Certain musculoskeletal disorders present in many older women can also make the pelvic examination and pap smear difficult. A woman with such a problem is often unable to lie in the usual supine position with legs in stirrups. The left lateral position has been described as a feasible alternative. Because of their higher costs and unproven benefit in reducing invasive disease, these techniques are not part of the standard of care for cervical cancer screening. Little has been written about the need to continue cytological screening in women who have had hysterectomies.
Many older women are often unsure of the type of hysterectomy they had subtotal or total.
The caregiver thus needs to determine whether or not a cervix is present. If the cervix is present, then the guidelines for women who have not undergone hysterectomy apply. ACOG states that the cost effectiveness of cytologic screening for vaginal neoplasia after removal of the cervix for benign disease has not been demonstrated. Finally, it is important to note that the pap smear is but one facet of the pelvic examination. Regardless of the number of pap smears ultimately obtained, periodic pelvic examinations will facilitate detection of remediable and often asymptomatic genito-urinary pathology.