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.
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.
The NHMRC
recommends that women who have had previous high grade lesions
(moderate or severe dysplasia) or high grade lesions that have been
completely excised at hysterectomy, should continue to have vault
smears done. It is suggested that annual vault smears be performed
for 5 years, then two yearly vault smears.
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. Follow up is at the discretion of the gynaecologist, but
would generally entail yearly vault smears.
Previous gynaecological cancer or invasive malignancy
These women are
also 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.
Cancer of the
vagina is a rare disease. Women who have had their cervix removed
by hysterectomy, who have not had cancer and who have had normal
smears before their hysterectomy, do not, if they have no symptoms
of pain, abnormal discharge or bleeding from the vagina, need to
continue to have screening Pap smears.
Where women
have any of the indications listed above, they may need to continue
to have screening Pap smears and if women have symptoms, these need
to be investigated.
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