When the NHS letter inviting women for their smear test drops through the letterbox every five years, it’s not exactly a moment for celebration.
For many, the intimate test – offered to those aged 25 to 64 – may well be only a mildly discomforting experience, but one they feel is necessary. After all, the tests are thought to prevent 5,000 deaths from cervical cancer every year.
But for others – perhaps menopausal women whose tissues have thinned, those with conditions such as endometriosis where scar tissue may lie near the cervix, as well as victims of sexual violence – the fear of the smear is very real.
In fact, according to the NHS, nearly a third of those eligible, around 4.6 million women, have missed their latest test.
The most common reason is embarrassment, according to a 2022 survey of 3,000 women by the Department of Health And Social Care (42 per cent gave this explanation). A further 28 per cent cited fear of it being painful.
Now it’s hoped that this figure will drop as NHS England begins sending out DIY self-sampling kits in the coming months to women who are six months overdue for a test or who have never attended.
A self-sample test is less invasive than an in-person test, which involves the vaginal walls being held open with a speculum. Instead, the home kits contain a long, soft swab – similar to a long cotton bud – along with instructions, a test tube to place the swab in and a discreet pre-paid envelope to post it back to a lab.
Like a smear test done by a clinician, the DIY test does not look for cancer itself, but instead checks for the human papillomavirus (HPV), which may lead to cancer over time.
However, unlike traditional tests, where the nurse takes a sample of cells from the actual cervix (the opening of the womb, which can be anywhere between 3in to 6in deep inside), women taking the home tests will not need to be as precise, simply using the swab to take a sample from the walls of the vagina.
For many, the intimate test – offered to those aged 25 to 64 – may well be only a mildly discomforting experience, but one they feel is necessary
The most common reason among those who have missed their last smear test is embarrassment at 42 per cent, while a further 28 per cent cited fear of it being painful
Dr Sangeeta Khinder, a consultant gynaecologist at The Whittington Hospital and London Gynaecology clinic, explains: ‘Home HPV tests don’t need to sample directly from the cervix because HPV is shed from cervical cells into the vaginal canal.
‘And modern molecular testing is now sensitive enough to detect the virus from less invasive vaginal samples.’
The NHS cervical screening programme used to involve collecting cells from the cervix and ‘smearing’ them on a glass plate to study for pre-cancerous changes – hence the name.
But today, those samples are placed into a tube of liquid. If the cervical cells collected show signs of HPV infection, they are then examined for early signs of abnormal changes that could develop into cancer.
‘That second step is important because not all HPV infections lead to cancer,’ says Dr Khinder. ‘Identifying cell changes helps us distinguish between transient infections and those that are progressing toward disease.’
Accordingly, if the new home test detects HPV, women will then be called for a follow-up test, in which a cell sample is collected in the traditional way.
However, the hope is the new kits will spare many women this step, encouraging them to keep up to date with screening.
‘For some women, traditional cervical screening can be uncomfortable or painful,’ says Dr Khinder. ‘This is particularly true in conditions such as endometriosis, vaginismus or significant pelvic pain disorders, where the tissues are more sensitive.
‘Vaginal dryness, common after the menopause, can contribute. Not having had children can sometimes make it feel more uncomfortable, as the vagina may be tighter, but this varies between individuals. Anxiety and prior negative experiences can also amplify discomfort.’
The tests – both clinical and DIY – look for 14 strains of HPV which cause almost all cervical cancers, a disease that kills around 700 women a year.
Results from the home kits will arrive in two to three weeks and are said to be reliable.
Crucially, research has shown it’s an effective way of reaching those who would not otherwise attend screening.
‘The decision to send out these kits follows strong evidence from two major trials which demonstrated the potential to boost cervical screening uptake by up to 400,000 women per year in England,’ says Sophie Brooks, health information manager at Cancer Research UK, which helped fund one of the trials. ‘Many face barriers which mean they might not attend a clinician- based cervical screening – embarrassment, fear of pain, cultural sensitivities or maybe just difficulty in fitting in the appointments around day-to-day life.
While the new NHS tests are free, private self-sampling tests have been available for a while
‘Evidence shows that self-sampling can help reduce some of these barriers and help them take part in a life-saving programme that works for them. We’re really excited about it.’
Dr Khinder emphasises that screening is designed to be repeated – ‘not a one-off test’.
‘No screening test is perfect,’ she says. ‘HPV testing is highly sensitive for detecting the strains most strongly linked to cervical cancer, but it doesn’t pick up every possible case.
‘The key point is that when detected early through screening, outcomes are excellent, which is why participation in these programmes is so important.’
Early-stage cervical cancer can often be treated very effectively with surgery, sometimes preserving fertility. Chemotherapy or radiotherapy may be needed when the disease is more advanced.
Cervical screening is still necessary, even for women who have been vaccinated against HPV.
The first HPV vaccine in the UK was rolled out for girls aged 12 to 13 in 2008 and extended to boys in 2019. Adults aged 25 to 45 can access the vaccine through private clinics for around £200 per dose, with two to three required.
‘The HPV vaccination – depending on when people had it – protects against strains 6 and 11, which are most responsible for genital warts,’ says Helen Hyndman, a nurse at gynaecological charity The Eve Appeal. ‘But also strains 16 and 18, which are responsible for around 70 per cent of cervical cancers.
‘If you’ve had the vaccine more recently [since 2012] you will also be protected against seven of the high-risk strains of HPV. But that still leaves several that you’re not protected against, which is why we test for all 14.’
While the new NHS tests are free, private self-sampling tests have been available for some time. Writer Leah Hardy, 62, a married mother-of-two from north London, has used them for ten years.
‘I have always found conventional smear tests inconvenient, undignified and painful,’ she says.
‘It used to be agonising, probably because I have endometriosis with internal scarring. So the moment self-sampling became available, I used them instead.
‘I pay around £50 from my local chemist and, frankly, I have no idea why any woman would opt for the awful rigmarole of a speculum when you can use a wand as slim as a Covid swab in the privacy of your own home.’
Leah adds: ‘I’ve heard women say they wouldn’t use a home test because they’re scared of “getting it wrong” or because they’d “need a mirror” to see their cervix. But you don’t actually need to touch the cervix.
‘The one downside is that NHS GPs refuse to accept the results of private tests, so still nag you about going in for screening. It’s hopelessly out-of-date thinking.’
Dr Khinder says it’s not that GPs dismiss such private tests outright, but that NHS screening follows a specific, quality-assured pathway. ‘NHS cervical screening isn’t just the test – it’s an entire safety system,’ she says.
‘Every sample is processed in accredited labs, results are quality-checked, and patients are automatically recalled and followed up if needed.
‘Even if the result of a private test is accurate, it may not meet the same standards of documentation, traceability, and automatic recall. This means the NHS can’t rely on it, so patients are often asked to repeat the test within the screening programme.’
