Dr Margaret answers emailers’ embarrassing problems
in this monthly problem page.

Cervical smears

Dear Dr Margaret
I haven’t had a cervical smear for ages. I just can’t face it. Is it really necessary?

As you obviously realize, a cervical smear (Pap smear) is an important test. It detects pre-cancerous or cancerous at the cervix. For example, statisticians now estimate that over the next 30 years, regular cervical smears will prevent 1 in 50 women from developing cervical cancer.

The cervix is the neck of the uterus (womb) at the top of the vagina. It has a small hole in its centre, to allow menstrual blood to flow out from the uterus, and sperm to travel upwards. You can feel the cervix by putting your fingers into your vagina and pressing upwards – it feels round in shape.

Having the smear. To take the smear, the nurse or doctors inserts a plastic or metal ‘speculum’ into the vagina. This holds the walls of the vagina apart, so that the cervix is visible at the top of the vagina. The cervix may be slightly to the back or front of the vagina (depending on the position of the uterus), so don’t be surprised if the nurse has to wiggle the speculum to get a good view. A wooden spatula, like a specially-shaped lolly stick, is used to scrape off some cells from the around the edge of the hole. Most women don’t like having cervical smears. It is undignified and, although it is not painful, you may notice a scraping feeling while the smear is being taken.

Smear worries. You don’t say what aspect of having a smear upsets you particularly. If it is embarrassment or indignity, just tell yourself firmly that it is for your own health. Remind yourself that the whole procedure lasts only a minute or two. The doctor or nurse taking the smear does it all the time, so for them it is no big deal.

Maybe you have found smears uncomfortable previously because the doctor or nurse did not use any lubricating gel on the speculum. In the past, it was thought that even a water-based gel might interfere with the test but, in a study involving more than 2,900 women, researchers in the USA have found this is not the case. So ask the doctor or nurse taking your smear to use a water-based gel.

Or are you worried about the result of the test? Slight abnormalities are common, so a repeat test might be needed and is not a cause for worry. A UK study provides the following figures. If 100 women have smears every 5 years for 20 years, about 16 will have an ‘abnormal smear’ result at some time and 8 will need to be investigated more fully by a proper tissue sample (biopsy), but only 4 will end up having treatment for cancerous or serious pre-cancerous changes.

The future. The good news is that smear tests may not be necessary for women under the age of 25. UK researchers recommend cervical smears every 3 years for women aged 25–49 years, and every 5 years for those aged 50–64 years. At present, some UK health authorities offer screening every 3 years, and some every 5 years.

Researchers are also investigating more user-friendly methods. In a recent study, women took their own smears in private, by inserting a special brush 5–6 cm into the vagina, rotating it five times, and then placing it bottle of special preservative solution. Unfortunately, the results were not quite as good as when smears were taken by the doctor using the wooden spatula, but this sort of research is a step in the right direction.

Back-up information – do you want it?
I am sometimes asked where I get all the information for www.embarrassingproblems.com. Some of the information comes from my own experience, some comes from asking specialists and some comes from consulting scientific research papers. The research papers I consulted on cervical smears are listed below. In the past, I have usually not listed the scientific papers, but I may to do so in future. Let us know what you think.

Garcia F, Barker B, Santos C et al. Cross-sectional study of patient- and physician-collected cervical cytology and human papillomavirus. Obstetrics and Gynecology 2003;102:266–72.

Melnikow J. Water soluble gel lubricant on vaginal speculums had no effect on cervical cytology results. Evidence Based Medicine 2003; 8:78–9.

Raffle AE, Alden B, Quinn M et al. Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented. British Medical Journal 2003;326:901–4.

Sasieni PD. Outcomes of screening to prevent cancer: think of screening as insurance. British Medical Journal 2003;327:50.

Sasieni P, Adams J, Cuzick J. Benefit of cervical screening at different ages: evidence from the UK audit of screening histories. British Journal of Cancer 2003;89:88–93.

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