Colposcopy

See Also

Indications

See Cervical Dysplasia
Decision rules are based on chance of finding CIN3 or worse with >=4% probability
Cervical Intraepithelial Neoplasia (CIN)
1. Persistent LSIL (or CIN 1)
2. HSIL (or CIN 2 or CIN 3)
ASCUS Pap Smears
1. Persistent ASC-US or HPV positive for high risk type (e.g. HPV 16 and 18)
2. ASC-H (cannot rule-out HGSIL)
Atypical Glandular Cells (AGC)
1. All subtypes except atypical endometrial cells
2. Endometrial Biopsy for atypical endometrial cells

Preparation
Patient

Consent
Questions
Ibuprofen 800 mg, 30 minutes before procedure

Exam
External

Bimanual
1. Uterus size and pain on palpation
2. Cervix position
3. Cervical Motion Tenderness (CMT)
Vulva
1. Obvious condyloma
2. Apply Acetic acid after cervical exam
3. Avoid acetic acid before performing Pap Smear

Approach
Low Risk Patients

Criteria
1. Atypical Squamous Cells of Undetermined Significance (ASC-US)
2. High Risk HPV that is not HPV 16 or HPV 18
3. Low Grade Squamous Intraepithelial Lesion (LSIL)
Colposcopy Interpretation
1. Normal without squamous metaplasia
  1. Endocervical sampling (ECC) in non-pregnant patients if squamocolumnar junction not fully visualized
  2. Follow-up in one year
2. Low Grade Colposcopy Findings
  1. Endocervical sampling (ECC) in non-pregnant patients if squamocolumnar junction not fully visualized
  2. Obtain 2 targeted biopsies
3. High Grade Colposcopy Findings
  1. Endocervical sampling (ECC) in non-pregnant patients if squamocolumnar junction not fully visualized
  2. Obtain 2-4 targeted biopsies

Approach
High Risk Patients

Criteria
1. HPV 16 or HPV 18
2. Persistent high risk HPV
3. Persistent abnormal cytology
4. High Grade Squamous Intraepithelial Lesion (HSIL)
5. ASC-H
6. Atypical Glandular Cells of Undetermined Significance (AGUS Pap Smear)
Colposcopy Interpretation
1. Normal without squamous metaplasia
  1. Consider random biopsy at squamocolumnar junction (SCJ)
  2. Evaluate non-cervical sources (vulva, vagina)
  3. Endocervical sampling (ECC) in non-pregnant patients indications
    1. Squamocolumnar junction not fully visualized or
    2. ASC-H or HSIL or
    3. Age > 45 years AND HPV 16 or HPV 18
2. Low Grade Colposcopy Findings
  1. Endocervical sampling (ECC) in non-pregnant patients
  2. Obtain 2-4 targeted biopsies
3. High Grade Colposcopy Findings
  1. Follow Very High Risk Management as below

Approach
Very High Risk Patients

Criteria
1. Age >25 years old AND
2. HPV 16, HPV 18, HSIL or CIN 3 risk >60%
Management (same as for high grade Colposcopy Findings in a high risk patient)
1. Consider Immediate LEEP if age > 25 years OR
2. Obtain 2-4 targeted biopsies
3. Consider random biopsy at squamocolumnar junction (SCJ) at unsampled quadrants
4. Endocervical sampling (ECC) in non-pregnant patients

Exam
Cervical (without colposcope)

Warmed Speculum
Vaginal stint indications
1. Obese patient
2. Multiparous patients
Cervical Exam without microscopy
1. Signs of obvious inflammation
2. Gonorrhea and Chlamydia testing
3. Pap Smear with HPV Testing

Exam
Cervical (Under Colposcopy)

Apply Acetic Acid (5%) with cotton swab every 5 min
Scan entire Cervix at low power (5x)
Observe Vascular patterns at high magnification
1. Consider use of the green filter
Consider Lugol's Solution to clarify lesion sites
1. Sharply outlines potential biopsy sites
Mentally Map areas or obtain pictures
Is Colposcopy Adequate?
1. Is Entire Squamocolumnar Junction (SCJ) visualized?
  1. Consider Kogan endocervical speculum
2. Any visualized lesions seen in entirety
3. Endocervical curettage (ECC) is negative
4. Colposcopy and biopsies agree with Pap Smear

Technique
Biopsies

Endocervical Curettage (ECC)
1. Contraindicated in pregnancy
2. Efficacy: Conflicting results
  1. One study found CIN3 cases only by ECC in 11% of cases
    1. Pretorius (2011) J Low Genit Tract Dis 15(3): 180-8 [PubMed]
  2. Another study found CIN2+ cases only by ECC in just 1% of 13000+ cases
    1. Gage (2010) Am J Obstet Gynecol 203(5): 481 [PubMed]
3. Indications
  1. Unsatisfactory Colposcopy after low grade CIN finding
  2. Evaluation of high grade lesion
  3. Evaluation of AGCUS (also requires Endometrial Biopsy or other evaluation)
4. Technique
  1. Perform last after other biopsies are taken
  2. Consider topical benzocaine on swabs
    1. Leave in endocervical canal for 30 seconds
  3. Kevorkian curette rotated 360 degrees twice
Cervical Punch Biopsy
1. Obtain 3 mm samples at multiple sites
  1. Choose sites with acetowhite changes and other findings suggestive of CIN (including low grade changes)
  2. Do not limit biopsies to only high grade changes as this may miss more than 40% of CIN2+ lesions
    1. Multiple biopsy sites is key to adequate sampling
    2. Massad (2003) Gynecol Oncol 89(3): 424-8 [PubMed]
  3. Avoid biopsies of normal appearing Cervix as these have low yield of abnormalities (3.8%)
    1. Pretorius (2011) J Low Genit Tract Dis 15(3): 180-8 [PubMed]
  4. Random sampling (e.g. 4 quadrant sampling) is not recommended
    1. Pretorius (2004) Am J Obstet Gynecol 191(2): 430-4 [PubMed]
2. Start with inferior sites and work upwards
  1. Less blood interference from other biopsy sites
3. Not necessary to include normal margins in biopsy
4. Do not use Monsel's until after all biopsies taken
Ectocervical Brush (experimental)
1. New stiff bristled brush designed for Colposcopy
2. More effective than cervical Punch Biopsy
  1. Brush correlation with loop excision: 76-79%
  2. Punch Biopsy correlation with loop excission: 53%
3. Significantly less pain than with Punch Biopsy
4. References
  1. Monk (2002) Obstet Gynecol 100:1276-84 [PubMed]

Technique
Coagulation of Bleeding

Monsel's Solution
1. Should be thickness of toothpaste
2. Swab out excess Monsel's and Bloody debris
Silver Nitrate
1. For isolated bleeding sites

Technique
Ending of Procedure

Observe vaginal walls while removing speculum
1. Use a dental mirror pre-heated in warm water
Patient rests supine for several minutes
Diagram exam
1. Document cervical os
2. Document Squamocolumnar junction (SCJ)
3. Document biopsy sites

Education
Post-Procedure instructions

No intercourse or tampons for 7 days
Return to clinic
1. Foul vaginal odor or discharge
2. Pelvic Pain
3. Fever
Follow-up for histology results in 2 weeks

Procedures

See Cervical Intraepithelial Neoplasia Procedures

Resources

(2019) ASCCP Guidelines
1. https://www.asccp.org/management-guidelines

References