Do You Need a Pap After a Hysterectomy?
Frederick R. Jelovsek MD
There is no overall medical agreement as to whether women need routine Pap smear screening after they have had a hysterectomy. Some task forces have recommended that no Pap smears are needed while others have recommended every 3-5 years or at physician discretion. A recent article, Fox J et al.: The effect of hysterectomy on the risk of an abnormal screening Papanicolaou test result. Am J Obstet Gynecol. 1999; 180:1104-9, looks at the frequency of abnormal Pap smears in women who have had a hysterectomy. With it, we can answer several questions.
How many women have had hysterectomies in the U.S.?
In this study of women over 50 years of age, 25% had a hysterectomy. It has been estimated that 12 million women in the U.S. have had a hysterectomy. It is also estimated that 44-55% of these women continue to have regular Pap smears.
How often do women have abnormal Pap smears ?
In this study of 21,152 Pap smears in women over age 50, 8.2/1000 smears showed ASCUS (atypical smears of undetermined significance), dysplasia or cancer. Of women who had a uterus in place, the rate of abnormal smears was 10.4/1000. One other study of women showed an incidence of 13/1000 abnormal Paps in women with a uterus.
How much less frequently do women with hysterectomy have abnormal Paps?
Compared to rates of abnormal Pap smears of 10-13/1000 in women with a uterus in place, this study found a rate of 1.7/1000 for women with a hysterectomy. Another study found an abnormal Pap rate of 3.5/1000 hysterectomized women followed for an average of 14 years in a university clinic. Even in a very high risk population, one study of women with hysterectomy found a 14.7 abnormal Pap rate which approaches that of a normal population who still have their uterus.
How can a women have an abnormal Pap smear after hysterectomy?
The changes in epithelium that take place on the cervix to produce abnormal Pap smears can also take place at the end of the vagina. A woman can develop vaginal dysplasia especially if she has previously been known to have cervical dysplasia. Therefore a woman whose hysterectomy was for either cervical cancer or cervical dysplasia should continue to have regular, yearly Pap smears even after hysterectomy.
How is an abnormal Pap smear or vaginal dysplasia treated if the cervix and uterus is already removed?
The evaluation of a vaginal Pap abnormality is the same as a cervical Pap abnormality. A colposcopy and a biopsy is performed to make sure what is the worst change present in the epithelium. The treatment is then governed by the biopsy result, not the Pap result. If the biopsy shows moderate or severe dysplasia or even carcinoma in situ, destruction of the tissue affected is the treatment of choice. Most often it is ablated with a laser as an office or outpatient surgery treatment.
In summary, if you have never had an abnormal Pap smear and you have had a hysterectomy, it is reasonable to have a Pap smear every 5 years and some authorities would say you do not need to have them at all. If you had a very minor Pap abnormality that just had to be followed but not treated with freezing, laser, cautery. LEEP or cone cervical biopsy, then having a Pap about every 3 years after a hysterectomy would be a safe approach. If you have had treatment for an abnormal Pap or the hysterectomy was performed for abnormal Paps, then it would be safest to continue to have a Pap smear annually because the HPV virus is probably still present in the vaginal cells.
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