Pap smears after total hysterectomy

Pap Smears After a Hysterectomy

Q: Will I still need Pap smears after a hysterectomy?

A: You might, depending on the type of hysterectomy you undergo. The purpose of the Pap smear is to detect cervical cancer by taking a sample of cells from the lowest part of the uterus (cervix) and examining them microscopically. Most women have their uterus entirely removed during a hysterectomy, and since they don’t have a cervix afterward, they don’t need Pap tests. Women who have a partial hysterectomy, which preserves the cervix, definitely need Pap smears.

However, if you do need Pap smears, you may not need to get them every year. The American College of Obstetricians and Gynecologists says that some women who’ve had three normal Pap smears in a row do not need to get annual Pap tests. They can have them every second or third year instead. It’s best to discuss your individual case with your gynecologist, who can tell you whether you should continue having Pap tests after your hysterectomy and how often to get them.

In addition, whether you have regular Pap smears or not after your hysterectomy, it’s important to remember that you still need to see your gynecologist every year. Pelvic exams are the best — and probably only — way to screen for ovarian and peritoneal cancers. At present, there is no other test that’s been proven useful in detecting these cancers.

Orli R. Etingin, MD, is professor of medicine in clinical obstetrics and gynecology at New York-Presbyterian Hospital/Weill Cornell Medical Center.

Nov. 9, 1999 (Chicago) — Rarely is less cancer screening considered good medicine. However, in women who have had prior hysterectomies, less is more, according to Mona Saraiya, MD, MPH, speaking on a panel here at the 127th annual meeting of the American Public Health Association. Although most of these women have had a recent Pap smear, it is usually not necessary, she says.

Some women have had a supracervical hysterectomy, which leaves the cervix intact. In these women a Pap smear is still valid. Also, if the woman had the surgery because she had cervical cancer or premalignant lesions, periodic Pap smears are required.

However, most women are still getting routine Pap smears after hysterectomy, says Saraiya, an epidemiologist in the CDC’s division of cancer prevention and control. “The reason we do a Pap is to detect cervical cancer,” she tells WebMD. Therefore, the procedure is unnecessary for most of these women, she says.

In a review of data from surveys conducted by the CDC through 1994, Saraiya and colleagues compared women’s histories of Pap smears with their hysterectomy status. Among all the respondents, 74% of the women who had had a hysterectomy also reported having a Pap smear within the last three years. This result was comparable to respondents who had not had hysterectomies, of whom 77% had had a Pap smear.

The clinical indications for a Pap smear cannot account for the lack of a discrepancy between these groups, says Saraiya. Less than 1% of the 600,000 hysterectomies performed annually leave the cervix intact, she says. Furthermore, more than 90% of hysterectomies are for conditions unrelated to cancer, such as fibroids, she says.

“Only 4% to 15% of women who have had hysterectomies should be getting Pap smears — not 74%,” she says. “Of the 12.4 million post-hysterectomy women who have had a recent Pap smear, 10.6 million to 11.9 million didn’t need it.” However, these data are limited because they are based on surveys, she says.

Many women do not know if the cervix was removed at the time of their hysterectomies. In these cases, a woman can ask her physician to find out by giving her a pelvic examination, she tells WebMD.

By the way, doctor: Do I need a Pap test after hysterectomy?

Published: January, 2006

Q. I had a hysterectomy in my 50s. Do I still need to have Pap tests?

A. It depends on why the hysterectomy was performed and whether your cervix was removed during the procedure. If you had an abdominal hysterectomy and the surgeon didn’t remove your cervix, you’ll need to continue having Pap tests on a schedule determined by your age and risk for cervical cancer. If your cervix was removed during hysterectomy for a benign condition, such as fibroids or endometriosis, you don’t need further Pap tests. But if you had a hysterectomy because of cervical, ovarian, or endometrial cancer, your clinician will need to continue Pap tests to monitor for any changes in your vaginal tissues.

