A significant number of women undergo hysterectomy in the United States—about 33 percent by age 60. Approximately 85 percent of these surgeries are done for benign uterine disease. Because the incidence of vaginal cancer is quite low, the need for vaginal cuff smears following hysterectomy is probably unnecessary in most women. A large study published in 1996 that included more than 5,000 women reached such a conclusion. However, this study did not observe future outcomes in the patient population. Current guidelines do not provide a clear consensus on the issue of post-hysterectomy Papanicolaou smears (see accompanying table). Videlefsky and colleagues performed a study to address the need for vaginal cuff smears. They included women with high-grade prehysterectomy lesions and assessed long-term outcomes in these patients.
|Determine whether the hysterectomy was done for a benign condition.|
|Determine whether there were any underlying co-existing genital-tract malignancies or dysplasia at the time of or preceding the hysterectomy, including ovarian, vaginal or perineal abnormalities.|
|Assess the probability of vaginal infections based on the history of sexual practices and previous sexually transmitted diseases.|
|Consider the practice setting. Patients more likely to develop vaginal cancers include those from lower socioeconomic groups, patients with HPV infection and patients who are immunocompromised.|
The study retrospectively identified women who had undergone total hysterectomy for benign conditions and had follow-up vaginal cuff smear testing over a nine-year period. They identified 2,066 patients who met study criteria and randomly selected 220 from their sample.
The mean age of the patients who underwent hysterectomy was 44 years. Before hysterectomy, low-grade squamous intraepithelial lesions were noted in 12 women and high-grade squamous lesions in 44. The remaining 164 had no cytologic abnormalities noted before their hysterectomies were performed. During the follow-up period, a total of 1,211 vaginal cuff smears were performed. The average follow-up period was 89 months, with a range of three to 175 months. Only seven women had abnormal cytologic findings (dysplastic lesions) on vaginal cuff smears during the follow-up period. Four of the patients did not undergo further biopsy or other interventions. Three underwent biopsy, laser treatment or excision of the abnormality. There were no cases of invasive carcinoma. On long-term follow-up of these seven women, repeat vaginal cuff specimens were negative. There was no significant correlation between prehysterectomy abnormalities and post-surgical vaginal cuff abnormalities.
The authors conclude that their data are consistent with those of previous studies in concluding that vaginal cuff smear testing is not necessary in women who have undergone hysterectomy for benign conditions.