Frequently asked questions for health professionals

How the CervicalCheck programme operates
Cervical screening for women who present with the following situations
Cervical screening in relation to pregnancy, breastfeeding and miscarriage
Processing of smear tests
Management of results
Referral to colposcopy
HPV testing following treatment at colposcopy
Additional information

How the CervicalCheck programme operates:

How does CervicalCheck invite women to be part of the programme?
When will a woman be called back after her first CervicalCheck smear test?
Informed consent of women
Women attending gynaecology services

Cervical screening for women who present with the following:

A woman has presented with an invitation letter and is in one of the following categories; is a virgin, has an intellectual disability, has had a hysterectomy, or is post natal. Is it appropriate to screen at this time and what do I need to do in this instance?
Should women who have sex with women have a smear test?
A woman has presented with a letter inviting her for a free smear test. She has had a total hysterectomy, what do I do?
I don’t know if the woman has a cervix post hysterectomy, what should I do?
A woman has requested a smear test but is under the care of a colposopy clinic, what should I do?
My patient is HIV positive and needs annual cytology, what do I do?

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Cervical screening in relation to pregnancy, breastfeeding and miscarriage:

A woman is pregnant and has received a CervicalCheck invitation letter, what should I do?
Can abnormal smear tests affect pregnancy? Does taking a smear test in pregnancy cause miscarriage?
A woman has had a miscarriage and has received a letter of invitation, when should I take the smear test?
Should I take a smear test on women who are post natal?
A woman is still breastfeeding, is it appropriate to take a smear test?

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Processing of smear tests:

I need to take a clinically indicated smear test, what do I do?
Do I need to take a smear test before inserting an IUD?
Why do I need to include the Personal Public Service Number (PPS No.)?
What is the CSP ID and do I need to record it on the form?
How early will CervicalCheck accept a repeat smear test for processing?
How long before an expiry date should the vials be used?
Why do I have to wait three months to repeat a sample that was expired/ inadequate?
Will women get a reminder for a repeat smear test following an abnormal result?
If a woman has a smear test at 57, 58 or 59 years (and has not had a previous Programme smear test) – will she be re-called?
I submitted a vial that was expired; I cannot understand why this smear test cannot be processed?
I submitted a sample that was expired; I cannot understand why this smear test cannot be processed?
What is abnormal follow-up (failsafe)?

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Management of results:

Why is there a recommendation for ‘refer to colposcopy’ when the result is negative?
There is a comment on the report stating that the smear test pattern is predominantly parabasal, what does this mean?
There is a comment regarding endometrial cells seen in a negative smear test, what is the significance of this?
Why is there a recommendation for ‘refer to gynaecology’ on this result when the result is negative?
Should I check the result and management recommendations on the result forms?
The smear test report shows TZ cells absent but the woman has still received a normal result with normal re-call – why is this?

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Referral to colposcopy:

What must a GP do when referring a woman to colposcopy?

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HPV testing following treatment at colposcopy

What is HPV?
How common is HPV infection?
How do women become infected with the virus?
What is the immune response to HPV?
Can HPV infection be treated?
Why are we using HPV testing following colposcopy treatment?
How is the test done?
Can a HPV test be performed in primary care through the CervicalCheck programme?
How will HPV testing affect women?
Smear test schedule
Evidence based papers and further reading

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Additional information:

Does cervical cancer run in the family?
Is there evidence regarding the benefits of screening for woman aged under 25 years?

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How does CervicalCheck invite women to be part of the programme?

CervicalCheck operates an organised call, re-call system of invitation, in line with best international practice. This ensures an effective and efficient population approach to screening that maximises target population coverage.

CervicalCheck has developed a register (list) of eligible women nationwide aged 25 to 60 through up-to-date information received from the Department of Social Protection, from self-registration and colposcopy details. Every woman on the register has been allocated a CSP ID. Over each three year screening round, CervicalCheck will send an invitation letter by post to eligible women on this list who have never had a CervicalCheck smear test inviting them for their free smear test.

In addition to call and re-call letters of invitation, direct programme entry by smeartakers of eligible women who have not yet had a CervicalCheck smear test has been introduced. Smeartakers can facilitate a smear test for these new eligible women without the woman having a letter of invitation during the normal course of a consultation or by recruiting the woman directly. A woman's eligibility can be checked online under the 'Check Woman's Eligibility' tab in this section.

Eligible women must be normally resident and have a postal address in the Republic of Ireland.