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By Halle G. Sobel, MD Elise Everett, MD and Laura D. Lipold, MD

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A 50-year-old woman presents for a new patient visit. She underwent vaginal hysterectomy for menorrhagia 4 years ago, with removal of the uterus and cervix. Tissue studies at that time were negative for dysplasia. Her previous physician performed routine Papanicolaou (Pap) tests, and she asks you to continue this screening. How do you counsel her about Pap testing after hysterectomy for benign disease?

Screening guidelines

Introduced in 1941, the Pap test is an example of a successful screening tool, improving detection of early cervical cancer and reducing rates of morbidity and death due to cervical cancer. Early stages of cervical cancer are the most curable. 1

Screening in women who have a cervix

In 2012, the US Preventive Services Task Force (USPSTF) updated its 2003 recommendations for cervical cancer screening. 1 In the same year, the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology published a consensus guideline. 2 This was followed by publication of a guideline from the American College of Obstetricians and Gynecologists. 3 These guidelines all recommend Pap testing for cervical cancer every 3 years in women ages 21 to 65. In women ages 30 to 65, the screening interval can be lengthened to every 5 years if the patient undergoes cotesting for human papillomavirus (HPV). These recommendations apply only to women with a cervix.

No screening after hysterectomy for benign indications

Women who undergo hysterectomy with complete removal of the cervix for benign indications, ie, for reasons other than malignancy, are no longer at risk of cervical cancer. Pap testing could still detect vaginal cancer, but vaginal cancer is rare and screening for it is not indicated. The USPSTF 2003 and 2012 guidelines recommend not performing Pap testing in women who had had a hysterectomy for benign indications. 1

Vaginal cancer is rare

Although cervical and vaginal cancers share risk factors, vaginal cancer accounts for only 0.3% of all invasive cancers and 1% to 2% of all gynecologic malignancies in the United States. 4

A review of 39 population-based cancer registries from 1998 to 2003 found the incidence rate for in situ vaginal cancer to be 0.18 per 100,000 women, and the incidence rate for invasive vaginal cancer was 0.69 per 100,000. Rates were higher in older women and in certain ethnic and racial groups, including black and Hispanic women. 4

When the cervix is removed during hysterectomy for a benign indication, the patient’s risk of vaginal cancer or its precursors is extremely low. Pearce et al 5 reviewed Pap tests obtained from the vaginal cuff in 6,265 women who had undergone hysterectomy for benign disease. Their 2-year study reviewed 9,610 vaginal Pap tests, and in only 5 women was vaginal intraepithelial neoplasia type I or II found, and none of the 5 had biopsy-proven vaginal cancer. Only 1.1% of all Pap tests were abnormal. The authors concluded that the positive predictive value for detecting vaginal cancer was 0%. 5

A retrospective study by Piscitelli et al 6 in 1995 looked back 10 years and found an extremely low incidence of vaginal dysplasia in women who had undergone hysterectomy for a benign indication. Their findings, coupled with the high rate of false-positive tests, do not support cytologic screening of the vagina after hysterectomy for a benign indication. The data also suggested that 633 tests would need to be performed to diagnose 1 case of vaginal dysplasia. 6 Other studies have also reported a low yield of vaginal cuff cytologic testing after hysterectomy for benign disease.

Therefore, given the low prevalence of disease and the lack of evidence of benefit of screening after hysterectomy for benign indications, Pap testing of the vaginal cuff is not recommended in these patients. 7

Screening for women at high risk after hysterectomy

For women with a history of grade 2 or 3 cervical intraepithelial neoplasia who have undergone hysterectomy, there are only limited data on subsequent disease risk.

