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‘Health Chatter’: Research Department of Behavioural Science and Health Blog



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.

  1. Screening and Immunisations team. Cervical screening programme: England, 2016-17. Health and Social Care Information Centre, 2017, p. 1 – 76.
  2. 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.
  3. Sherman SM et al. Cervical cancer is not just a young woman’s disease. BMJ 2015, 350:h2729.
  4. Freeman et al. Acceptability of non-speculum clinician sampling for cervical screening in older women: A qualitative study. JMS, in press.

8 Responses to “Cervical screening without a speculum: a future option for older women?”

  • 1
    Jane Marfleet wrote on 11 August 2019:

    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.

  • 2
    Laura Marlow wrote on 12 August 2019:

    Thank you for sharing your experience. We agree that HPV self-testing could make a real difference.

  • 3
    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.

  • 4
    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!

  • 5
    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!

  • 6
    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.

  • 7
    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!

  • 8
    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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