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Can you be too old for a smear test?

I spend much of my time explaining to my patients that 'their' latest condition becomes more common with age. But cervical cancer is slightly different, and the good news is that while it may take a while, there does come a time when the risk drops.

Make no mistake - cervical cancer is a cancer, and it's a killer. But in many other respects it's different to other cancers. Firstly, it's almost invariably caused by a virus - in this case the human papillomavirus, or HPV. There are many strains of HPV, and only a few lead to cancer (others cause genital warts). HPV is so common that pretty much any woman who's ever had sex is at risk, even if her only ever partner is her husband.

How do you get cervical cancer?

Most women exposed to HPV fight it off with their own immune system. But in some women it lays in wait in the body. Years later it can cause abnormalities in the cells of the cervix which eventually turn to cancer. There's no way of knowing which women will get rid of it naturally, and in the early, pre-cancerous stages you won't know you have it unless you have a cervical screening test.

That's the bad news - one of the other main differences is good news. Before 'full-blown' cervical cancer develops, the cells on the surface of the cervix go through early, pre-cancerous changes. These range from 'low grade' to 'high grade' and can be picked up with cervical screening. It usually takes years for invasive cancer to develop from these early changes. And that means early changes found on cervical screening can almost always be treated and removed before they ever do serious harm. So basically, having regular cervical screening can actually stop you getting cancer.

What your screening results mean

Across the UK, women are invited for a cervical screening test every three years from the age of 25-49. Some early changes aren't cancerous or even pre-cancerous, but in the past there was no way to work out if they might progress to become cancerous. For that reason, every woman with an abnormal cervical screening result would be flagged for review - either with an early repeat screening (for borderline or low-grade cell changes) or by being referred for a colposcopy, to examine the cervix in more detail.

However, today laboratories check for high-risk strains of HPV, as well as for cell abnormalities. If no such strain of HPV is found, there is usually nothing to worry about. So the possibilities for your results are:

  • No abnormal cells and no high-risk HPV found - you'll be invited for screening again at the normal time (three years later if you're under 50, five years later if you're over 50).
  • No abnormal cells, but high-risk HPV found - you'll be invited back early for screening (after one year). The high-risk HPV will usually be gone by then, but if it's found three times in a row, you'll be referred for colposcopy.
  • Abnormal cells with borderline or low-grade cell changes but no high-risk HPV - you'll be invited for screening again at the normal time (three or five years later, depending on your age).
  • Abnormal cells with borderline or low-grade cell changes, with high-risk HPV - you'll usually be invited for colposcopy.
  • Abnormal with high-grade cell changes - you'll be invited for colposcopy, regardless of the HPV result.

The risk doesn't disappear at 50

Cervical cancer is often thought of as a young woman's disease. Just over one in 40 women in their late 20s have a high-grade abnormal result, compared to under one in 200 among women aged 50-64.

But while it is more common in younger women, the risk doesn't disappear when you reach 50. Cancers which do develop tend to do so more slowly, which is why women are only invited for screening every five years from the age of 50. And if you've had normal results until the age of 64, your risk is tiny, so you don't need to worry about cervical screening from then on. Until then, though, there's no room for complacency - women aged 50-64 are more likely to be diagnosed with advanced-stage cervical cancer than their younger counterparts.

As in so many other health areas, more mature women are leading the way where protecting themselves against cervical cancer is concerned. Latest figures show that a much higher proportion of 50- to 64-year-olds are taking up their screening invitations compared to 25- to 49-year-olds.

Worryingly, however, cervical screening rates are dropping in all age groups. Cervical screening coverage is at a 20-year low, and this is continuing to decline year on year. Of the 4.46 million women invited for screening in 2017-18, only 3.18 million were tested. And over the past two years, coverage has declined by more in the older age group (a 1.8% drop) compared to the younger age group, which has seen a 1.1% drop.

Maybe it's because your worried it will be more uncomfortable after the menopause? Vaginal dryness can make cervical screening (and sex) uncomfortable, but your doctor will be happy to prescribe topical cream for a few weeks before the cervical screening test to minimise any discomfort. Please remember - it's a small price to pay for peace of mind!

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