A woman must sign the Cervical Cytology Form to take part in the programme and avail of a free CervicalCheck smear test. The Cervical Cytology Form has an information sheet attached to it explaining the smear test process and why consent is needed. The information sheet is available in Polish, Arabic, Chinese (Mandarin), French, German, Irish, Latvian, Lithuanian, Romanian, Russian and Spanish. All translated information sheets are available to view and download in the 'Useful forms and downloads' section of this site.

The smeartaker should check a woman's date of birth (DOB) before taking the smear test to ensure the sample is for the correct woman
Smeartakers are responsible for giving women their results
Smeartakers are responsible for making referrals as advised by the laboratory

When will a woman be called back after her first CervicalCheck smear test?

Women who join the Programme, regardless of age, will need to have two negative smear test results; three years apart before they move onto a five yearly re-call. Women aged 25 to 44 will be invited for a free smear test every three years and following two consecutive no abnormality detected smear test results women aged 45 to 60 will be invited every five years.

If a woman or her smeartaker is unsure about eligibility for a CervicalCheck smear test, they can check online under the 'Check Woman's Eligibility' tab on the left hand side of this page or contact CervicalCheck on Freephone 1800 45 45 55 for advice.

Informed consent of women

A woman's consent, by signature or by witnessed mark, is required to participate in CervicalCheck. Only the woman herself may provide consent. Consent to participate can never be given by a third party.

The Information Sheet for Women (cover sheet of the Cervical Cytology form) should be provided to every woman who attends for a smear test. It explains to a woman what her consent means within the cervical screening programme.

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What about women attending gynaecology services?

CervicalCheck is based in the primary care setting. Women are encouraged to attend a smeartaker – doctor or nurse - in the community.
However, some women who have not previously participated in the Programme and are attending public gynaecology services may have a smear test taken here. The cytology report goes to the gynaecology clinic. Any follow-up recommendations need to be followed up by the clinic where the test was taken. This includes giving the woman her result.

A CervicalCheck smear test may be taken in gynaecology clinics on eligible women in the following circumstances:

• Women whose Smeartaker has experienced technical difficulties in taking a smear test
• Women with suspected endocervical disease
• Women at risk of default from participation in the Programme
• Women within the CervicalCheck programme who require a repeat smear test following an abnormal smear test taken at the gynaecology clinic.

Taking a smear test outside the woman’s screening recommendations will result in a change in her screening cycle therefore delaying her from availing of her free cervical smear test in primary care.

Generally, women will not attend gynaecology clinics over a long period of time and following a normal result, they should be encouraged to return to a Smeartaker in the primary care setting for their regular CervicalCheck smear tests.

What about private patients?

CervicalCheck offers a free service to women in the primary care setting and in publicly-funded hospitals. Smear tests taken in the context of a private consultation are not included and will need to secure cytology laboratory services outside of CervicalCheck.

A woman has presented with an invitation letter and is in one of the following categories; is a virgin, has an intellectual disabled, has had a hysterectomy, or is post natal. Is it appropriate to screen at this time and what do I need to do in this instance?

Every woman who receives an invitation letter may not be sexually active. If she has never been sexually active, then the research evidence shows that the woman’s chance of developing cervical cancer is very low indeed. In these circumstances, a woman might choose to decline the invitation for cervical screening on this occasion. If a woman is not currently sexually active but has had partners in the past, it is recommended that she continues screening. Women with intellectual disability should be considered on a case by case basis and the consent process also needs to be considered. You may contact the programme office to discuss further and request an 'opt-off' form if appropriate or click on link to download form - Opt-off Form

Should women who have sex with women have a smear test?

Yes. Cervical screening recommendations do not differ for women who have sex with women. They may contract HPV through their own previous sexual behaviour with men. In addition, HPV can be transmitted through lesbian sex by a female partner who has had previous heterosexual sex. Modes of transmission are commonly understood to include vaginal penetration with fingers and skin to skin contact. HPV may also be transmitted through the use of sex toys.

A woman has presented with a letter inviting her for a free smear test. She has had a total hysterectomy, what do I do?

CervicalCheck does not determine a woman’s post hysterectomy screening needs. The responsibility lies with the clinically responsible doctor as to whether the woman requires screening. Some women who have had hysterectomy, do still require screening. Consideration should be given to:

The type and reason for hysterectomy
The pre hysterectomy screening history
The management recommendation guidelines where appropriate (Cervical Cytology Management Recommendations Explanatory Guide)
If it is decided that a woman does not require a cervical smear test you can click on the Hysterectomy Data Collection Form to download. This form must be returned to the CervicalCheck programme office

I don’t know if the woman has a cervix post hysterectomy, what should I do?

