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Cervical screening without a speculum: a future option for older women?
By Laura Marlow, on 19 February 2018
In the UK, women are invited for cervical screening (the ‘smear test’) between the ages of 25 and 64, and although uptake is high it has been falling for some years across all age groups (1). A number of studies have focused on improving uptake among younger women (2), but a recent BMJ article called for work to focus on the needs of ‘older’ women too, given that half of all cervical cancer deaths are in women over 50 (3). One particular issue for older women can be that screening becomes more painful following the menopause. Lower oestrogen levels can cause thinning and dryness of the vaginal walls and it’s estimated that half of all post-menopausal women have these symptoms. This can mean that inserting the speculum (the instrument used to open the vagina for examination) is particularly painful for some ‘older’ women. Dr Anita Lim at King’s College London has been awarded funding by Cancer Research UK to explore a different procedure for collecting samples without a speculum. Samples collected without the speculum would be tested for human papillomavirus (HPV) and women would only need to have further examination if they were found to be HPV positive.
Collaborating with Dr Lim, we led some exploratory work to assess the acceptability of this potential alternative (4). Published online last week in the Journal of Medical Screening, the work included focus groups and interviews with 38 women aged 50-64 who had a variety of cervical screening histories (‘up to date’, ‘overdue’ and ‘never been screened’). As expected, many of the women reported negative experiences of the speculum during cervical screening and found its insertion was sometimes painful, particularly after the menopause. Women were generally positive about the idea of screening without a speculum and thought it would be less invasive than the current procedure. However, some women were concerned that this method could be less accurate, because the swab might touch other areas and collect unwanted cells, and the sample-taker would not be able to clearly see the cervix without a speculum. Women said they would want sufficient information and reassurance, particularly about the effectiveness of non-speculum sampling compared to current cervical screening.
The findings from this study suggest that HPV testing on clinician-collected samples taken without a speculum could be an acceptable alternative to conventional cervical screening. It might be particularly useful for older women who have had difficulty with the speculum examination, potentially due to post-menopausal changes. Dr Lim will continue to explore the acceptability of introducing clinician-collected non-speculum sampling alongside assessing how well the test works, but preliminary work suggests introducing this procedure could improve screening uptake among 50-64 year-olds who have put off attending.
- Screening and Immunisations team. Cervical screening programme: England, 2016-17. Health and Social Care Information Centre, 2017, p. 1 – 76.
- Kitchener HC et al. A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC). Health Technol Assess 2016, 20(68):1-138.
- Sherman SM et al. Cervical cancer is not just a young woman’s disease. BMJ 2015, 350:h2729.
- Freeman et al. Acceptability of non-speculum clinician sampling for cervical screening in older women: A qualitative study. JMS, in press.
23 Responses to “Cervical screening without a speculum: a future option for older women?”
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Laura Marlow wrote on 12 August 2019:
Thank you for sharing your experience. We agree that HPV self-testing could make a real difference.
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Jane Dickson wrote on 20 January 2021:
Thank you for this very important paper.So sorry to read of Jane Marfleet’s experience.
I would also really like to see some research being done on how difficult it is for women who haven’t had children to have smear tests. The cervix ‘hides away’ and finding it, in my case, has taken nurses up to 40 minutes. They usually have to call for back up from a doctor to perform the test. It is excruciatingly painful, especially since the menopause. What I find very hard to cope with is that although I now always explain upfront how difficult it will be, I am never listened to. It would save so much time for the NHS and so much pain for me if I could have a muscle relaxant and strong painkiller before having the smear but no one will believe how hard it is and I would appreciate some research to help clinicians to open their minds to the situation for ‘older’ women.
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Meg wrote on 3 August 2021:
Gel and a very thin thiny speculums we used to call virgin speculums can be used for mature ladies and most find these much better.
The cervix can then still be viewed so you know you are getting the cells from the right area!
