Cervical screening trouble shooting

• Get the woman to lie flat. If the headrest of the couch is elevated it can cause the pelvis to become titled and make the cervix less visible.
• Elevate the pelvis. Ask the woman to place her fisted hands under the gluteal area.
• Use the largest/longest speculum that is comfortable for the woman. Often the cervix is not visible because the speculum is too short. Always consider the woman's size, parity and degree of relaxation when choosing a speculum.
• Reposition the speculum. It is important to angle the speculum towards the woman’s coccyx. It is helpful to allow a little time after passing the speculum to allow the woman to relax. Do not open the speculum until it is fully inserted. Opening and closing the speculum, rocking it from side to side and changing the angle of the insertion may help to bring the cervix into view.
• The cervix may be obscured by flaccid vaginal walls. If using a wider longer speculum does not hold back the vaginal wall the following procedure can be helpful.
  1. Cut a disposable rubber/latex glove 1cm from the tip of the thumb digit.
  2. Pull the open end of the thumb digit over the closed speculum.
  3. Pass the speculum with the remainder of the disposable glove hanging out of the vagina as the speculum is opened.
  4. The glove digit will hold back the flaccid vaginal walls and allow the cervix to come into view.
• If a woman has a high BMI or has poor range of movement of their hips e.g M.S or arthritis, the left lateral position may be more comfortable and help with visualising the cervix.

Important: If the cervix is present but cannot be visualised, do not take a screening test. Ask for help from a colleague and if cervix is still not visualised refer to colposcopy for screening.

Creating a comfortable and supportive cervical screening experience is important to ensure success.

Cervical screening can be a routine procedure for some women, while for others, it can be a source of anxiety or distress. Healthcare professionals play a key role in ensuring that every woman feels safe, respected, and in control during her appointment.

Step 1: Preparing the environment.

• Ensure the room is warm, quiet, and fully equipped with all necessary supplies.
• Consider using soft lighting and soothing background music to create a calming atmosphere.
• Provide privacy and reassurance that the appointment is confidential.

Step 2: Welcoming and building rapport.

• Greet the patient warmly, express gratitude for their attendance, and check how they’re feeling.
• Use inclusive, jargon-free language to enhance understanding and comfort.
• Share your experience as a sample taker to subtly reassure any anxieties.
• Offer multilingual resources where needed.

Step 3: Managing anxiety and distress.

• Explain the procedure clearly before starting—knowing what to expect can ease fears.
• Encourage a support person (friend or family) to attend if desired.
• Offer a translator if English is not the woman’s first language.
• Teach relaxation techniques, such as deep breathing, to help manage anxiety.
• Speak gently and reassuringly, keeping the conversation light and supportive.
• Validate their emotions—let them know it’s okay to feel anxious, and they’re in control.

Additional support & next steps

• If a woman’s anxiety is severe, consider a mild relaxant (at the discretion of the CRD).
• In cases where screening is not possible due to anxiety or trauma, refer to a colposcopy unit/SATU unit for specialist care.
• After the screening, check in with the patient and provide any necessary follow-up support.

Resource available: Trauma informed care clinical update

Eligibility depends on the type of hysterectomy:

• Sub-total hysterectomy: cervix or cervical remnants remain
• Total hysterectomy: entire cervix removed

Click here to read more about different types of hysterectomies.

Documenting a sub-total hysterectomy on the screening form.

If a woman has had a sub-total hysterectomy, her cervix is still intact, she should be screened as per the general population.  This is documented on the screening form by:

• Ticking the sample site as cervix.
• Ticking the sub-total hysterectomy box

Correct documentation of a sub total hysterectomy

• Confirms you have viewed the cervix in its entirety.
• Ensures the woman gets the correct recall as per the general population.

Screening requirements following a Total Hysterectomy:

If the total hysterectomy is for

• Non-CIN or non-cancer pathology reasons:
  • No further cervical screening is needed. 
  • The treating clinician or the GP should complete the Hysterectomy Data Collection Form and advise the woman she requires no further screening.
  • Click here to access the Hysterectomy Data Collection Form.
• Treatment of CIN, or unexpected CIN is noted on histology,
  • The woman should be referred to colposcopy by the Gynaecologist who performed the hysterectomy for follow-up.
  • If the Gynaecologists omits to refer the woman to colposcopy this can be done by her GP, requesting the woman be seen for post hysterectomy screening.
  • The treating colposcopist will determine the follow-up and discharge instructions.
• Total hysterectomy but her histology is unknown,
  • Such as in cases where there is no available documentation detailing her procedure and outcome.
  • She should undergo one further screening test documenting sample site as a vault and  Total hysterectomy ticked on the form. 
  • If this HPV test is negative, she can be discharged from screening, provided her doctor signs and returns the Hysterectomy Data Collection Form to CervicalCheck to confirm that the woman requires no further screening.
  • If this HPV test is positive, she will be recalled as per the general population. 

Click here to read the full Guidance Note on screening after hysterectomy.

Documenting a Total hysterectomy on the screening form

If a woman has had a Total hysterectomy her cervix has been removed, her screening requirements will depend on the reason for her total hysterectomy.
This is documented on the screening form by:

• Ticking the sample site as Vault.
• Ticking the Total hysterectomy box

Completion of the Hysterectomy Data Collection Form.