The onus is on the smeartaker to obtain as much information about the procedure as possible. If this is difficult to find, a speculum examination will establish whether the cervix is still insitu. Advise the woman if a digital examination is going to be carried out.

A woman has requested a smear test but is under the care of a colposcopy clinic, what should I do?

If a woman presents for a smear test who has not yet been discharged from a colposcopy clinic, check the most recent correspondence from the clinic to determine if she is due a smear test. If a smear test is taken outside of the recommendations of the colposcopy clinic, it can have an impact on the treatment plan the colposcopy clinic has scheduled for a woman.

A woman is pregnant and has received a CervicalCheck invitation letter, what should I do?

Women with a negative screening history or women who have never been screened may defer their smear test until they are three months post-natal by calling CervicalCheck on 1800 45 45 55. If a previous test was abnormal and in the interim the woman becomes pregnant, then the repeat test should not be delayed but should be taken in mid-trimester, unless there is a clinical contraindication. If she has been referred to colposcopy she should attend her appointment.

Can abnormal smear tests affect pregnancy? Does taking a smear test in pregnancy cause miscarriage?

Pregnancy has no adverse effect in the progression of abnormal cells or the development of cervical cancer. Occasionally women may experience slight bleeding after having a smear test in pregnancy but a smear test will not make the woman more likely to miscarry.

A woman has had a miscarriage and has received a letter of invitation, when should I take the smear test?

The woman should wait three months before having a smear test.

Should I take a smear test on women who are post natal?

A woman does not require a screening smear test postnatally unless she is due to have a smear test within her call, re-call recommendations.

A woman is still breastfeeding, is it appropriate to take a smear test?

Once the woman is three months post natal and requires a smear test, proceed with the test and document clearly on the Cervical Cytology Form that the woman is breastfeeding.

I need to take a clinically indicated smear test, what do I do?

A smear test is a screening test, not a diagnostic test. If a woman presents with clinical concerns she should be referred to gynaecology for further assessment. The referral should not be delayed by either taking a smear test or awaiting results.

Do I need to take a smear test before inserting an IUD?

No. Unless the woman is due for a test within her call / re-call recommendations.

Why do I need to include the Personal Public Service Number (PPS No.)?

Primary Care Reimbursement Scheme (PCRS) requires a PPS No. for payment processing
It is a unique identifier which ensures that the correct result is matched with the right woman

In relation to the CSP ID No. – the more demographics that are on the form, the easier it will be to match the woman.

What is the CSP ID and do I need to record it on the form?

The CSP ID is a unique number assigned to women on the CervicalCheck database. It is used by the Programme Office as an additional identifier to match a cytology or colposcopy record to our screening database.

This number is found on correspondence issued from the programme in relation to a woman. It is also provided on the online eligibility check.

Please note that it will only be present on a cytology result if the number is recorded on the request form and will always be labelled as the CSP ID. It is not mandatory to record it on the request form but where it is available it should be provided.

How early will CervicalCheck accept a repeat smear test for processing?

Never less than three months for an unsatisfactory/inadequate
Never less than five months for a six month repeat
Never less than 10 months for an annual repeat smear test

The Programme laboratories return samples taken in less than three months to the smeartaker. These samples will not be processed.

How long before an expiry date should the vials be used?

The vials should be within 10 days of the expiry date to allow for transit and processing issues.

Why do I have to wait three months to repeat a sample that was expired/inadequate?

Taking a smear test before three months can result in a sub-optimal sample as it may take this length of time for the cells to regenerate on the cervix. The 'European Guidelines for Quality Assurance in Cervical Cancer Screening' states in section 6.3.1 that 'the cervical epithelium needs time to regenerate after cytology. Repeat cytology should not be performed less than three months after a previous pap smear'. The NCSS 'Guidelines for Quality Assurance in Cervical Screening' states in section 4.8.1 that 'there must be a minimum of three months between any two smear tests'. Samples taken before the three months has lapsed will not be processed. You will be notified by CervicalCheck that the smear test was 'repeated too soon', with a recommendation to repeat in three months.

Will women get a reminder for a repeat smear test following an abnormal result?

The result letter advises a woman when she is due a repeat smear test and CervicalCheck does not send a separate letter of invitation. Failsafe reminders will activate if the woman’s smear test/result is not received within two months of the recommended repeat time.

If a woman has a smear test at 57, 58 or 59 years (and has not had a previous Programme smear test) – will she be re-called?