The speculum is slender only inch if that thick and every surgery should have some!
Half the cancers are found in mature age groups and smears only every 5 yrs.
So ladies need to attend and the smear must be as pain-free as possible! -
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Meg wrote on 3 August 2021:
Maybe they can swab for hpv which is a wart virus without a speculum but smears require you to see the cervix and collect cervical cells which a speculum allows you to do.
Having the wart virus in the past can change cells in the cervix and you may not have the wart virus anymore when you are swabed.
If present the wart virus can be picked up with a swab, a smear is a totally different though and requires you to see the cervix in order to collect the correct cells! -
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Meg wrote on 3 August 2021:
My friend has to go to the hospital gynae to have her smear she has a colostomy bag and has internal adhesions due to her bowel operation which have attached to her cervix womb vagina etc They find it hard to bring her cervix down into view to get a smear sample from it and she has to get into all positions and the whole thing is very painful so she uses strong pain killers.
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Meg wrote on 3 August 2021:
It is still painful for ladies who have had children after menopause when the vagina is dry and thin. This should not be underestimated and will put women off going for a smear!
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Caro Pearson wrote on 14 September 2021:
I have had similar experiences and have had to today re-book my test as described above, the cervix could not be seen. The pain was bad despite taking both ibuprofen and paracetamol. I have now been offered an appointment with a GP and a prescription for Diazepam to see if that works.
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Priscilla Rojo wrote on 27 September 2021:
I just had my 57th birthday in July and in August started to experience the symptoms of a period when I wiped after urinating I found drops of blood. Continued to monitor the weekend no more blood but my body continued to feel like I was on my period. Made appt with my doctor went in and she tried to do a Pap smear but to painful was referred to a gyn and tried same thing painful beyond any other pap smear. I am currently waiting to be referred to another doctor to possibly put me under to perform test. I’ve never had issues before so I truly believe it is menopause.
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Lizzie wrote on 26 November 2021:
I had a smear this morning, the second in the space of a year because HPV was detected. I am probably perimenopausal (age 45) but the pressure and pain made me cry and I am really sore now. It really would deter other women from the procedure and there must be another way. Please more research! It’s vital we have this screening but I’ll be resorting to much stronger pain relief next time.
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Jill wrote on 22 February 2022:
I have just had a smear test, and it was painful beyond belief and I was told she used a slim speculum. I think of myself as having a high pain threshold, but if I am asked to return I could not go through that again. I was crying out. I was told to relax, it was excruciating. I am 65 so should be my last one, each smear test has become more painful each time. I really think that nobody can understand how much it hurts unless it is really bad for them too. There must be a better way. I would not have gone today if I had known it would be that bad. I thought there may be something wrong with me, why it hurt so much, but reading above maybe I am not alone, but I don’t hear this pain being talked about.
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Juliet Blackledge wrote on 7 March 2022:
I echo all the comments hear. At 57 I’m post menopausal and the latest smear I had was excruciating despite the smallest speculum being used. It took 3 attempts and I was really distressed. I now have to go back again for a second smear because apparently I have 2 cervixes (no one has EVER told me this before).
Surely there must be a better less-invasive way to do the testing – why must women suffer with this level of pain. The only advice the GP could give was to take painkillers before the exam.
If men had to have this done the medical establishment would have found a better way decades ago. -
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Abby wrote on 11 March 2022:
My last two smear tests since the menopause have been excruciatingly painful. The nurse couldn’t get a sample because the speculum caused bleeding. She said that if stirrups are used (as in a gynaecologist’s clinic), it is a lot easier to position the patient and insert the speculum, but not all GP surgeries can afford these. She said that using oestrogen cream for a few weeks before the smear test can help with the pain.
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Janet wrote on 24 March 2022:
I can agree with all of these ladies comments.
I am 56 and just had my smear test,took 3 attempts. The pain was excruciating. 2 hours later and I am still in pain.