Wiener et al 8 followed 193 post-hysterectomy patients who had a history of cervical intraepithelial neoplasia with Pap testing annually for more than 10 years for a total of 2,800 years of follow-up. The estimated incidence of abnormal cytology (0.7/1,000) was higher than in the general population. 8

Thus, for these women and for others at high risk who have undergone hysterectomy and have a previous diagnosis of cervical cancer, who had been exposed to diethylstilbestrol, or who are immunocompromised, Pap testing to screen for cancer in the vaginal cuff is recommended, as they are at higher risk of dysplasia at the vaginal cuff. 2

Practice trends, areas for improvement

Despite recommendations against screening, many providers continue this non-evidence-based practice. 4

The 2000–2013 National Health Interview Survey of women age 20 or older who had undergone hysterectomy asked about their most recent Pap test by self-report. Women were excluded if they had a history of cervical cancer, if they had had a Pap test for another health problem, or if the result of the recent Pap test was not known. In 2000, nearly half (49.1%) of the respondents said they had received a Pap test in the previous year; in 2013, the percentage undergoing testing was down to 32.1%, but testing was unnecessary in 22.1%. Screening was largely due to clinician recommendations, but it was initiated by patients without clinician recommendations in about one-fourth of cases. 9Lack of knowledge of the revised 2012 guidelines was cited as the primary reason for unnecessary screening. 10

A study of provider attitudes toward the cancer screening guidelines cited several reasons for nonadherence: patient concern about the guidelines; quality metrics that are incongruent with the guidelines; provider disagreement with the guidelines; risk of malpractice litigation; and lack of time to discuss the guidelines with patients. 11

As the healthcare landscape changes to team-based care, the clinician and the entire healthcare team should educate patients about the role of vaginal cancer screening after hysterectomy for benign reasons. Given the limited time clinicians have with patients during an office visit, innovative tools and systems outside the office are needed to educate patients about the risks and benefits of screening. 11 And notices in the electronic medical record may help busy clinicians keep up with current guidelines. 10

The clinical bottom line

Pap testing to screen for vaginal cancer in women who have undergone hysterectomy for a benign indication is an example of more testing, not better care. Evidence is lacking to justify this test in women who are not at high risk of cervical cancer. To reduce the overuse of cytology screening tests, providers need to stay informed about evidence-based best practices and and to pass this information along to patients.

We should focus our resources on HPV vaccination and outreach to increase screening efforts in geographic areas with low rates of Pap testing rather than provide unnecessary Pap testing for women who have undergone hysterectomy for a benign indication.

This article originally appeared in Cleveland Clinic Journal of Medicine, 2018 June;85(6):456-458. Read the full article, Is Pap Testing Still Needed After Hysterectomy?

  1. Moyer VA; US Preventive Services Task Force. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med 2012; 156(11):880–891, W312. doi:10.7326/0003-4819-156-12-201206190-00424
  2. Saslow D, Solomon D, Lawson HW, et al; American Cancer Society; American Society for Colposcopy and Cervical Pathology; American Society for Clinical Pathology. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol 2012; 137(4):516–542. doi:10.1309/AJCPTGD94EVRSJCG
  3. Committee on Practice Bulletins—Gynecology. ACOG practice bulletin number 131: screening for cervical cancer. Obstet Gynecol 2012; 120(5):1222–1238. doi:10.1097/AOG.0b013e318277c92a
  4. Wu X, Matanoski G, Chen VW, et al. Descriptive epidemiology of vaginal cancer incidence and survival by race, ethnicity, and age in the United States. Cancer 2008; 113(10 suppl):2873–2882. doi:10.1002/cncr.23757
  5. Pearce KF, Haefner HK, Sarwar SF, Nolan TE. Cytopathological findings on vaginal Papanicolaou smears after hysterectomy for benign gynecologic disease. N Engl J Med 1996; 335(21):1559–1562. doi:10.1056/NEJM199611213352103
  6. Piscitelli JT, Bastian LA, Wilkes A, Simel DL. Cytologic screening after hysterectomy for benign disease. Am J Obstet Gynecol 1995;173(2):424–432. pmid:7645617
  7. Stokes-Lampard H, Wilson S, Waddell C, Ryan A, Holder R, Kehoe S. Vaginal vault smears after hysterectomy for reasons other than malignancy: a systematic review of the literature. BJOG 2006; 113(12):1354–1365. doi:10.1111/j.1471-0528.2006.01099.x
  8. Wiener JJ, Sweetnam PM, Jones JM. Long term follow up of women after hysterectomy with a history of pre-invasive cancer of the cervix. Br J Obstet Gynaecol 1992; 99(11):907–910. pmid:1450141
  9. Guo F, Kuo YF. Roles of health care providers and patients in initiation of unnecessary Papanicolaou testing after total hysterectomy. Am J Public Health 2016; 106(11):2005–2011. doi:10.2105/AJPH.2016.303360
  10. Teoh DG, Marriott AE, Isaksson Vogel R, et al. Adherence to the 2012 national cervical cancer screening guidelines: a pilot study. Am J Obstet Gynecol 2015; 212(1):62.e1–e9. doi:10.1016/j.ajog.2014.06.057
  11. Haas JS, Sprague BL, Klabunde CN, et al; PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) Consortium. Provider attitudes and screening practices following changes in breast and cervical cancer screening guidelines. J Gen Intern Med 2016; 31(1):52–59. doi:10.1007/s11606-015-3449-5