Yes. If the woman is new to CervicalCheck, she requires two negative smear test results three years apart, regardless of age.

I submitted a vial that was expired; I cannot understand why this smear test cannot be processed?

The expiry date on the vial is determined by the manufacturer. In order for this test to be valid under FDA rules the vial must be in date. Legally the result could be queried on an expired vial.

I submitted a sample that was expired; I cannot understand why this smear test cannot be processed?

Section 4.1 Part (e) of the contract: to provide smear test samples only to the designated lab within five working days of conducting the smear test
The test will not be processed if either the vial or sample has expired

What is abnormal follow-up (failsafe)?

Failsafe is a written communication sent by CervicalCheck to the woman and to the doctor with clinical responsibility in the primary care setting when the woman does not attend for:

Her recommended smear test (following an ‘inadequate’ or ‘not normal’ result)
Her colposcopy referral
Her post colposcopy cervical smear tests

Failure to complete and return the failsafe results in inaccurate information being stored on the woman's file.

Doctors who receive an Abnormal Follow-up Form for a woman from the programme may respond online using the Abnormal follow-up facility on this website.

Why is there a recommendation for ‘refer to colposcopy’ when the result is negative?

If the smeartaker details a suspicious cervix on the cytology form, the laboratories are instructed to make the recommendation to refer to colposcopy. Clinical suspicion will always override a smear test as it is a screening test with unavoidable false negative/positive results. Smeartakers should not wait for a result before making a referral to gynaecology if there is clinical suspicion.

There is a comment on the report stating that the smear test pattern is predominantly parabasal, what does this mean?

Parabasal cells are immature squamous cells seen on the cervix in the absence of oestrogen. They are often seen in post menopausal or post natal women or in those who are taking a progesterone only pill. It is not a cytological abnormality.

There is a comment regarding endometrial cells seen in a negative smear test, what is the significance of this?

Bethesda requires the laboratory to note the presence of normal looking endometrial cells in an otherwise negative smear test in women over 40 years as there is a very small chance of this indicating endometrial adenocarcinoma. It should be interpreted clinically based on the woman’s menstrual history and examination.

Why is there a recommendation for ‘refer to gynaecology’ on this result when the result is negative?

If the Cervical Cytology Form details abnormal bleeding the laboratory is instructed to make the recommendation to refer for gynaecological assessment (clinical correlation is suggested).

Should I check the result and management recommendations on the result forms?

Yes, it is recommended to check that the text reads correctly on the result and that the management recommendation is correct for your patient’s history.

The smear test report shows TZ cells absent but the woman has still received a normal result with normal re-call – why is this?

An absence of TZ cells does not affect re-call in an adequate/negative smear test
TZ cells are not required to deem a smear test as adequate
If a negative result is given, normal re-call stands
Evidence of TZ sampling is considered to be a measure of competency
It is reassuring to see this evidence and in training our trainees are expected to reach an 80 per cent TZ sampling standard, captured in an audit of a minimum of 30 adequate smear test results
It is more difficult to sample the TZ in post menopausal women
Smear test reports using Bethesda comment on TZ cells

What must a GP do when referring a woman to colposcopy?

When referring to colposcopy, the GP must:

Use a Colposcopy Referral Form
Include the smear test report with the referral
Clearly document any clinical findings

What is HPV?

HPV is a DNA virus that infects skin or mucosal cells. It is thought to infect three quarters of women of reproductive age. There are more than 100 known HPV genotypes, at least 13 of which cause cancers. These are known as oncogenic or high risk genotypes.

Oncogenic HPV types cause cancers of the cervix, anogenital cancers and some cancers of the head and neck. The two most common of these (genotypes 16 and 18) cause approximately 70 per cent of all cervical cancers. HPV types 6 and 11 cause genital warts, a common benign condition which does not require increased screening.

How common is HPV infection?

HPV infections are very common with up to 80 per cent of the population likely to be infected. In the vast majority of cases there are no symptoms and the infection resolves sponanteously, usually within eighteen months.

How do women become infected with the virus?

HPV is acquired during sexual activity via skin to skin contact. Infection can result from sex between men and women as well as same sex partners. Infection can persist for many years without symptoms and it is not possible to know when the infection occurred. In addition some HPV infections can be reactivated spontaneously following many years.

What is the immune response to HPV?

Women acquire immunity through local immune systems, only a minority of women develop serum antibodies after natural infection. The degree of protection and duration of immunity after natural infection are not known. Re-infections with the same genotype are thought to occur. HPV infection persists longer in immunosuppressed individuals. Cigarette smoking is known to reduce the immune respose to HPV infection.

