Whether your first smear test is looming or you’re dreading your three-yearly appointments, ‘smear fear’ can be a very real phenomenon. In fact, in a 2019 survey from Jo’s Cervical Cancer Trust of more than 2,000 women aged 25 to 35 it was revealed that 81 per cent felt embarrassed about going for a smear test, while 58 per cent were scared it would hurt - and of those who had put it off or avoided screening in the past, their main reasons were that they felt scared or vulnerable.
We get it - a smear test isn't going to be the highlight of anyone's day, and there are many factors involved in smear avoidance be it due to a dread of a cold speculum, shyness, lack of time or a previous bad experience, but anxiety needn’t be one of them. It's a life-saving appointment that everyone with a cervix should keep in their diary. In Cervical Cancer Prevention Week, we spoke to doctors to sort the facts from the fiction in terms of what to expect from a smear test, and how to deal should you be suffering from pre or post-appointment anxiety and what to expect if your smear is abnormal.
How smear tests work
Answered by Katy Clifford, Consultant Obstetrician and Gynaecologist, Imperial College Healthcare NHS Trust.
Why do we have a smear test?
The NHS cervical smear programme begins at 25 years old in England, and routine smears should be performed every three years until the age of 50, and then every five years after that until the age of 65.
The smear test is a method of obtaining cells from the cervix (neck of the womb) for analysis in the laboratory. It aims to pick up early cellular changes that can either be monitored until the smear returns to normal, or treated at early stage to prevent severe abnormalities or cervical cancer developing. [Please note the video below shows photos of a cervix, a cervix with abnormal cells and an image of a colposcopy appointment].
We now know that significant abnormalities of the cells are caused by high risk HPV ( human papilloma virus ) which is transmitted through sexual intercourse, but is very common. In most cases, the HPV infection is cleared by the body's immune system without causing significant harm but in some cases the HPV infection persists, and it is this group, who are at risk of severely abnormal smear or cervical cancer.
Nowadays all 12-13-year-old girls (and boys) should receive the vaccine against the two most important and virulent types of HPV (16 and 18), which account for 75 per cent of cases. This means that in the future there should be far fewer people having abnormal smears, with further reductions in cervical cancer. However as there is only around 75 per cent protection from the current vaccine (as other types of HPV apart from 16 and 18 can cause changes), you still need to have smears even if they have received the full vaccination course.
What happens in a smear test?
The smear test can be a little uncomfortable but is usually not painful. The whole episode usually takes one to two minutes only and there is no need to dread it!
Remember that the clinician taking the smear (either a doctor or nurse) will have undergone appropriate training and is usually very experienced. The majority of clinicians will have taken many, many smears in their professional life and so will be used to dealing with anxious people. They should be able to put anyone at ease before starting the examination and there is no need to be embarrassed. You should be offered the option of bringing along a chaperone if that helps to reassure you.
Before the test begins, the person is asked to undress from the waist down behind a screen and either put on a gown or have a sheet placed over her when lying on the couch. They will then be asked to bring up their knees towards their chest and flop open their legs. It is a good idea to take some slow, deep breaths to aid relaxation at this point.
These days, a clear plastic speculum is usually used instead of a metal speculum, which is more comfortable. If a metal speculum is used, it can be warmed with warm water which is helpful. There are different sizes of speculum (small, medium and long) and the most appropriate size should be chosen, for example a small speculum is most often used if you have not had children.
Lubricating jelly should be used with the speculum to ease insertion (although avoiding jelly right at the tip of the speculum). The most important element in terms of comfort is for the clinician to insert the speculum gently and slowly into the vagina, allowing you to keep your pelvic floor relaxed. Once fully inside the vagina, the speculum can be opened gently to allow visualisation of the cervix which usually gives rise to a stretchy feeling which can be a little uncomfortable but should not be painful.
Cells are obtained from the cervix by rotating the a brush through 360 degrees at the cervix, and this can be a bit uncomfortable as well. The cells from the brush are then transferred into a vial. It’s vital for a clinician to have a calm, gentle approach, explaining each step of the process, and it helps for the person to be as relaxed as possible. This is easier said than done I know!
