SA Cervix Screening Program

Hysterectomy informationfor health workers

Pap smears after hysterectomy Whether or not women need to keep on having Pap smears after a hysterectomy depends on

• What type of hysterectomy they had • Why they had a hysterectomy • And if their Pap smears were normal before the hysterectomy

Around 2 in every 5 Australian women are likely to have a hysterectomy

Total hysterectomy Hysterectomy is the removal of the uterus. In most cases the cervix is removed with the uterus and this is called a total hysterectomy. Sometimes the fallopian tubes and ovaries are also removed - a salpingo-oophorectomy. When women have had their cervix removed, Pap smears can be taken from the top of the vagina. This is called a Vault smear. In this case the test is to look for changes in the cells of the vagina, which if left untreated might lead to cancer of the vagina. Cancer of the vagina is very rare. The risk of developing VAIN (vaginal intra-epithelial neoplasia) or vaginal cancer is higher in women who have had a previous abnormal smear or CIN at hysterectomy, where the risk of development of VAIN or vaginal cancer is mainly determined by the adequacy of excision of the CIN. Women previously treated for gynaecological cancer are also at risk for recurrent disease in the region of the vaginal vault.

Sub-total or partial hysterectomy Sub-total hysterectomy entails removing the body of the uterus, but leaving the cervix. This operation is not performed frequently however some women who have had a sub-total hysterectomy may not realise that they still have a cervix.

Which women need to keep having smears after hysterectomy? • Previous Pap smear results unknown. Many women do not know the results of the Pap smears they had before their hysterectomy, and may not know if they have ever had an abnormal Pap smear. Women who do not know their past Pap smear results should have at least one vault smear. If the result of that test is normal, they do not need to have further screening smears. Previous high grade abnormal smear • The majority of women diagnosed as having vaginal intra-epithelial neoplasia or vaginal cancer have had previous abnormal smears or high grade lesions at the time of hysterectomy. Women who have had high grade lesions adequately treated prior to hysterectomy may have had HPV testing. If two screens have been negative, then they may not require future smears.

National Cervical Screening Program. A joint Australian, State and Territory Government Initiative. Previous low grade abnormal smear • There is not enough evidence to indicate that vault smears should continue to be performed in women who have a previous history of low grade lesions.

High grade lesion at hysterectomy • The risk of later vaginal abnormalities is thought to be mainly related to the adequacy of excision of the cervical lesion at the time of hysterectomy. If there are concerns about the adequacy of excision, there may be a risk of VAIN or invasive cancer in the region of the vault. Women who have a hysterectomy for high grade cervical abnormalities require continued screening. The role of HPV testing requires further investigation.

Previous gynaecological cancer or invasive malignancy • These women are at risk of recurrent disease in the regions of the vaginal vault and women with a past history of vulval or cervical cancer can develop new malignancy in the vagina. Pap smears should continue at the discretion of the treating gynaecologist or oncologist.

Previous vaginal intraepithelial neoplasia • These women are at risk for development of VAIN in other parts of the vagina and Pap smears should continue at the discretion of their treating specialist.

Sub total or partial hysterectomy • Women, who have had a subtotal hysterectomy where their cervix has not been removed, need to keep having regular Pap smears until the age of 70.

Women who are severely immunosuppressed as a result of disease or therapy • Immune impairment is a predisposing factor for squamous cell malignancy of the lower genital tract and women who are severely immunosuppressed should continue to have vault smears. This may include women living with HIV, recipients of organ transplants and women on cortisone or other immunosuppressant therapies.

Women who were exposed to DES in utero • Diethylstilboestrol is a drug that was prescribed to pregnant women to prevent miscarriage. It was used in Australia in the 1950’s and 1960’s. Women who were exposed to Diethylstilboestrol in utero (DES daughters) are at an increased risk for clear cell cancer of the vagina and cervix. The life time risk is small (1:1000-10000) but they should continue to have Pap smears from the vaginal vault, as well as colposcopy and careful palpation of the vaginal walls at yearly intervals.

Remember…

Cancer of the vagina is a rare disease. Women who have had their cervix removed by hysterectomy, have not had cancer and have had normal smears before their hysterectomy do not need to continue to have Pap smears if they have no symptoms of pain, abnormal discharge or vaginal bleeding. Women who have any of the indications listed above may need to continue to have Pap smears and if women have symptoms, these need to be For more information, pleaseinvestigated. contact: Megan van Zanten, Senior Project Officer, SA Cervix Screening Program, Telephone: 08 82268185 Email: [email protected] Website:For more www.sahealth.sa.gov.au/papsmear information and advice.

• Speak to your doctor or call the women’s health information line on 1300 882 880.

•www.ausgoal.gov.au/creative-commons For information about Pap smears and screening for cervical cancer you can © Departmentsearch for Health on and Ageing,the Governmentweb at of www.sahealth.sa.gov.au/papsmearSouth Australia. All rights reserved. November 2012. FIS:12166 ISSN:1836 0874 or call 13 15 56