Guidance

5. Management of cases relating to pregnancy, menopause, contraception and hysterectomy

Updated 27 September 2024

1. Pregnant individuals

1.1 Cervical screening during pregnancy

If an individual has been called for routine screening and they are pregnant, the test should be deferred. An individual referred with an abnormal screening test should have colposcopy in late first or early second trimester unless there is a clinical contraindication.

If a previous colposcopy was abnormal and in the interim the individual becomes pregnant, then the colposcopy should not be delayed.

If a pregnant individual requires colposcopy or a screening sample after treatment (or follow up of untreated cervical intraepithelial neoplasia grade 1 (CIN1)), their assessment may be delayed until after delivery.

The colposcopist may wish to perform colposcopy only at a follow up appointment scheduled during pregnancy. If a repeat screening sample is due, and the individual has missed or defaulted their appointment prior to pregnancy, a screening sample or colposcopy during pregnancy can be considered.

1.2 Colposcopy during pregnancy

An individual who meets the criteria for colposcopy should be examined in the colposcopy clinic even if they are pregnant.

The primary aim of colposcopic examination of a pregnant individual is to exclude invasive disease and to defer biopsy or treatment until the individual has delivered.

Individuals seen in early pregnancy may require a further assessment in the late second trimester at the clinician’s discretion. If excision for diagnostic purposes is clinically indicated it is feasible and acceptable to individuals. This is usually reserved for individuals with colposcopic high grade disease and concerns about cancer. If an individual declines treatment in early pregnancy they should be seen for postpartum colposcopy.

1.3 Colposcopy follow up after pregnancy

Clear follow up arrangements should be made for postpartum assessment of individuals whom have been referred with an abnormal screening test or suspicious looking cervix who have had an abnormal colposcopy.

1.4 Colposcopic evaluation of the pregnant individual

Colposcopic evaluation of a pregnant individual requires a high degree of experience.

If CIN1 or less is suspected

The individual should be managed as per the screening algorithm (see the cervical screening pathway requirements guidance).

If CIN2 or CIN3 is suspected

Repeat colposcopy at the end of the second trimester. If the pregnancy has already advanced beyond that point, repeat 3 months following delivery.

If invasive disease is suspected

If invasive disease is suspected, clinically or colposcopically, a biopsy adequate to make the diagnosis is essential. Studies published in 2013 and 2017 showed that that excisional treatments are safe in pregnancy in the first and second trimester.

All excisions are associated with a risk of haemorrhage and such biopsies should be taken only where appropriate facilities to deal with haemorrhage are available. Punch biopsy suggesting CIN only cannot reliably exclude invasion.

2. Use of contraceptives

2.1 Individuals with abnormal cervical screening results

Individuals with abnormal cervical screening results should not be advised to change from the oral contraceptive pill (OCP) if it is a successful method of contraception for them. An abnormal result should not influence the choice of contraception.

2.2 Individuals with an intra-uterine system (IUS)

Give individuals with an IUS clear information on the clinic’s management policy about whether their IUS will be removed or not. They will need to know if they have to use alternative methods of contraception and if they have to schedule their treatment to coincide with the first half of their menstrual cycle. It is not necessary to remove an IUS to perform local treatment.

There is no evidence an IUS has any effect on hrHPV persistence or progression. If there is a need to remove the IUS, inform the individual prior to treatment and give appropriate advice about the need for additional contraception.

2.3 Use of condoms

Condom use may promote hrHPV clearance and CIN1 regression in conservative management, but this depends on their consistent use for at least 3 months.

3. Menopause and use of hormone replacement therapy (HRT)

3.1 Postmenopausal individuals

The incidence of hrHPV positivity and abnormal cytology is low in postmenopausal individuals with previous normal results. The use of systemic HRT is not known to alter the risk of cervical disease. Colposcopic examination and adequacy can be improved by the use of topical HRT.

3.2 Postmenopausal bleeding

In an adequately screened individual, postmenopausal bleeding is not an indication to take a cervical screening sample. The investigation of abnormal bleeding after the menopause must include direct visual inspection of the cervix. A cervical sample is not an appropriate test for investigating postmenopausal bleeding.

All unexplained bleeding should be referred to a gynaecologist.

4. Hysterectomy

4.1 Individuals undergoing a hysterectomy for reasons other than cervical cancer

All patients in the cervical screening age range undergoing a hysterectomy for gynaecological reasons other than a diagnosis of cervical cancer should have a negative test result within the routine recall screening interval. Otherwise, a cervical sample should be taken as part of their preoperative investigations.

4.2 Individuals being considered for hysterectomy

All patients being considered for hysterectomy who have an abnormal test result or symptoms attributable to cervical cancer should have diagnostic colposcopy and an appropriate biopsy.

4.3 Hysterectomy as treatment for histologically proven CIN

Hysterectomy is a recognised treatment for histologically proven CIN if there are co-existing conditions appropriately treated by hysterectomy.

4.4 Hysterectomy as treatment for persistent abnormal endocervical cytology

Hysterectomy is an acceptable form of treatment in cases where abnormal endocervical cytology persists despite a prior excisional biopsy of adequate size. This is provided that all measures to exclude occult invasion have been applied.

4.5 Mapping vaginal abnormalities

Patients with CIN should have any abnormality on the vagina mapped by colposcopy or Lugol’s iodine at the time of surgery to ensure that any coexisting VaIN is recognised and excised at the time of the hysterectomy.

4.6 Correlation of histology with cytology

The histology of the resected uterus should be correlated with prior cervical cytology as part of the quality assurance process.

4.7 Follow up after hysterectomy

After hysterectomy, follow up is advised as outlined in chapter 4.