Can HPV infection be treated?

At present there is no effective treatment for HPV infection but the immune system clears most infections.

Why are we using HPV testing following colposcopy treatment?

HPV testing is designed to improve the early detection of women who may need repeat treatment as well as avoiding unnecessary testing for women at low risk of recurrence. The traditional follow up of treated women invloves annual cytology screening for 10 years before they return to routine screening. The addition of HPV testing will help many women avoid these repeated tests.

How is the test done?

HPV testing is performed on the cytology sample taken in colposcopy. After the cytology slides have been prepared the residual material is used to test for high risk HPV.

Can a HPV test be performed in primary care through the CervicalCheck programme?

No, it is not possible to order a HPV test in the primary care setting through CervicalCheck at this time.

HPV testing is being implemented in the colposcopy setting for women who have been treated for precancerous abnormalities.

How will HPV testing affect women?

Women will be given information about the HPV test, yet we recognise that HPV testing may cause anxiety in some women and some may seek more information from health professionals. The benefits of HPV testing, including reducing the number of smear tests, should be highlighted.

Schedule of smear tests

Previous schedule of smear tests for women

Previous schedule of smear tests for women diagram

New schedule (tests at colposcopy clinic)

New schedule (tests at colposcopy clinic) diagram

Evidence based papers and further reading

Evidence based papers and further reading - references can be downloaded by clicking on the links below:

Castellsagué X. (2008) Natural history and epidemiology of HPV infection and cervical cancer. Gynecol Oncol. 2008 Sep;110(3 Suppl 2): Unit of Infections and Cancer, Institut Català d'Oncologia, IDIBELL, CIBER-ESP. S4-7xcastellsague@iconcologia.net

Cuschieri KS, Cubie HA. (2005) The role of human papillomavirus testing in cervical screening. J Clin Virol. 2005 Mar;32 Suppl 1:S34-42.

Jones J, Saleem A, Rai N, Shylasree TS, Ashman S, Gregory K, Powell N, Tristram A, Fiander A, Hibbitts S. (2011) Human Papillomavirus genotype testing combined with cytology as a 'test of cure' post treatment: the importance of a persistent viral infection. J Clin Virol. 2011 Oct;52(2):88-92. Epub 2011 Aug 9.

Matsumoto K, Oki A, Furuta R, Maeda H, Yasugi T, Takatsuka N, Hirai Y, Mitsuhashi A, Fujii T, Iwasaka T,et al. (2010) Tobacco smoking and regression of low-grade cervical abnormalities. Cancer Sci 2010;101:2065–2073.

MCCaffrey K, Waller J, Nazroo J, Wardle J, (2006). Social and Psychological impact of HPV testing in Cervical Screening: A qualitative study. Sex transm infect 2006; 82(2): 169-74.

McIntyre-Seltman, K., Castle, P., Guido, R., Schiffman, M., Wheeler, C. (2005): Smoking is a Risk Factor for Cervical Intraepithelial Neoplasia Grade 3 among Oncogenic Human Papillomavirus DNA–Positive Women with Equivocal or Mildly Abnormal Cytology. Cancer Epidemiology Biomarkers & Prevention Vol. 14, 1165-1170.

Mesher D, Szarewski A, Cadman L, Cubie H, Kitchener H, Luesley D, Menon U, Hulman G, Desai M, Ho L, Terry G, Williams A, Sasieni P, Cuzick J. (2010): Long-term follow-up of cervical disease in women screened by cytology and HPV testing: results from the HART study. Br J Cancer. 2010 Apr 27;102(9):1405-10. Epub 2010 Mar 30.

My patient is HIV positive and needs annual cytology, what do I do?

(CervicalCheck Cervical Cytology Form)

Does cervical cancer run in the family?

No. Daughters and other female relatives of women with abnormal smear tests, pre-cancerous cells (CIN) or cervical cancer do not have an increased risk of abnormal smear tests, pre-cancerous cells or cervical cancer.

Is there evidence regarding the benefits of screening for woman aged under 25 years?

See the latest evidence under section ‘Evidence papers and further reading’ – Effectiveness of cervical screening with age. This summarises the work done for the UK Advisory Committee on Cervical Screening and is the most up-to-date evidence base as to why the population programme does not screen women below the age of 25.

However, if a woman under the age of 25 has had a previous abnormal result and she is within the follow-up period, CervicalCheck will process the smear test and manage the woman within the CervicalCheck. Payment will not be processed to the smeartaker.