From the Guidelines
Pap smears after a hysterectomy are recommended based on the type of hysterectomy performed and the reason for the surgery, with the most recent guidelines from 2018 indicating that women who have had a total hysterectomy for benign conditions do not require routine Pap tests, unless they have a history of CIN2/3 or cervical cancer 1. For women who have had a supracervical hysterectomy, regular Pap screening is recommended according to age-appropriate guidelines. Women with a history of cervical cancer, high-grade precancerous lesions, or who had a hysterectomy due to cervical cancer should continue screening with vaginal cuff Pap smears every 3-5 years for at least 20 years after the hysterectomy, regardless of age. Additionally, women with a history of HPV infection, immunosuppression, or exposure to diethylstilbestrol (DES) in utero may require continued screening based on individual risk assessment, as stated in the 2018 guidelines 1. The rationale for these recommendations is that without a cervix, the risk of developing cervical cancer is eliminated in women with no history of cervical abnormalities, while those with previous cervical pathology remain at risk for recurrent disease at the vaginal cuff. Some key points to consider include:
- Women who have had a total hysterectomy for benign conditions do not require routine Pap tests, unless they have a history of CIN2/3 or cervical cancer 1
- Women who have had a supracervical hysterectomy should continue regular Pap screening according to age-appropriate guidelines
- Women with a history of cervical cancer or high-grade precancerous lesions should continue screening with vaginal cuff Pap smears every 3-5 years for at least 20 years after the hysterectomy
- Women with a history of HPV infection, immunosuppression, or exposure to diethylstilbestrol (DES) in utero may require continued screening based on individual risk assessment, as stated in the 2018 guidelines 1. Regular follow-up with a gynecologist is important to determine the appropriate screening schedule based on individual risk factors, and to ensure that any potential issues are caught and addressed early on, in order to prioritize morbidity, mortality, and quality of life as the outcome 1.
From the Research
Indications for Progestin after Hysterectomy
The decision to use progestin after hysterectomy depends on various factors, including the presence of a uterus, menopausal symptoms, and individual risk/benefit analysis.
- According to 2, estrogen treatment is sufficient for women who have undergone hysterectomy, and progestin is not necessary unless there is a need to reduce the risk of unopposed estrogen-dependent conditions.
- A study by 3 found that progestin-only therapy can be effective in managing vasomotor symptoms in postmenopausal women, but the optimal route and dosage have not been established.
Menopausal Symptoms and Progestin Therapy
Progestin therapy can be used to manage menopausal symptoms, including hot flashes and vaginal atrophy.
- Research by 4 suggests that estrogen therapy alone is superior to estrogen plus progestogen in terms of breast cancer risk and cardiovascular protection.
- A study by 5 compared the cardiovascular and metabolic effects of medroxyprogesterone acetate (MPA) and conjugated equine estrogen (CEE) in women who underwent hysterectomy with bilateral ovariectomy, and found that MPA had favorable effects on inflammatory markers, BMI, and triglyceride levels.
Progestogen Safety and Tolerance
The safety and tolerance of progestogens in hormone therapy are important considerations.
- According to 6, many progestogens have been extrapolated to have similar side effects and intolerance based on limited data, but short-term clinical studies suggest that micronized progesterone and dydrogesterone may be safer progestogens with an acceptable metabolic profile.
- The Women's Health Initiative (WHI) study and its reanalysis demonstrate a higher risk of breast cancer and cardiovascular risk with the combination of CEE and MPA compared to CEE alone 6.