Is a smear test required after hysterectomy?

By Dr Abdelmageed Abdelrahman on the 24 October 2012

Dr Abdelmageed Abdelrahman explains the appropriate GP safety netting for women

Cervical smear showing CIN 3 (Photograph: SPL)

Women who have had a hysterectomy with CIN are potentially at risk of developing vaginal intraepithelial neoplasia (incidence 1%)¹ and invasive vaginal disease. There is no clear evidence, however, that colposcopy increases the detection of disease on follow-up.²

According to the NHS Cervical Screening Programme (NHSCSP), women who have undergone hysterectomy are no longer eligible for recall because they have no cervix. Their vault cytology after treatment of CIN must therefore be managed outside the programme.

The responsibility for implementing follow-up policies rests with the gynaecologist and will be informed by the lead colposcopist. A gynaecologist discharging a patient requiring further vault cytology should ensure the GP receives written guidance for follow-up. The clinician in charge (gynaecologist or GP) will be responsible for failsafe mechanisms for this small group of women.

HYSTERECTOMY AND NO PAST HISTORY OF CIN
Histology/pretreatment smear history	Follow-up
Woman on routine recall	No vaginal vault cytology
Woman not on routine recall	Vaginal vault cytology six months after hysterectomy

HYSTERECTOMY AND PAST HISTORY OF CIN
Histology/pretreatment smear history	Follow-up
Complete excision of CIN	Vaginal vault cytology six and 18 months after hysterectomy
Incomplete or uncertain excision of CIN:	Follow-up as if cervix is still in situ and depends on CIN grade:
CIN 1	Vault cytology at six, 12 and 24 months
CIN 2/3	Vault cytology at six and 12 months followed by nine annual vault cytology samples (whichever is later)

It is recommended that high-risk groups, such as cases of incomplete excision, should be dealt with at the colposcopy clinic up to the age of 65 years or until 10 years after surgery, whichever is later.² The boxes (above right) summarise the follow-up required.

Women who have subtotal hysterectomy will have their cervix in situ, so must remain within the NHSCSP. Women who have a radical trachelectomy as part of conservative management of cervical cancer should remain in the care of the gynaecologist or oncologist. Follow-up is recommended with colposcopy and cytology.

The presence of high-risk HPV in the cervix increases the risk of CIN. Its absence implies almost no risk at that time. So HPV testing can be helpful in predicting risk of treatment failure (that is, test of cure).