Forgotten reasons for a cervical smear

In 2015/16, more than one million UK women chose not to have their cervical smear test. Cervical screening rates are currently at their lowest levels for 19 years.

The smear test is a quick test which saves lives. There has been a 50% reduction in cervical cancer in the UK since the screening programme was introduced in the UK.

It may be relevant to inform women about the full range of benefits from having a cervical smear – not just the very real protective effect of preventing cervical cancer – which seems sometimes forgotten!

Reasons to have a cervical smear – other than cervical cancer prevention

The aim of the cervical screening programme is to detect abnormal cells on the cervix, and prevent the development of cervical cancer – this is called “squamous carcinoma.”

However, attending for your cervical smear may have a lot of other consequences:

1. The doctor/nurse will ask you if you have had irregular bleeding between your periods or after sex. If so, they will examine you, but should refer you to colposcopy whether or not they do take the smear.

2. If you have been having irregular bleeding, this is an opportunity to discuss this.  In the vast majority of cases this will not be cervical cancer.

Irregular bleeding on your contraception

The Combined Pill

Irregular bleeding is:

• Common especially if you miss pills, or do not take the at the correct time intervals.
• It may be due to the constituents of the Pill and the Pill may need changing.
• Bleeding patterns are better with 30 mcg rather than 20 mcg pills. Bleeding patterns are better with more progestagenic pills.
• Check you are not taking any medicines that could interfere with your pill, such as St John’s Wort.

Progestagen-only Methods

Irregular bleeding is:

• Pill (POP):  the most common side effect. It may improve with time.  As the POP is a low dose pill – called a ‘mini pill’ – some women may benefit from taking two pills a day (unlicensed use, but common clinical practice).
• Injectable contraception: very common.  Have the next injection early.  Usually given every 12 weeks, but can be given again after 8 weeks if required.
• Implant: a very common side effect of Nexplanon.
• IUD/Mirena IUS: a very common side effect with IUD/Mirena IUS (“copper coil/hormone coil”) users. IUD users often experience a few days premenstrual spotting, periods are longer and heavier, then tail off slowly. Mirena IUS users get spotting at random.
•  Ensure the IUD/IUS is correctly fitted, and have the threads checked.
• In all of these cases pregnancy must be excluded.
• To manage the bleeding in women on progestogen only methods, if there are no contraindication, bleeding patterns are better with a Combined Pill, and swapping to or adding in the Combined Pill is likely to help.  It is actually completely sensible for example for someone using the implant Nexplanon, to also take the Combined Pill. The Pill controls the bleeding, and the implant is a fail-safe against any missed pills.

3. In all of these cases, a sexual history should be taken, and a full STI screen offered, i.e. for chlamydia, gonorrhoea, HIV and syphilis.

Advice will be given about a range of issues including safe sex and STI prevention.

4. Women sometimes disclose other new issues at the smear test. For example, a sexual assault, the need for emergency contraception (the morning after pill), or painful sex, which may be associated with menopause, or psychosexual problems.

• Sexual assault:  there will be a detailed range of questions, including whether or not police involvement is required, if there are safeguarding issues, and if a referral to the local Sexual Assault Referral Centre (SARC) is needed. http://thesurvivorstrust.org/sarc/
• Emergency contraception: this needs to be given as soon as possible after unprotected sex. This will prevent 95% or more of unplanned pregnancies, but using reliable contraception long term is much more effective option. https://www.fpa.org.uk/sites/default/files/emergency-contraception-your-guide.pdf
• Menopause – requires menopause consultation. Due to local oestrogen deficiency – ‘atrophic vulvovaginitis.’ It’s preferable to treat this before attempting the smear. Vaginal oestrogen cream or pessaries, are a low dose, mild oestrogen. Safe and effective. The usual regime is to use either one pessary/one application of cream, every night for 2 weeks, every other night for 2 weeks, then twice a week, and return in 6 weeks for the smear test. https://www.menopausematters.co.uk/dryness.php
• Psychosexual problems – often very hard to talk about. https://www.ipm.org.uk/24/common-problems

5. Taking the smear involves an examination of the genitalia.

Sometimes other infections/conditions are diagnosed –

• Genital warts
• Herpes
• Candidiasis –“thrush,” usually treated before taking the smear.
• Bacterial vaginosis – not serious but can be unpleasant for the sufferer and is easily treated.
• Cervicitis – this is inflammation on the cervix. There may be a mucopurulent discharge. If you take a sample and look under the microscope there are lots of pus cells. This condition can be asymptomatic. It can be caused by chlamydia, or gonorrhoea, but in women who test negative to these infections it is said to be a ‘non specific genital infection.’ If ignored, these pus cells can crowd the smear and make it difficult or impossible to interpret. Usually cervicitis will be treated before a smear is taken. Recent and current sexual partners should also be treated. 
• Pelvic Inflammatory Disease
• Vaginal wall prolapse
• Atrophic vulvovaginitis – see above

6. Smears are now tested in the laboratory for the Human Papilloma Virus (HPV). This may be present even if there are no visible genital warts.

• Actinomycetes. Most common in IUD/IUS users. If present you will be advised the best course of action. Sometimes you may need to have your IUD/IUS changed.

7. Rarely, a smear will show abnormal cells, called ‘glandular neoplasia.’ A full range of tests are required to exclude gynaecological cancers higher up the genital tract.

What a lot of additional reasons to go for your smear test!

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