What if a Pap test cannot be performed on the cervix?

When a Pap Test Cannot Be Performed on the Cervix

If a Pap test cannot be performed on the cervix, screening is not required in women who have had a total hysterectomy with cervical removal, unless the surgery was performed for cervical cancer or its precursor lesions. 1, 2

Clinical Algorithm for Determining Need for Screening

Step 1: Determine Cervical Status

• Women who have had a total hysterectomy (cervix removed): No routine Pap testing is required unless the hysterectomy was performed due to cervical cancer or precursor lesions 1, 2

• Women with supracervical hysterectomy (cervix intact): Continue regularly scheduled Pap tests according to standard age-based screening guidelines 2

Step 2: If Cervix is Present but Inaccessible

When the cervix is present but a satisfactory sample cannot be obtained, this creates an "unsatisfactory Pap test" (UPT) scenario. The management depends on HPV cotesting results:

• For women aged 30+ with HPV cotest available:

  • If HPV is negative: The negative predictive value for high-grade squamous intraepithelial lesion (HSIL) is 99.6%, meaning the risk of missing significant disease is extremely low 3
  • Repeat screening can be safely extended beyond the traditional 2-4 month window, though guidelines still recommend 2-4 months 3
  • If HPV is positive for genotypes 16 or 18: Direct referral to colposcopy is required 3

• For women aged 21-29 (cytology alone recommended):

  • Repeat the Pap test in 2-4 months to obtain an adequate sample 3
  • Consider using different sampling techniques or devices (endocervical brush, cytobrush) to improve sample adequacy 4

Step 3: Address Sampling Technique Issues

A critical pitfall is inadequate sampling of the transformation zone (the junction between endocervix and exocervix), which is where most cervical cancers originate 4:

• A satisfactory smear must include metaplastic and/or endocervical cells from the transformation zone 4
• Traditional Ayre spatula alone captures transformation zone cells in only approximately 50% of samples 4
• Use combination sampling devices (spatula plus endocervical brush) to improve adequacy 4

Step 4: Document and Counsel

• Document the reason why cervical sampling cannot be performed (anatomical absence, technical difficulty, patient factors) 5
• Avoid the common pitfall of confusing a pelvic examination with actual Pap testing—many women believe they had a Pap smear when only a pelvic exam was performed 5

Special Populations

• All women, regardless of sexual orientation, should be considered for cervical cancer screening if they have a cervix 2
• Women with no history of vaginal intercourse have extremely low cervical cancer risk and may defer screening based on shared decision-making 6