Pap Test Usually Unnecessary after Hysterectomy

Q:  I have heard conflicting opinions about this topic and would appreciate hearing yours.

After having a hysterectomy (uterus and ovaries removed), is it necessary to have a Pap test?

My doctor, a family practice physician, said it is not necessary. Do you think I'd get a different answer from an obstetric-gynecologist?

A:  Many people do not realize the purpose of a Pap test: It is to screen for cervical cancer, the cervix being the part of the uterus (or womb) that is the baby's way out and the only visible part during pelvic examination.

A hysterectomy almost always means removing the whole uterus, and thus the cervix is removed, too. (A hysterectomy does not indicate whether the ovaries were removed; we use a second term for that - oophorectomy.)

It follows then, that there is little point in screening for cancer of the cervix if you don't have a cervix.

And there is consensus among all the major organizations: the US Preventive Services Task Force (a governmental body concentrating on the health of the populace), the American College of Obstetrics and Gynecology, and the American Academy of Family Physicians all recommend against Pap testing after hysterectomy.

The main study that led to this conclusion involved about 10,000 women who had their uterus removed for benign reasons (such as bleeding or fibroids). About 1% of these women had an abnormal Pap test, but none of these abnormal tests proved to be cancer or pre-cancer, therefore subjecting these women to further testing - and likely some anxiety - unnecessarily.

There are a couple important caveats:

First, if you had your uterus removed because of cancer, the Pap test may still be useful, because, in this setting, it serves as a cancer surveillance test instead of a screening test, which tries to pick up disease in a healthy population.

Second, abandoning Pap testing does not necessarily mean omitting the pelvic examination, which can check for other problems of the vulva, vagina, and ovaries.

There are still some physicians who continue Pap testing after hysterectomy in certain individuals (those at increased risk for cervical cancer), to screen for vaginal cancer (a very rare cancer), and as a matter of routine, but there is no convincing study to support this practice.

Julie L. Mitchell, MD, MS, is an Assistant Professor of Medicine at the Medical College of Wisconsin. She practices at the Froedtert & The Medical College of Wisconsin General Internal Medicine Clinic - East. Her column appears in the Milwaukee Journal-Sentinel.