Muiris Houston: Should we replace the smear test with a swab?

It is rare to meet a patient who feels nonchalant about a pelvic examination or cervical smear test. The majority of women find the procedure either embarrassing or uncomfortable, even if it only takes about two minutes or so to perform.

Speaking to the patient experience website, healthtalk.org, 64-year-old Marjory said her last cervical smear test was so painful she would not be attending again. (http://www.healthtalk.org/peoples-experiences/cancer/cervical-abnormalities-cin3-and-cgin/views-cervical-screening#ixzz4aXxytS9z )

As a post-menopausal woman, she is one of a group who may find the examination more challenging. Women with disabilities, those with previous experience of physical or sexual trauma, and patients from sexual minorities are among those who report finding the procedure distressing.

A review article in the US Journal of General Internal Medicine noted that a pelvic examination is an intrusive experience for many women who feel exposed and lack control. Emotional distress and fear of pain are cited as reasons for reduced adherence to cervical screening. Therefore, the examination should be performed with cultural sensitivity and procedural excellence, the authors say.

While placing a woman in metal stirrups provides easy examiner access to the vagina, some patients experience it as disempowering, abusive, and humiliating, they note. (A “no-stirrups” method, in which the patient is examined with the heel of each foot resting on a corner of the couch, is standard practice in these islands)

Is there anything your doctor could do to minimise the discomfort you may feel when having a smear test? Rather than rush straight into the procedure, it helps to be asked how you are feeling.

This allows you to say if you are nervous or scared, and to explore the reasons as to why you may be feeling that way. Research suggests women prefer to be asked at this initial chat if they have have experienced sexual trauma in the past. Victims of sexual abuse generally want their physicians to be aware of their situation, although many struggle to reveal the information on their own.

You should ask to be “walked through” the procedure and in particular be given some information about the type of vaginal speculum to be used. Some experts suggest that a useful strategy for calming a patient’s anxiety is to allow her to see and perhaps even hold the speculum prior the examination.

The Pap smear detects pre-cancerous cellular changes and is the cornerstone of the National Cervical Screening Programme, Cervical Check. It offers regular smear tests to 1.2 million eligible women aged 25 to 60 in the Republic.

But changes are under way internationally. Australia will shift its screening test to one for the human papilloma virus (HPV) in December (HPV infection is almost always responsible for cases of cervical cancer). This test not only improves the ability to detect changes on the cervix, but should also improve screening rates for women who have never had a Pap smear. Under the new scheme women who experience anxiety and who have been under screened in the past will be able to take a vaginal swab themselves which is then sent for testing.

Might women here benefit from a similar change? The national screening service says it is awaiting the outcome of Health Technology Assessment (HTA) on the use of HPV testing as the primary screening technology for cervical screening.

“If those findings and recommendations present a potential improvement in terms of clinical and cost effectiveness of cervical screening through the use of HPV testing as the primary screening technology, then it is likely that a plan to change from the current use of cytology as the primary screening technology . . . will be pursued,” a spokeswoman said.

If this change comes to pass, with a vaginal swab option, it should offer a hitherto disadvantaged group of Irish women the chance to better protect their health.

mhouston@irishtimes.com

@muirishouston