I actually told her not to bother. I will never have one again . -
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Carol Horrell wrote on 2 June 2022:
Thank god someone is trying to find an alternative to speculum. I had my coil removed yesterday, I am 66. The pain from the speculum was excruciating. I now have the start of a UTI and Thrush. I am having to take pain killers to reduce the pain. There must be a better way.
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Sarah wrote on 12 June 2022:
I’m 55 and just in menopause – my last experience was painful and sore. I wonder if oestrogen pessaries in the run up would be worth considering. I’ve heard they’re excellent as part of ‘localised HRT’ for those concerned about lack of lubrication so should be effective for reducing pain even if only around the time of the scheduled smear?
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Wilson Fox wrote on 13 July 2022:
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Anna wrote on 23 July 2022:
I have been putting off my smear as really scared because the last two were painful and caused soreness and bleeding. The nurse was somewhat dismissive just telling me to relax more. Which isn’t possible because it’s the discomfort that causes progressive tension. The hard metal instruments look and feel like something fr a Victorian operating theatre and I would have thought that the 21st century medical and technology advances would have resulted in a more comfortable painless technique. A routine check shouldn’t have to be a painful ordeal.
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Lorna wrote on 1 August 2022:
I’m 54, post menopausal with vulvodinia, and have just had an excruciatingly painful smear. The pain during the examination was intense and left me with the feeling of my insides falling out and the need to push. Perhaps all the prodding of the cervix replicated some stages of childbirth. . Apparently, my cervix is hard to find and very tight. It added to the trauma the worry that I may not be able to hold on ….. no doubt making me more tense.
Afterward I could hardly walk because I was shaking so much.
I then had to drive home ….. no previous advice that this might not be a great idea.
I have lupus and have had all sorts of tests and things over the years and consider myself to have a high pain threshold and accepting of procedures, but this was truly horrible.
Surely some local pain relief could be considered. -
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Melly wrote on 12 August 2022:
Hi, i`m 54, post meno, Just had a smear done this morning. Not had 1 for about 6 years as kept putting it off. Always been uncomfortable, but today was way beyond that. Nurse used small speculem, but as soon as she opened it i was in agony, actually cried out. Couldn`t find my cervix ( it always hides, tilted right back), so had to come out, + try again, cried out again. 3 hrs later + i`m still very sore + uncomfortable. Feels like i`ve bashed about inside. I hope + pray someone can come up with a better way to do it. Shouldn`t have to feel like this.
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Deborah wrote on 5 November 2022:
I have a tilted cervix and going for a smear test is extremely painful. Even when using a smaller speculum. I’m 50 and the pain has definitely increased with age. The last smear test I went for had to abandoned so got to go through the trauma again soon. Finding this page has made me realise it’s not just me, so thanks for that. A smear test without a speculum would be fantastic. I’ve got everything crossed that this will happen very soon.
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Ann wrote on 30 November 2022:
Hi Ann,
It’s a great comfort to read the above, I thought is was just me. So glad I’m not alone. The nurses don’t seem to understand the pain, how can you relax when you are in pain. There is no empathy and any advise is meaningless. I have had many tests over the years but never anything as painful. Surely a local anaesthetic could be administered similar to the dentist especially for groups known to experience issues such as post menopausal women.Ann
Thankyou for this important and highly relevant paper . With hindsight, I would loved to have had the option of HPV self testing. Sadly, I stopped going for cervical screening when I was age 50y partly because I found examination by speculum very painful and I didn’t see the point of being ‘tortured’ to check for a disease I thought I had little risk for.. I got symptoms in 2016, age 60y, and was diagnosed with a stage 2a cervical cancer. The side effects of the treatment have had a very negative and life changing impact on me. It’s very sad to think that for the sake of some simple intervention I might have had many more years of a better quality of life. In my opinion better supportive measures, such as HPV self testing, to enable improved uptake of cervical screening can’t come too soon.