Hysterectomy and abnormal Pap smears
Abnormal Pap smears indicating vaginal dysplasia can occur following a hysterectomy, but they are very uncommon and occur in less than 3% of cases. The Pap is taken of the vaginal cuff when no cervix is present.
In J Am Board Fam Pract 2000 Jul-Aug;13(4):233-8:
Routine vaginal cuff smear testing in post-hysterectomy patients with benign uterine conditions: when is it indicated?
Videlefsky A, Grossl N, Denniston M, Sehgal R, Lane JM, Goodenough G Department of Family and Preventive Medicine, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA 30335, USA.
“Background: By the age of 60 years, an estimated 33% of women will have undergone a hysterectomy. Approximately 85% of these hysterectomies are performed for benign disease. The object of this study was to evaluate cytologic findings from vaginal cuff smears in patients who have undergone hysterectomy for benign uterine conditions.
Methods: We conducted a community-based retrospective study and follow-up of women with vaginal cuff cytologic smears who had had a hysterectomy for benign uterine conditions. A total of 220 women were randomly selected who had one or more vaginal cuff smears. The main outcomes measures were invasive carcinoma, dysplastic lesions, and infections detected by vaginal cuff smear testing. The setting was a large inner-city hospital.
Results: Ninety-seven percent of 220 women who underwent hysterectomy for benign uterine conditions and who were observed for an average of 89 months had no cytologic abnormalities on vaginal cuff smears. Cytologic evaluation found no invasive carcinomas. Dysplastic lesions were detected in 7 patients (3%). Seventy percent of patients (n = 154) had one or more infections; these infections included bacterial vaginosis (106), trichomoniasis (95), candidiasis (40), koilocytosis suggestive of human papilloma virus (HPV) infection (3), and cytopathic effect of herpes (4). The prevalence of koilocytosis was much higher in the patients with dysplasia (P = .0003).
Conclusions: Most routine vaginal cuff cytology screening tests need not be performed in women who have had a hysterectomy for benign uterine conditions.”
In Am J Obstet Gynecol 1995 Aug;173(2):424-30; discussion 430-2:
Cytologic screening after hysterectomy for benign disease.
Piscitelli JT, Bastian LA, Wilkes A, Simel DL Division of General Obstetrics-Gynecology, Duke University, Durham, NC, USA.
“Objective: Our purpose was to determine the effectiveness of vaginal cytology tests after hysterectomy for benign disease.
Study design: We studied a 10-year retrospective cohort of patients after hysterectomy (n = 697 women, 9074 woman years). Patients were excluded if they had any type of invasive gynecologic malignancy. The main outcome variable was development of a vaginal cytologic abnormality, evaluated with Kaplan-Meier estimates and proportional hazards regression.
Results: We found 33 abnormal cytology results; most were of little clinical significance except for two biopsy-proven dysplasia cases. When we controlled for age, the risk was 4.67 for patients with a history of a cervical cytologic abnormality (95% confidence interval 2.1 to 10.6). We needed 633 tests to detect one true positive case of vaginal dysplasia.
Conclusions: The low incidence of vaginal dysplasia and carcinoma, combined with the high false-positive rate, supports decreasing the number of screening tests performed for these low-risk patients.”
In JAMA 1996 Mar 27;275(12):940-7:
Effectiveness of vaginal Papanicolaou smear screening after total hysterectomy for benign disease.
Fetters MD, Fischer G, Reed BD Department of Family Practice, University of Michigan, Ann Arbor, 48109-0708, USA.
“Objective: Using literature review, we assessed (1) Papanicolaou smear screening recommendations after hysterectomy for benign disease, (2) total hysterectomy for benign disease as a risk for vaginal dysplasia or carcinoma, and (3) effectiveness of screening for vaginal carcinoma after total hysterectomy for benign disease.
Data sources: We considered (1) organizations' recommendations about screening, (2) references from major textbooks of gynecology, and (3) Medline searches of English-language studies published from 1966 through 1995 using the search strategy (hysterectomy and vaginal smears) or (vaginal smears and vaginal neoplasms).
Study selection: Published or verbal confirmations of screening recommendations were eligible. Criteria for assessing risk of vaginal dysplasia or carcinoma included original research, documented reports of hysterectomy as an exposure, and evidence of preinvasive vaginal disease or vaginal carcinoma outcomes. We sought data assessing burden of suffering, screening efficacy, and effectiveness of early detection.
Data extraction: Descriptive and analytic data from each study were abstracted.
Data synthesis: Screening recommendations were categorized by the organizations' positions: two opposed screening, two supported screening, and six lacked specific guidelines. Data on the risk between total hysterectomy for benign disease and subsequent vaginal carcinoma were organized by study design (three case control, two cohort, and 13 case series) and described. Data on screening effectiveness were organized to address the criteria advocated by the US Preventive Services Task Force.
Conclusions: There are conflicting guidelines on screening after hysterectomy and conflicting data on the risk of vaginal carcinoma after total hysterectomy for benign disease, though the best-designed research suggests no association. There is insufficient evidence to recommend routine vaginal smear screening in women after total hysterectomy for benign disease."