The National Cervical Screening Policy
Cervical Screening in Special Circumstances
National Information Statements
The National Cervical Screening Policy is a key part of the cervical screening pathway and states that routine Pap smears should be carried out every two years for women who have no history of abnormal pathology or no current symptoms.
All women who have even been sexually active should start having Pap smears between the ages of 18 to 20 years, or one or two years after first sexual activity, whichever is later.
Pap smears may cease at the age of 70 years for women who have had two negative Pap smears within the last five years. Women over 70 years who have never had a Pap smear, or who request a Pap smear, should be screened.
This policy applies only to women without symptoms that could be due to cervical pathology. Women with past history of high grade cervical lesions, or who are being followed up for previous abnormal smears should be managed in accordance with the NHMRC guidelines: Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities.
Cervical Screening in Pregnancy
Queensland Health has a Policy and Protocol for Cervical Screening in Pregnancy. It states a Pap smear should be offered to every woman booking for antenatal care who has not had cervical screening within the past two years, and to any woman with a history of abnormal symptoms or treatment of cervical abnormalities who has not been followed up in accordance with national guidelines.
It is recommended that Pap smears are offered to women, where appropriate, to at least 28 weeks of pregnancy and in selected other women into their third trimester, if it appears likely that they may have difficulty presenting for screening in the post natal period.
Pap smears have not been associated with an increased rate of miscarriage or pre-term labour. If a woman is concerned and is reluctant to agree to have a Pap smear, the provider should emphasise to the woman the importance of having a Pap smear performed at an early date post-natally. It is also recommended that every woman with unexplained bleeding in early pregnancy should have her cervix visualised via a speculum to ensure that unexpected malignancy is not the cause.
Cervical Screening after Hysterectomy
Whether a woman needs to have a Pap smear following hysterectomy depends on:
When the cervix was removed during the operation, a woman may need to have Pap smears from the vault (top) of the vagina if:
If a woman has a subtotal hysterectomy, where the cervix is not removed and is present then the normal screening regime applies.
Symptomatic women
It is important to remember that women with abnormal symptoms (intermenstrual bleeding, post-coital bleeding or post-menopausal bleeding) are not to be screened as per the National Cervical Screening Policy as this only applies to asymptomatic women. In such situations a Pap smear may be conducted as part of the investigative workup that would include referral for further investigation.
Women with any of the above signs or symptoms or any other signs or symptoms of concern should be referred for further tests to a specialist gynaecologist so that their condition can be assessed and an appropriate management plan formulated. Women with intermenstrual bleeding or post-coital bleeding should be managed in accordance with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Guidelines for the management of intermenstrual and postmenopausal bleeding. These guidelines recommend appropriate management of women presenting with intermenstrual or post-coital bleeding and referral indications.
Cervical screening guidelines for women with special circumstances are included in the NHMRC guidelines: Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities. In these circumstances the interval between Pap smears and recommendations relating to screening differ as these women are not participating in population screening given their risk profile.
Guidelines for Immunosuppressed Women
Immunosuppressed women are at increased risk of developing a persistent productive HPV infection that may develop into cervical cancer. Women may be immunosuppressed because of HIV infection or the effect of drugs, such as those used to prevent rejection of transplanted organs/tissues or to treat autoimmune diseases such as systemic lupus erythematosus, ulcerative colitis or asthma. Immunosuppressed women have an increased risk of intraepithelial neoplasia of 20% (compared with less than 5% for general population). The management of these women is complex and should be carried out in specialist centres.
Guidelines for women exposed in utero to diethylstilboestrol (DES)
DES was given to pregnant women between 1940 and 1970 to provide luteal support to those with previous poor pregnancy outcome. Although DES exposure in utero rarely leads to vaginal adenocarcinoma, vaginal adenosis occurs in 45% of these women and structural abnormalities are present in 25%. DES-exposed women should be offered annual cytological screening and colposcopic examination of both the cervix and vagina with a clinician experienced in colposcopy of the lower genital tract. Screening should begin at any time at the woman's request and continued indefinitely.
National Information Statements
National Information Statements can be found on the National Cancer Screening website.
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© The State of Queensland (Queensland Health) 2008.
