Is a Pap smear necessary for a patient who has undergone a hysterectomy with ovaries (ovarian organs) remaining?

Pap Smear Screening After Hysterectomy with Retained Ovaries

Pap smear screening is not indicated for women who have undergone a total hysterectomy (including removal of the cervix) for benign disease, even if the ovaries remain. 1

Rationale for Discontinuing Pap Screening After Total Hysterectomy

The decision to discontinue Pap smear screening after hysterectomy depends primarily on:

1. Whether the cervix was removed:

   • If the cervix was completely removed (total hysterectomy), Pap screening is unnecessary
   • If the cervix remains (subtotal/supracervical hysterectomy), continue screening as per guidelines for women with an intact cervix

2. Reason for hysterectomy:

   • If performed for benign disease: no further Pap screening needed
   • If performed for cervical precancer or cancer: continued surveillance is required

Key Guideline Recommendations

The U.S. Preventive Services Task Force (USPSTF) clearly states there is "convincing evidence that continued screening after hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer provides no benefit" 1.

The American Cancer Society similarly recommends that "screening with the Pap test is not indicated for women who have had a total hysterectomy, including removal of the cervix, for benign gynecologic disease" 1.

Special Considerations

Documentation Requirements

Before discontinuing screening, ensure proper documentation of:

• Complete removal of the cervix (verified by physical examination or pathology report)
• Benign indication for hysterectomy
• No history of high-grade cervical neoplasia

When to Continue Screening After Hysterectomy

Pap screening should continue in women who have had a hysterectomy if:

• The cervix was not removed (subtotal/supracervical hysterectomy)
• The hysterectomy was performed for cervical cancer or high-grade precancerous lesions (CIN2/3)
• There is insufficient documentation about the type of hysterectomy or reason for the procedure

For women with a history of CIN2/3, screening should continue until there is a 10-year history of no abnormal/positive cytology tests, including documentation that the three most recent consecutive tests were technically satisfactory and interpreted as normal 1.

Common Pitfalls in Post-Hysterectomy Screening

Despite clear guidelines, research shows that unnecessary Pap screening after hysterectomy is common:

• Nearly 10 million women who have undergone hysterectomy are being screened unnecessarily 2
• Approximately 69% of women who had undergone hysterectomy reported having a Pap smear within the past 3 years, even years after guidelines recommended against this practice 2
• Only 67% of women correctly identified whether their cervix had been removed during hysterectomy and whether they needed future cervical cancer screening 3

Retained Ovaries and Screening

The presence of ovaries after hysterectomy does not affect the recommendation regarding Pap smear screening. The ovaries are not related to cervical cancer risk, and their retention does not necessitate continued cervical cancer screening if the cervix has been completely removed for benign disease.

Clinical Decision Algorithm

1. Determine if the cervix was completely removed:

   • Review operative report and pathology
   • Perform physical examination if documentation is unclear

2. Determine reason for hysterectomy:

   • If for benign disease → discontinue Pap screening
   • If for cervical neoplasia → continue screening

3. Assess patient risk factors:

   • History of CIN2/3 → continue screening until 10 years of normal results
   • History of DES exposure or immunocompromised status → continue screening

4. Patient education:

   • Explain rationale for discontinuing screening
   • Clarify that ovarian cancer screening is separate from cervical cancer screening
   • Address common misconceptions about hysterectomy and cancer screening

By following these evidence-based guidelines, unnecessary screening can be avoided while ensuring appropriate surveillance for women who remain at risk for vaginal neoplasia.