The speculum is then gently withdrawn, and you should be offered a tissue to wipe up any extra jelly before getting dressed behind the screen. It’s not uncommon to have a little spotting or very light bleeding for a few hours after the smear, and this is not a cause for concern. You can resume normal activities, including sexual intercourse as soon as you wish.
What does an abnormal smear mean?
The most likely result is that the smear is normal and the next test can be done at the routine time interval.
However, if laboratory analysis showed that the cells are mildly abnormal, then a subsequent test is automatically done on the same sample by the laboratory to test for high risk HPV. If the specimen is high risk HPV negative, then the mild abnormality is deemed not to be significant and the cervical cells will return to normal without the need for further investigation. The next smear should then be done at the routine time interval
If the HPV test is positive, or the cells are more significantly abnormal, then you will be advised to have a colposcopy, which is an outpatient examination usually performed in a hospital outpatient setting. It takes about ten minutes. During a colposcopy, the cervix is examined with a magnifying lens and painted with various solutions before a biopsy is taken.
Following this, advice will be given as to whether the cervix needs treatment (again, usually done as an outpatient), or the patient can be managed conservatively with follow up smears and/or repeat colposcopy if there a good chance that the cellular changes will resolve spontaneously. All colposcopies in the UK are performed by experienced colposcopists who will explain the process in detail, along with the possible outcomes.
If results return as 'abnormal', should I be worried?
Answered by Davina Deniszczyc, GP and Medical Director Of Nuffield Health
No. While it is important to follow up an abnormal result, the whole point of a smear is to pick up pre-cancerous changes. They are changes we can easily and simply treat before anything nasty occurs. Hence attending often means capturing risks and issues early. An abnormal result does not mean cancer.
What can I do to make the smear test more bearable?
Plan ahead so you’re not rushed. Take your time getting to the appointment so that you don't feel stressed when you arrive.
When you’re in the clinic, ask the doctor or nurse to explain each step to avoid any nasty surprises. I ask my patients to have their ankles wide apart and pop their hands under their bum to lift up their hips a bit - this means that I get a better view, so it's quicker, and there is less 'searching' using the speculum, which can be uncomfortable.
A small amount of lubricant can be used on the speculum by the doctor, which makes the whole process more comfortable. I ask my patients to take a deep breath in and breathe out as I insert the speculum, then to concentrate on deep breathing techniques. Focusing on breathing can take your mind off what's happening down below.
Specula come in different sizes, so ask the doctor which size they have used and you can request that size next time.
Is it normal to feel embarrassed?
Everyone feels embarrassed. Imagine being a doctor and having to go for your smear; most of the time we may even know the person who's doing it!
Let the doctor know if you do feel embarrassed. We do so many we can become desensitised, but we can amend our examination style if we know you’re feeling uneasy. If anything embarrassing does occur it won’t stick in the doctor’s mind - with the number of patients we see, by the end of the week we can't recall who it happened to.
I'm still a little taken aback when ladies strip in the middle of the room without prompting and jump onto the bed! There is no etiquette, but you can always ask for guidance throughout the appointment. Everyone is different, and don't think we are taking notes or comparing pubic hair grooming, underwear style and so on. This simply isn't on our radar!
What do I do if a smear is scheduled during my period?
We can't do a smear during a period as the blood interferes with the process. Simply reschedule!
Can you have sex before a smear test – should you use a condom if you do?
Dr Zoe Williams supporting Loose Women's #faceyoursmear campaign tells ITV: "It is best to refrain from sex altogether for 24 hours before a smear test, or there is an increased risk that the laboratory who receive the sample will not be able to process it. Using a condom will not help with this, in fact condoms and spermicides are even more likely to affect the quality of the sample. So one day of abstinence every three years is advised."
Still nervous about attending your smear test? Self-testing at thome is an option, but there are certainly pros and cons to consider .
If you’d like to find out more, read our fact sheet on how to spot the signs of HPV and cervical cancer and the misconceptions surrounding it .