papanicolaou (Pap) smear tests of the vaginal vault are a means of detecting recurrent invasive or preinvasive disease of the lower female genital tract in women who do not have a cervix uteri
indication for Pap smear tests of vaginal vault
current policy in the UK is to follow up with vaginal vault smears those women who have had a hysterectomy for high-grade preinvasive disease of the cervix
purpose of undertaking vault smears on asymptomatic women who had no abnormal cervical pathology at hysterectomy is to screen for vaginal intraepithelial neoplasia (VAIN) and prevent vaginal cancer
VAIN is 150 times less common than cervical intraepithelial neoplasia (CIN), and vaginal cancer is one of the rarest gynaecological malignancies (0.7 per 100 000 women in UK)
risk factors for VAIN include: CIN, immunosupression, genital warts/human papilloma virus infection, radiation therapy and smoking
besides VAIN, the only group of women appearing to be at increased risk of primary vaginal cancer are those whose mothers took diethylstilbestrol during pregnancy
schedule for vault smears following hysterectomy:
women who have had a hysterectomy with CIN present are potentially at risk of developing vaginal intraepithelial neoplasia (incidence 1%) and invasive vaginal disease
Patients within the cervical screening age who are undergoing hysterectomy (for another gynaecological cause) should have a negative test result within the screening interval. Otherwise a cervical sample should be obtained preoperatively (3).
women who have had a hysterectomy with CIN present are potentially at risk of developing vaginal intraepithelial neoplasia (VAIN) and invasive vaginal disease. There is no clear evidence that colposcopy increases the detection of disease on follow up. Expert consensus opinion recommends that (3)
for women on routine recall and with no CIN in their hysterectomy specimen, no further vaginal vault cytology is required
women not on routine recall, and with no CIN in their hysterectomy specimen, should have vaginal vault cytology at six months following their hysterectomy
women who undergo hysterectomy and have completely excised CIN should have vaginal vault cytology at six and 18 months following their hysterectomy
for women who undergo hysterectomy and have incompletely excised CIN (or uncertain excision), follow up should be as if their cervix remained in situ
CIN 1: vault cytology at six, 12 and 24 months
CIN 2/3: vault cytology at six and 12 months, followed by nine annual vault cytology samples
follow up for incompletely excised CIN continues to 65 years or until 10 years after surgery (whichever is later)
as women who have undergone hysterectomy have no cervix, and so are no longer eligible for recall within the NHSCSP, their vault cytology following treatment of CIN must be managed outside the programme
since women who have undergone subtotal hysterectomy still have their cervix, they should remain in the National Screening Programme (3)
Notes:
by the age of 65 years, the proportion of women having a hysterectomy reaches a third in the USA and 20% in the UK (60,000 procedures annually)
subtotal surgery (sparing the cervix) is undertaken in less than 3% of the hysterectomies performed in the UK
total hysterectomy includes removal of the cervix uteri leaving the vagina as a blind ending pouch; since the cervix has been removed, there is no possibility of the development of a primary cervical cancer and thus no indication for routine cervical screening
benign indications (e.g. excessive bleeding or fibroid disease) account for more than 90% of hysterectomies in the UK
proportion of hysterectomies performed for cancer or precancerous lesions has been reported to range from 6 to 10%
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