Pap Smear Guidelines After Hysterectomy

Decision Algorithm Based on Hysterectomy Type and Indication

The American Cancer Society recommends that women who had a total hysterectomy for benign reasons do not need Pap smears, as this screening provides no benefit and should be discontinued 1, 2, 3
Women who had a total hysterectomy for benign disease should stop all Pap screening immediately if the cervix was completely removed, with a verification step to confirm through medical records review that the cervix was removed and the indication was benign 1, 2, 3, 4
Vaginal cancer is extremely rare, with an incidence of 1-2 per 100,000 women per year, and screening the vaginal cuff in this population has essentially zero benefit, with a need for 663 Pap tests to detect one case of vaginal dysplasia, and no improvement in patient outcomes 1, 2

Women with in utero DES exposure should continue screening indefinitely due to elevated risk for both vaginal and cervical clear cell adenocarcinoma 1, 2, 5
Immunocompromised women, including those with HIV infection, solid organ transplant, stem cell transplant, or chronic immunosuppressant therapy, should continue screening indefinitely 5, 6, 7

Women who had a subtotal (supracervical) hysterectomy should continue regular cervical cancer screening exactly as if they had not undergone hysterectomy, since their cervix remains intact, with cytology every 3 years (ages 21-65) or co-testing every 5 years (ages 30-65) 1, 3, 4, 7
Women who had a total hysterectomy for high-grade precancerous lesions (CIN2/3) should continue screening for 20-25 years after treatment, even if this extends well past age 65, with initial screening every 4-6 months until three consecutive normal vaginal cytology tests are achieved within 18-24 months, then annual screening for the full 20-25 year period 1, 2, 5
Women who had a total hysterectomy for cervical cancer should continue screening indefinitely for as long as they are in reasonably good health, as they remain at increased risk for vaginal cancer, regardless of age or time since hysterectomy 1, 2, 5, 6