How long should Pap (Papanicolaou) smears be continued in women who have undergone a hysterectomy due to recurrent dysplasia?

Pap Smear Screening After Hysterectomy for Recurrent Dysplasia

Women who have had a hysterectomy for recurrent dysplasia should continue vaginal cuff cytology screening until they have three documented, consecutive, technically satisfactory normal/negative cytology tests with no abnormal/positive tests within a 10-year period. 1

Screening Recommendations Based on Hysterectomy Indication

For Hysterectomy Due to Recurrent Dysplasia (CIN2+):

• Initial follow-up schedule: Every 4-6 months 1
• Continue screening until achieving:
  • Three consecutive normal/negative vaginal cytology tests
  • No abnormal/positive tests within a 10-year period
  • All tests must be technically satisfactory 2, 1

For Hysterectomy Due to Benign Disease (Different from Your Case):

• No routine vaginal cancer screening is required 2
• Screening can be discontinued after total hysterectomy for benign disease 2

Rationale for Continued Screening

1. Persistent Risk: Women with a history of CIN2/3 remain at risk for vaginal intraepithelial neoplasia even after hysterectomy 2

2. Evidence of Risk: A long-term study of 193 women with CIN who underwent hysterectomy found that while the risk is low (0.7 per 1000 women-years), it remains higher than in the general population 3

3. Long-term Follow-up Data: After 20 years of follow-up, 96.5% of women with a history of CIN who underwent hysterectomy continued to have normal smears, indicating a small but persistent risk 3

Important Clinical Considerations

• If abnormal cytology is found during surveillance, proceed directly to colposcopy and biopsy rather than just repeating cytology 1

• The risk of vaginal cancer after hysterectomy for dysplasia is extremely low but not zero, with studies showing very few cases of high-grade lesions in follow-up 4

• Once the criteria for discontinuation are met (three consecutive normal tests with no abnormal results in 10 years), screening should not resume for any reason, including having a new sexual partner 1

Documentation Requirements

Thorough documentation should include:

• Hysterectomy type and date
• Indication (recurrent dysplasia in your case)
• Previous cytology results
• Current vaginal cuff status
• Plan for continued screening 1

While the overall risk of vaginal cancer after hysterectomy is low, the presence of recurrent dysplasia as the indication for hysterectomy justifies continued surveillance until the specified criteria for discontinuation are met. This approach balances the need for appropriate cancer surveillance with the goal of avoiding unnecessary testing.