Should a Papanicolaou (Pap) smear be performed before or after Intrauterine Device (IUD) removal?

Pap Smear Timing Relative to IUD Removal

Perform the Pap smear before IUD removal, as cervical cytology screening is not required prior to IUD removal and should follow standard screening intervals independent of the removal procedure. 1

Rationale for This Approach

The CDC's U.S. Selected Practice Recommendations explicitly states that screening asymptomatic women with cervical cytology before IUD insertion is not necessary due to high baseline cervical screening rates in the U.S., low incidence of cervical cancer, and the high likelihood that cervical cancer would already be diagnosed through routine screening. 1 This same principle applies to IUD removal—the procedure itself does not necessitate cervical cytology screening.

Key Clinical Considerations

Cervical cytology and IUD procedures are independent processes:

• Pap smears should follow age-appropriate screening guidelines (typically every 3-5 years depending on age and co-testing) regardless of IUD status 1
• The presence or removal of an IUD does not change cervical cancer risk or screening requirements 1
• Cervical cancer incidence in the U.S. is only 8.1 per 100,000 women per year, and approximately 87% of women aged 22-30 are already up-to-date with screening 1

Practical workflow:

• If a Pap smear is due based on screening guidelines, perform it at the same visit as IUD removal for patient convenience 1
• The Pap can be obtained either before or after removal—there is no evidence suggesting one sequence is superior
• If the patient is not due for cervical cytology screening, do not perform it solely because of the IUD removal 1

Special Circumstances

The only scenario where cervical assessment matters for IUD removal is confirmed cervical cancer:

• Women with diagnosed cervical cancer awaiting treatment should not undergo IUD insertion (U.S. MEC Category 4), and the IUD should be removed at the time of cancer treatment 1
• However, this represents a diagnostic situation, not a screening scenario 1

Actinomyces-like organisms (ALOs) on Pap smear:

• If ALOs are incidentally found on cervical cytology in an asymptomatic IUD user, neither IUD removal nor antibiotic treatment is required 2, 3
• The risk of developing symptomatic pelvic actinomycosis is extremely low despite ALO presence 2, 3
• IUDs should be changed at least every 5 years to limit actinomycosis risk, but this is standard practice regardless 2

Common Pitfalls to Avoid

• Do not delay IUD removal to obtain Pap smear results if the patient desires removal—the procedures are independent 1
• Do not perform unnecessary Pap smears just because a patient is having an IUD removed—follow standard screening intervals 1
• Do not remove an IUD based solely on ALO findings on a Pap smear in asymptomatic women 2, 3