Medically reviewed by:
Brad Campbell, MD, McLeod OB/GYN Assoc. and Paul Chandler, MD, McLeod Women’s Care

A national primary care physician group has said that women no longer need an annual exam and pap smear. McLeod Gynecologists Paul Chandler, MD and Brad Campbell, MD still recommend this continuing care for women – even for women who’ve had a hysterectomy, the removal of a woman’s uterus that can help with problems, such as bleeding and endometriosis. Here’s what they told women at a recent community forum:

Here is a summary of the remarks by Drs. Campbell and Chandler.

Paul Chandler, MD
There are other organs in your pelvic area other than your uterus, fallopian tubes and ovaries. You still have a vagina, vulva and breasts. Those all need to be checked.

There’s a lot of controversy right now about whether you need a Pap smear after you’ve had a hysterectomy? I get this question a lot. My answer is YES.

Vaginal cancer is rare. But I have seen pre-cancerous changes of the vagina in women after hysterectomy. So, I still do Pap smears. Not as often as I normally would, but I still do them.

There are other masses that can appear in the pelvis. You can get cancer of the vulva or the anus. You can get bladder cancer.

I had a patient come in not too long ago for her annual check up. During the normal exam, I found a huge mass on her upper abdomen. It turned out that she had renal cancer. There are a lot of things you can pick up on during the general examinations. So, I still recommend that women have an exam and Pap smear, even after a hysterectomy.

We have a professional organization – The American College of Obstetricians & Gynecologists, or ACOG, – that creates standards of care. They say that if a woman has had a hysterectomy, your chance of getting cancer of the vagina is really low. But I ask, “Do you want to be that one women, who gets it?”

They are sitting in their ivory tower, while most Gynecologists are in the trenches dealing daily with patients. We’re going to be the ones taking care of you. So, I still do Pap smears after hysterectomy.

Brad Campbell, MD
ACOG’s recommendation is that if you’ve had an abnormal Pap smear, you should have a Pap smear at least every other year for 20 years, following an abnormal Pap smear or after your hysterectomy.

In general, does a woman who is 65 years old, has never had a Pap smear in her entire life and had a hysterectomy last year need another Pap smear? Probably not. If they are with the same partner, her risks are extraordinarily low.

You have to take into account everything about the patient. Just because your doctor didn’t give you a Pap smear last year, doesn’t mean he was wrong and you need to find a new doctor.

Now, the professional organizations are also recommending that we space out your Pap smears at 3 or 5 years. They know – and the studies show – that with this recommendation the risk of cervical cancer is going to go up. They recommended it because it’s cost-effective.

Now, whether or not that is the right thing to do for you – is up to you and your doctor.

We have to take into account what these organizations say and apply them toward our patients individually, rather than consider everyone the same.

Find a Gynecologist near you.

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