• CervicalCheck does not have access to a woman’s medical history or records.
• CervicalCheck does not automatically remove women from the Cervical Screening Register after hysterectomy, as the Programme does not have the relevant information.
• A woman can only be removed from the register by herself, or by her GP completing the Hysterectomy Data Collection Form.
• When a negative vault screening result is received CervicalCheck will automatically send a  Hysterectomy Data Collection Form  to the sample taker for completion. 

A woman will no longer receive invitation letters once the doctor returns the Hysterectomy Data Collection Form, confirming a total hysterectomy and no further need for screening (provided there is no history of CIN treatment or unexpected CIN on histology).

Once the form is processed and actioned on the register, the woman will be notified by post that she will no longer be invited for screening. 

Psychological well-being is a crucial consideration in cervical screening. Studies indicate that two in every five women will experience some form of abuse in their lifetime (click here to access CSO sexual violence report 2022). For those who have experienced sexual trauma, a cervical screening appointment can be distressing.

Healthcare professionals must be able to recognise the signs of trauma and integrate the principles of Trauma-Informed Care into their practice to ensure a compassionate and supportive experience.

Learn more: Trauma-Informed Care in Cervical Screening

To deepen your understanding, watch this webinar on Trauma-Informed Care and Cervical Screening.

CervicalCheck have added a clinical update on Trauma informed care in cervical screening  to our suite of clinical updates on Trauma informed care clinical update.

CervicalCheck have developed a quick guide to understanding best practice in Trauma informed care, please click here to access Trauma Informed Care Tip of the month

Specialist support in Sexual Assault Treatment

Trained SATU staff are skilled in providing trauma-informed cervical screening, ensuring a more comfortable and patient-centred experience for survivors of sexual violence.

Four of the six Sexual Assault Units (SATUs) in Ireland currently offer a specialist cervical screening service for people who have experienced sexual violence:

SATUs Providing Cervical Screening Services:
 ✅ Donegal SATU
 ✅ Dublin (Rotunda) SATU
 ✅ Galway SATU
 ✅ Waterford SATU

Future expansion of cervical screening clinics: Work is underway to extend this service to additional SATUs across Ireland.

Please refer to our webinar on Trauma Informed Care

Women who have undergone Female Genital Mutilation (FGM) may experience significant barriers to cervical screening, including:

• Language barriers.
• Cultural stigma surrounding cervical disease.
• Fear, anxiety, or trauma associated with medical examinations.

For some, the physical challenges of screening can be profound. If FGM has resulted in only a small opening for urination, it may be difficult to:
 ✅ Visualise the cervix.
 ✅ Take an adequate sample of cells.
 ✅ Conduct the procedure without causing pain.

🔗 For more information and specialist services, click here

Cervical appearances and influencing factors.

The appearance of the cervix varies due to several factors, including:

• Age – hormonal changes over time affect cervical texture and position.
• Parity – vaginal childbirth alters the size and shape of the cervix.
• Hormonal status – pregnancy, menopause, and contraceptive use influence cervical appearance.
• Infections – certain infections can cause inflammation, discharge, or unusual textures.
• Previous surgeries – procedures such as LLETZ, cone biopsy, or hysterectomy can leave scars or alter cervical structure.

Key considerations for sample takers:

By understanding these variations, sample takers can confidently assess the cervix and ensure high-quality sample collection.

By understanding these variations, sample takers can confidently assess the cervix and ensure high-quality sample collection.

Cervical ectropion occurs when glandular cells from the endocervical canal migrate to the outer cervix (ectocervix). This natural process, also known as eversion, is influenced by hormonal changes and cervical growth.

Best practices for taking a sample with cervical ectropion present:

If a wide ectropion is present, use a wide sweeping motion around the everted squamocolumnar junction to ensure a complete sample.

The cervical sample should contain:
✅ Squamous cells.
✅ Endocervical cells
✅ Cells from the transformation zone.

Recognising normal cervical changes helps ensure high-quality sample collection and reduces unnecessary concerns for patients.

Nabothian follicles are small, mucus-filled cysts on the surface of the cervix.

They are normal and benign findings during cervical screening.

The stratified squamous epithelium of the ectocervix grows over the columnar epithelium of the endocervix. This blocks the cervical crypts, trapping mucus inside, leading to cyst formation.

Appearance

Often seen on the cervix at different stages of ripeness—ranging from small, translucent bumps to larger, opaque cysts. 

🔍Key takeaway

Nabothian follicles do not indicate disease and typically require no treatment unless symptomatic.

Two main types of cervical polyps:

1. Sessile: broad-based and attached directly to the cervix.
2. Pedunculated: Attached by a thin stalk, allowing movement.

Screening considerations

If a polyp is present, the cervical screening test should proceed as usual.
Ensure the sample includes cells from the transformation zone.
Symptomatic polyps may require removal and referral to an ambulatory gynaecology unit for further evaluation.

If the polyp is causing symptoms such as:

• Unexplained Bleeding
• Persistent discharge
• Discomfort 

To ensure you take a high quality sample the cervix must be fully visualised, so excess mucus must be removed. It is important when removing the mucus that the cells on the cervix are not disturbed prior to sampling. Very gently place the non bristle end of the cervex brush into the mucus at the outer edge of the cervix. Rotate the brush into the mucus and the mucus will lift off.