Do I still need Pap smears after hysterectomy?

Conditions Expert Dr. Otis Brawley Chief Medical Officer,
American Cancer Society

Expert answer

Thank you, Sandra, for your question.

One of the most common operations done in the western world is the hysterectomy, or removal of the uterus.

The most common reasons for a hysterectomy are abdominal discomfort or abnormal bleeding due to fibroids. Fibroids are benign, non-cancerous tumors in the muscular wall of the uterus. They are extremely common.

The aim of screening is to find women who have cervical dysplasia, a precancerous condition, or to find women who have early cancer. Three major organizations -- the U.S. Preventive Services Task Force, the American College of Obstetrics and Gynecology and the American Cancer Society -- publish recommendations on cervix cancer screening. I work for the American Cancer Society.

In direct answer to your question, the three organizations agree that women who have a hysterectomy for benign disease and have the cervix removed in that operation do not need to have routine Pap smears. It is rare for a woman to have a hysterectomy and not have the cervix removed.

This is a good opportunity to review the cervix screening recommendations for women who have a cervix. Cervical cancer is a disease that kills a significant number of women, and screening has the potential of preventing most of these deaths.

All three organizations strongly recommend screening for cervical cancer in women who have been sexually active and have a cervix. The American College of Obstetrics and Gynecology recommends starting at age 21; the other two groups recommend starting at age 21 or three years after the onset of sexual activity, whichever comes first.

The Preventive Services Task Force recommends stopping at age 65, and the American Cancer Society suggests stopping at age 70 for women who have a history of normal tests and are not otherwise at high risk. The American College of Obstetrics and Gynecology says it is reasonable to stop screening in women at 65 to 70 years of age if they have had three or more consecutive normal smears.

The task force recommends screening every three years; the cancer society advocates annual screening (biennial if using liquid-based testing instead of the older glass slide technology), and the American College of Obstetrics and Gynecology recommends biennial screening for women under age 30.

Both the cancer society and the American College of Obstetrics and Gynecology suggest reducing the frequency to every two to three years for women aged 30 and older who have had three consecutive normal Pap tests.

Most would agree that more frequent screening is needed in those with HIV infection or immunosuppression or in women whose mothers took the estrogen Diethylstilbesterol while pregnant with them. The American College of Obstetrics and Gynecology recommends annual screening for women who have been treated for precancerous lesions or cervical cancer.

Most industrialized Western nations have national screening policies with a lot of variation between countries. Australia and Canada start screening at age 18. The Netherlands starts at age 30. Sweden stops at age 58, and Australia and Canada go to age 70. Some countries suggest screen every year and others every three years.

The take-home message is that the absolute most important issue is getting a high-quality Pap smear and adequate follow-up of abnormal findings. In one study, 13 percent of women with invasive serious cervix cancer had inadequate follow-up after an abnormal Pap smear, and an even larger number had never had a Pap smear in the 10 years prior to diagnosis.