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FOR most women, smear or Pap tests are an uncomfortable but necessary chore. More properly known as cervical cancer screening tests, they usually involve lying down with your legs apart while a doctor or nurse swabs some cells from the top of your vagina.

No one likes it, but it is not usually painful and quickly over with. If anything is wrong, a simple surgical procedure can remove the affected tissue before it develops into something more sinister. In the UK, most women between 25 and 64 are regularly offered tests and usually accept, however grudgingly, as cervical screening is seen as a no-brainer.

And yet, perhaps we should be putting a bit more thought into the whole approach. For those whose tests find abnormal cells, there are downsides to the follow-up procedure that removes part of the cervix: it can cause miscarriages and premature births, and a few say it has hurt their sex lives. To make matters worse, some women who don鈥檛 want the tests at all are getting pressured into having them, with this going far beyond the normal bounds of ethical practice.

鈥淲e are increasingly discovering that health screening can lead to overtreatment鈥�

The prevailing view is that any negatives are worth it if it saves your life. But abnormalities that show up on the screening tests usually go away by themselves. This fact is already leading UK doctors to debate whether some women would be better off with 鈥渨atchful waiting鈥�: not performing surgery, and repeating the test at a later date. Later this year they look set to restrict who is offered surgery.

Weighing the risks

Unlike most tumours, which result from random genetic mutations, cancer of the cervix is caused by a group of common sexually transmitted viruses called human papillomaviruses or HPV. In most women, the virus reproduces in the cervix for a while before the immune system manages to get rid of it. But in a minority, the virus never goes away and, after many years, the cells of the cervix begin multiplying out of control.

In a smear test, the cells brushed from the cervix are examined under a microscope. If they have abnormally large nuclei this suggests the virus is present. This can be confirmed with a biopsy, after which surgeons may remove a cone-shaped wedge of tissue about 1 or 2 centimetres long from the cervix.

The surgery was seen as very safe, but in the late 1970s concerns began to emerge that it was leaving women more prone to miscarriages and premature births. The cervix is the neck of the uterus, so it makes sense that removing part of it would leave it less able to keep the fetus inside. The latest research suggests the procedure raises the risk of miscarriage in the middle three months of pregnancy from , and the rate of premature birth from about . More controversially, some women claim the surgery has reduced their sexual enjoyment (see 鈥�A rare side effect?鈥�).

The overall risks are fairly small, though, and the sexual side effects remain disputed, so most people would probably judge these potential downsides worth it if the surgery removed cancerous cells. But it doesn鈥檛. In some cases, the infection would go away by itself. 鈥淭hat鈥檚 why doing no harm is very important, because this is not cancer: we are doing something to prevent cancer,鈥� says .

Doctors do already take this into account. Women with an abnormality classified as grade one 鈥� meaning less than a third of the cervix tissue鈥檚 thickness is affected 鈥� are usually advised to have a repeat check in a year. Those at grades two and three are usually recommended surgery.

But it now looks like that might be too hasty. Kyrgiou鈥檚 team that for most women with grade two abnormalities 鈥� in which up to two-thirds of the surface tissue is affected 鈥� the infection clears naturally, especially in women under 30.

, a gynaecologist at Lancashire Teaching Hospitals, UK, who is a member of the British Society for Colposcopy and Cervical Pathology, says the organisation will discuss its guidelines this year, so that women under 30 with grade two abnormalities may be offered watchful waiting instead of automatic surgery.

This potential change is motivated by an increasing discovery that health screening can lead to overtreatment: we are so keen to find and treat cancer that we do unnecessary surgery. Similar issues have emerged about prostate and breast cancer screening for certain groups.

Unlike with those cancers, though, surgery on the cervix is treated as such a trivial matter that screening is painted as a must. Adverts urging women to have their smear tests imply it should be done without question or even that .

While screening does save several thousand lives a year, the odds of it saving any one person鈥檚 life are only about . But that鈥檚 not the impression you get from those who provide screening tests. In the UK, women who ignore their invitations may be asked every time they visit the doctor to book a smear or even have one done on the spot. It鈥檚 partly because doctors are given targets for how many of their patients should be screened, says , a doctor in Glasgow, UK.

It can go beyond badgering. On chat forums such as , some women say their doctor has refused to let them have a prescription for the contraceptive pill without a smear, or has even threatened to deregister them unless they comply. 鈥淥ne woman who contacted me was pushed into a test that she didn鈥檛 want to have done and felt as though she had been raped,鈥� says McCartney.

鈥淎dverts urging women to have their smear tests imply it should be done without question鈥�

She points out that some women may have personal reasons for not wanting a smear test, such as those who have been sexually assaulted or have never engaged in sexual activity. 鈥淭here are women who are virgins or who find it painful and distressing, or decide they鈥檙e at such low risk the distress isn鈥檛 worth it.鈥�

No one is saying, of course, we should stop offering screening, or that women should not take it up. 鈥淚t does save lives,鈥� says Robert Music from the charity Jo鈥檚 Cervical Cancer Trust. 鈥淚f we see great numbers attending screening as well as getting vaccinated against HPV, we could get close to eradication of cervical cancer in younger women.鈥�

Indeed, many women are glad to reduce their risk of cancer by accepting the test. 鈥淏ut if someone doesn鈥檛 want it she should not be forced or cajoled into it,鈥� says McCartney. 鈥淓very woman should be allowed to choose for herself.鈥�

This article appeared in print under the headline 鈥淭he truth about cervical tests鈥