Do You Need Pap Smears After a Hysterectomy?

When Are Pap Smears Needed After a Hysterectomy?

swab for pap smear after hysterectomy
Do you need a Pap smear after a hysterectomy?. Credit: Istockphoto.com/Stock Photo©PhotoQueen123

Do you need to get yearly Pap smears after a hysterectomy?  What do you need to know in order to take the best care of your health going forward?

Pap Smears After Hysterectomy - Yes and No

You may or may not need a Pap smear after a hysterectomy. A hysterectomy refers to the surgical removal of the uterus, but this can be done in more than one way, and is done for more than one reason.  The answer about Pap smears depends on your answers to these questions, so let's look at these separately.

Abdominal v. Vaginal Hysterectomy - Cervix or Not?

Women who have undergone an abdominal hysterectomy may still need regular Pap smears in general because the cervix may still be intact. A hysterectomy in which the cervix is left in place is referred to as a partial hysterectomy or subtotal hysterectomy. In a complete or total hysterectomy, in contrast, the cervix is removed along with the rest of the uterus.

Women who have had a vaginal hysterectomy will not have a cervix since the cervix is always removed in this procedure.

Hysterectomy Due to Cancer

It is recommended that women who have a hysterectomy for cancer continue to have regular Pap smears whether or not they have a cervix. Women who have a history of an abnormal Pap smear, or are at high risk of developing cervical cancer, should also be regularly screened regardless of the type of hysterectomy performed and whether or not they have a cervix.

Hysterectomy Due to Benign Conditions

A hysterectomy is more often done for benign conditions such as uterine fibroids and dysfunctional uterine bleeding. When the cervix is removed during a hysterectomy and a woman has not had any previous abnormal Pap smears, the American College of Obstetrics and Gynecology states that Pap smears can be discontinued.

An exception is for women who were exposed to diethylstilbestrol (DES) in utero - in other words, for women whose mothers took the drug DES while pregnant. DES can increase the risk of an uncommon type of cervical and vaginal cancer called clear cell adenocarcinoma. DES was prescribed to pregnant women between 1940 and 1071 to decrease the risk of miscarriage. 

Summary of Recommendations

The first question is to determine if a hysterectomy was:

  • Total or complete hysterectomy - All vaginal hysterectomy procedures and some abdominal hysterectomies
  • Subtotal or partial hysterectomy - Some abdominal hysterectomies

For those who have a subtotal or partial hysterectomy, the guidelines are the same as a woman who has not had a hysterectomy since the cervix is still present.

For those who have had a total or complete hysterectomy with removal of the cervix, Pap smears should still be done if:

  • The hysterectomy was done for a cancerous or precancerous condition
  • If a woman has a history of an abnormal Pap smear (especially with a positive HPV test) or is at high risk of developing cervical cancer
  • If a woman's mother used DES during her pregnancy

Why a Pap Smear When the Cervix Has Been Removed?

A Pap smear is a highly effective means of cervical cancer screening, even when the cervix has been removed. During a Pap smear after the cervix has been removed, the doctor collects a sample from the vaginal cuff, the upper vagina where the cervix was once located. At can be difficult to understand this concept, but it is similar to the finding that some women may develop breast cancer even after a bilateral mastectomy. Some cells can remain behind after the surgery which could become cancerous.

When in Doubt, Ask Your Doctor

Remember, your doctor is your best source of health information. After a hysterectomy, ask whether your cervix was retained or removed. Although your doctor may have clarified this prior to surgery, there are times when the doctor decides to remove or retain the cervix during the actual surgery.

Annual Pelvic Exams Are Still Needed After a Hysterectomy

It's important to note that a Pap smear is only one part of an annual pelvic exam. A Pap smear is a screen for cervical cancer, but does not screen for other gynecologic problems. During the bimanual exam portion of an annual pelvic exam, physicians palpate the ovaries to feel for any abnormalities that could be suspicious for ovarian cancer or other ovarian condition. 

In addition to cancer of the cervix, the humanpapilloma virus (HPV) can cause cancers of the vulva and vaginal walls, which can be examined during an exam even though a Pap smear is not done. In this sense an exam would be even more important if someone has a hysterectomy for cervical cancer.

The importance of annual exams can be stressed by explaining one of the reasons that there has been so much debate about Pap smears after hysterectomy or with increasing age. The fear of some doctors is that by decreasing the need for Pap smears could inadvertently decrease the frequency at which women see their doctor - and potentially lead to a delay in the diagnosis of cancers such as breast cancer and ovarian cancers which are also screened for at these visits.

Importance of Pap Smears

Because of the effectiveness of Pap smears, many people do not realize how important they are. In the United States, cervical cancer is fairly uncommon. In most women, abnormal changes in the cervix are detected long before precancerous cells become cancerous, and treatment can be done. In contrast, cervical cancer is the 2nd leading cause of cancer deaths worldwide in women, second only to lung cancer.

Make sure to check the current Pap smear guidelines to see if you are up to date.

Sources:

Feldman, S., Goodman, A., and J. Peipert. Patient information: Cervical cancer screening (Beyond the Basics). Updated 03/28/16. http://www.uptodate.com/contents/cervical-cancer-screening-beyond-the-basics

National Cancer Institute. Diethylstilbestrol (DES) and Cancer. Updated 10/05/11. http://www.cancer.gov/about-cancer/causes-prevention/risk/hormones/des-fact-sheet

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