From the Guidelines
A vault smear is not recommended after a total hysterectomy for most women, but may be considered in specific situations such as a history of cervical cancer or pre-cancerous conditions. The decision to perform a vault smear after a hysterectomy depends on the individual's medical history and risk factors. For women who have had a total hysterectomy with removal of the cervix for benign gynecologic disease, cervical cancer screening is not indicated 1. However, women with a history of cervical intraepithelial neoplasia (CIN) 2-3, or women for whom it is not possible to document the absence of CIN 2-3 before or as the indication for the hysterectomy, should continue to be screened until they have a 10-year history of no abnormal/positive cytology tests 1. Some key points to consider include:
- Women who have had a subtotal hysterectomy should be screened following the recommendations for average-risk women who have not undergone hysterectomy 1.
- Women with a history of in utero DES exposure and/or a history of cervical carcinoma should continue screening after hysterectomy for as long as they are in reasonably good health and would benefit from early detection and treatment 1.
- The rationale behind these recommendations is that primary vaginal cancer is rare, and routine screening in low-risk women after total hysterectomy offers minimal benefit while potentially causing unnecessary anxiety and interventions 1. It's essential to discuss specific screening needs with a healthcare provider after a hysterectomy, taking into account the individual's medical history and risk factors.
From the Research
Vault Smear Recommendations After Hysterectomy
- The recommendation for vault smears after hysterectomy varies depending on the indication for the surgery 2, 3, 4, 5, 6.
- For women who have undergone hysterectomy for benign pathology, current guidelines recommend that vault smears should not be used as a routine follow-up test 2.
- However, if there is evidence of completely excised CIN II/III in the specimen, two vault smears (6 and 12 months post-surgery) are recommended 2.
- For women who have had a hysterectomy for cervical cancer, vault smears may be useful in the early follow-up period (first 5 years) to detect subclinical recurrence 3.
- Annual monitoring with vault smears may be justified in women who have had a hysterectomy for cervical intraepithelial neoplasia (CIN), especially if there are associated uterine lesions or cervical conization is not accessible 3.
- In women who have had a hysterectomy for benign uterine non-HPV-induced conditions, there is no need for systematic follow-up cytology 3.
- Vault cytology can be an accurate tool to detect local recurrences or vaginal intraepithelial neoplasia (VAIN) in women treated for cervical cancer or benign gynecological conditions 4.
- However, due to the extremely low prevalence of VAIN or vaginal cancer, vault smears may not be warranted in women hysterectomized for benign indications, especially in resource-constrained settings 4.
Specific Scenarios
- If a woman has a history of lower genital tract neoplasia, vault cytology should continue to be performed after hysterectomy 5.
- When colposcopy is being performed to investigate an abnormal Pap smear, the entire lower genital tract should always be examined to detect any potential vaginal intraepithelial neoplasia 5.
- In cases where carcinoma-in-situ of the cervix is detected at the time of hysterectomy, post-hysterectomy cytology may not be worthwhile due to the low risk of recurrence 6.