So, what is an STI test?

STI tests are either (and often a combination of) a blood test, a urine test or a swab during a pelvic exam (a pelvic exam is an umbrella term—typically during a pelvic exam your vulva, vagina, cervix, ovaries, fallopian tubes and uterus are checked) . “The only blood tests you do are for HIV, syphilis and hepatitis B, everything else is generally done with swabs,” says Dr. Amanda Selk, lead gynecologist at the Gynecology Colposcopy Clinic at Women’s College Hospital. “Gonorrhoea and chlamydia can be detected with a urine test if you have no symptoms, but if you have symptoms, we typically do swabs.” 

How do you get STIs?

Like the name suggests, sexually transmitted infections, including HPV, are passed through sexual activity. “Any sexual contact—penile-vaginal intercourse, penile-anal intercourse, genital-to-hand touching, oral intercourse—can all spread infection,” Selk says. Barrier contraception like condoms can help decrease the risk, but nothing is 100% effective. And since many of us think of condoms mainly as a birth-control option, and therefore use them only with penetrative sex, there are still plenty of other sexual experiences that can and do spread STIs. “Condoms are the best you can do without not having sex ever,” Selk says. As in, abstinence is the best way to not spread STIs, but condoms are the next best things. And in case you’re wondering…

Can I pass along an STI if I don’t have symptoms?

The answer is a resounding yes. In fact, that’s how most STIs do get transmitted. “The vast majority of things are passed on through asymptomatic people,” Selk says. This is the main reason why getting tested regularly is important so that asymptomatic people can be treated and prevent the spread of infection. “Because all STIs can present with no symptoms, more often people don’t know they’ve contracted one,” Dr. Reyhaneh Ghadaki says .

How can I get tested for STIs in Canada?

This depends on where you are, but access to STI testing is certainly easier in cities that have more facilities. But if you have access to a walk-in clinic, you should have access to STI testing, which is free across Canada. It’s important to ask for STI testing whether you opt to visit an anonymous sexual health clinic or your own doctor, and to ask which specific tests are being done. Since some infections are tested through urine, others through blood and even more through a pelvic exam, you likely won’t be tested for everything unless you ask. This goes for regular check-ups, too—don’t assume your doctor is checking for relevant STIs just because you had bloodwork done. You often need to request them, especially if you’re asymptomatic.

How often should you be tested for STIs?

“I recommend that my patients get tested if they have any symptoms, when they have a new partner or if they are concerned and have had unprotected intercourse,” says Dr. Ghadaki, medical director of the WellOne Medical Centre. But if you’re not showing symptoms or don’t have a new sexual partner? “A sexually active person should be tested yearly, at minimum, for STIs,” Selk says. This includes people in long-term or monogamous relationships, as it isn’t always clear when or how people may get an infection and of course, not everyone shows symptoms. If you are showing symptoms, you should absolutely get checked, even if this is more frequent than the one-year guideline. “When you test, you do find that people have STIs they don’t know about,” she says. “There’s no reason not to check.”

Got it. So, what is a Pap test?

It’s best to know what *exactly* you’re getting yourself into once you walk into your doctor’s office for a Pap test. For the uninitiated, you’ll start by putting your feet in stirrups followed by your doctor placing the speculum (a plastic device that looks like a duck’s beak) into your vagina so that they can clearly see your vagina and cervix. From there, the doctor will use a brush to collect cells from the cervix. It’s normal to have some light bleeding or spotting afterwards. A Pap may be done as part of a more thorough pelvic exam, which can often include your doctor inserting two fingers and palpating your abdomen to check your uterus and ovaries which can help indicate whether there are signs of ovarian cysts or uterine fibroids as well as STIs. Your doctor should be updating you on what they’re doing at every step so you know what’s going to happen next. And, it is fully within your right as a patient to have someone else—like a female nurse—in the room for support, safety and comfort, *especially* if your doctor is male. 

What’s the difference between a Pap test and a vaginal exam? 

According to Selk, because both Pap tests and STI tests use a speculum, people can often conflate the two, and think they’re getting a Pap test when they’re actually being tested for STIs. But there’s a big difference between the two tests—despite the use of similar instruments. “Paps are a specific test where you take cervical cells to test for pre-cancer changes related to HPV.” (Meaning, that Paps *only* test for abnormal cells on the cervix related to HPV whereas STI testing, if done via a pelvic exam, relies on swabs taken from the cervix or inside the vagina).

