Hysterectomy? Pap Smear May Be Unnecessary

But Don't Cancel Annual Ob-Gyn Appointment -- You Still Need Exam

From the WebMD Archives

June 22, 2004 -- Millions of American women are getting unnecessary Pap smears, a new study shows.

Some 10 million women who have had a complete hysterectomy are getting an annual Pap smear screening test for cervical cancer -- yet they are no longer at risk for the cancer.

"The vast majority of women are getting Pap smears that are not necessary," says lead researcher Brenda E. Sirovich, MD, MS, professor of medicine at Dartmouth Medical School and the Veterans Administration Outcomes Group in White River Junction, Vt.

Her report appears in this week's Journal of the American Medical Association.

"We're not saying women don't need Pap smears," Sirovich tells WebMD. "But if you had a hysterectomy that included removal of the cervix -- and you had no cancerous or precancerous cells -- then you don't need a Pap smear. If you think you will be getting a Pap smear [during your annual exam], discuss it with your doctor."

Just don't cancel your annual ob-gyn appointment; it's still very important. "All women need a pelvic exam," says Richard Guido, MD, professor of obstetrics, gynecology, and reproductive sciences at the University of Pittsburgh School of Medicine. "Potential for ovarian disease still exists and women need to be screened for it. They also need to have their vulva and external genitalia examined. ... They need wellness care, breast disease care, and lower genital tract issues addressed."

Pap Smear So Successful, Doctors Resist Giving It Up

The confusion stems from Pap smear guidelines issued in 1988 that failed to distinguish between women who have had a complete hysterectomy and those who have had a hysterectomy that left the cervix intact, leaving an area susceptible to cancer.

In a 1996 government advisory, guidelines clarified that Pap smears are unnecessary for women who have had a complete hysterectomy for benign (noncancerous) disease. That recommendation from the U.S. Preventive Services Task Force was based on several large studies, Sirovich writes.

To determine whether doctors were following the new advisory, Sirovich analyzed information from CDC nationwide telephone surveys conducted annually from 1992 to 2002 -- representing some 22 million women across the country who have had hysterectomies.

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During this 10-year period, she found no change in the number of Pap smears performed: Fully 69% of these women had the test. In 1992, before the guidelines for Pap smear screening changed, 69% had the test performed, compared with 69% in 1996, the year the task force made its recommendation. More recently, 69% of women surveyed in 2002 also had Pap smears done.

Sirovich then factored in circumstances warranting a Pap smear, like precancerous cervical cells in the past, DES exposure, or compromised immunity.

Even then, she found that upwards of 10 million American women -- or 46% of those who had hysterectomies -- were getting unnecessary Pap smears, Sirovich writes.

"The guidelines had no effect; the rates of Pap smear did not change," she tells WebMD. "Each year, more than two-thirds of these women reported having a current Pap smear."

A Pap smear can be uncomfortable as well as a waste of time and money, Sirovich says. "There is only so much time in an office visit. Time spent on a Pap smear is not spent on more important issues. Also, millions of unnecessary dollars are spent on unnecessary procedures."

"Any time there is a drastic change in practice guidelines, it takes awhile for doctors to feel comfortable with it," Guido tells WebMD. "[The Pap smear] has been so effective that doctors resist changing it. That's understandable. But physicians need to adapt to changes in medicine."

The U.S. Preventive Services Task Force advisory applies only to women who have a hysterectomy for benign disease, he says. "If women don't know if they had dysplasia [abnormal cells], they should get three annual Pap smears, and if those are negative, they don't need another. Also, if women have had dysplasia in the past, or if they had DES exposure or are immune-compromised, they need a Pap smear."

SOURCE: Sirovich, B. The Journal of the American Medical Association (JAMA), June 23/30, 2004; vol 291: pp 2990-2992. Brenda E. Sirovich, MD, MS, professor of medicine, Dartmouth Medical School; Veterans Administration Outcomes Group, White River Junction, Vt. Richard Guido, MD, professor of obstetrics, gynecology, and reproductive sciences, University of Pittsburgh School of Medicine.

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