STI testing can be done in an emergency room (if you’re there for pain or discharge, there’s a chance you’ll get one), but it’s important to emphasize that these are different tests than Pap tests. The two tests aren’t always done together and are testing for different things, despite both using the speculum. “Not all vaginal exams are Paps. Most of the time, it’s just a routine physical exam or [you’re] being tested for STIs, but that communication doesn’t always come across between practitioners and patients,” Selk says. The miscommunication comes when you get STI testing and think it’s a Pap because of the instrument (speculum) and the experience (having your vagina/cervix looked at). But just because you’re getting STI testing done, doesn’t mean you’re also getting a Pap.

As a Pap test only tests for HPV and cancer screening, it often won’t be done in an emergency room and, unless otherwise directed, should be done every three years during a physical exam at your doctor’s office. 

It’s important to know what tests are being done, both so you know when to schedule your next exam or test, but also so you know what feedback, if any, to expect. 

On a scale of one to 10, how much does a Pap test hurt?

Probably one of the biggest questions anyone with a vagina has when it comes to Pap smears is: Will it hurt? While the answer to this question depends on the individual experience (as well as one’s tolerance for discomfort), in my personal experience, the anticipation has been worse than the actual procedure. (FWIW, my doctor once took my blood pressure before a Pap and it was abnormally high. She did the Pap test, and then decided to re-take my blood pressure and it was completely back to normal.)

When should I start going for Pap tests?

If you’re sexually active (and therefore at risk for STIs), you should be getting regular Paps. 

What is HPV?

That *thing* they’re checking for during my Pap test is the human papillomavirus (HPV) which is a viral infection and, as mentioned above, the most commonly transmitted STI. There are many different strains and while some strains will resolve on their own, others can lead to genital warts or cervical cancer.

Don’t we all get HPV anyways?

This is a bit of a misconception but yes, many of us will get an HPV strain, without symptoms, and clear it without issue. In fact, Selk says that almost everyone under the age of 30 (and 70 to 80% of Canadians) will get a strain. Some of the strains cause cervical cancer, though not all of them. The problem is when you don’t clear the infection on your own and that’s what a Pap smear looks for—abnormalities that could lead to cervical cancer.

How can I prevent HPV?

HPV can be transmitted through vaginal, anal or oral sexual activities which makes almost all sexually active people at risk for contracting the virus. The HPV vaccine is highly effective at preventing HPV infections in the first place so they don’t have the chance to turn into cervical cancer—this is primary prevention. Secondary prevention is the stage where you get a strain and healthcare providers try to keep it from causing trouble. “Most people will clear it by themselves, and the biggest risk factor for cancer is when your body doesn’t actually clear it,” Selk says. This could be because of a variety of risk factors (including smoking and being immunocompromised), but sometimes healthy people don’t clear it and doctors don’t always know why. That’s why it’s important to keep up with your regular Pap tests, even if you’ve had the HPV vaccine. “Countries that have good programs for screening, like Canada, have very little cervical cancer, because the programs work very well,” Selk says. “Most of the people with cervical cancer in Canada are those who have never had a Pap smear or who have not been screened in the last five years.”

Should I get the HPV vaccine?

The HPV vaccine is highly effective and recommended for all men and women, and is offered free to grade seven students in Canada. Dr. Ghadaki recommends the vaccine to everyone between the ages of nine and 50 as a preventative measure for HPV infections that can lead to cervical cancer. As an adult, the vaccine is three doses and can cost about $600 in total, though many insurance companies cover the vaccine. “When you’re older, there’s no reason not to get the HPV vaccine other than cost,” Selk says. And even if you’ve contracted a strain of HPV before, you should still consider getting the vaccine as it prevents against multiple strains of the virus.

What does an abnormal Pap test mean?

When you have an abnormal Pap test, it means that your test result isn’t necessarily clear—but that isn’t always cause for concern right away. In fact, one of the main reasons the recommendation for Pap test frequency recently changed to every three years (it used to be every year) was because many factors can contribute to an abnormal result, including having sex the day before your test, a bit of inflammation, even wearing a tampon. (According to Dr. Selk, changing testing every to every three years has shown no increase in cancer diagnoses and has decreased the flagging of mild abnormalities that clear on their own. Nonetheless, this three-year wait can cause a lot of stress. If it’s not time for your test but you are concerned, you can get one and should always talk to your doctor about your scheduled exams as they relate to your health or situation.) 

“There are grades of abnormal, so if there’s something that’s minimally abnormal, and they’re not sure what it is—it’s not a cancer, it may not even be HPV-related—that would be an example where we would just repeat the test,” Selk says. Repeating the test, or having another Pap test before the three-year mark could all be part of the plan to keep an eye on things. And depending on the degree of abnormality, your doctor will likely want to rule out or diagnose a pre-cancerous condition or cervical cancer. From there, you’ll be monitored for changes and in some cases, the pre-cancerous or abnormal cells will be removed via various treatments