Colposcopy is a procedure that allows a physician to take a closer look at a woman's cervix and vagina using a special instrument called a colposcope. It is used to check for precancerous or abnormal areas. The colposcope can magnify the area between 10 and 40 times; some devices also can take photographs.
Description
A colposcopy is performed in a physician's office and is similar to a regular gynecologic exam. An instrument called a speculum is used to hold the vagina open, and the gynecologist looks at the cervix and vagina through the colposcope instead simply by eye, as in a routine examination.
The colposcope is placed outside the patient's body and never touches the skin. The cervix and vagina are swabbed with dilute acetic acid (vinegar). The solution highlights abnormal areas by turning them white (instead of a normal pink color). Abnormal areas can also be identified by looking for a characteristic pattern made by abnormal blood vessels.
If any abnormal areas are seen, the doctor will take a biopsy of the tissue, a common procedure that takes about 15 minutes. Several samples might be taken, depending on the size of the abnormal area. A biopsy may cause temporary discomfort and cramping, which usually go away within a few minutes. If the abnormal area appears to extend inside the cervical canal, a scraping of the canal may be done. The biopsy results are usually available within a week.
If the tissue sample indicates abnormal growth (dysplasia) or precancer, and if the entire abnormal area can be seen, the doctor can destroy the tissue using one of several procedures, including ones that use high heat (diathermy), extreme cold (cryosurgery), or lasers. Another procedure, called a loop electrosurgical excision (LEEP), uses low-voltage high-frequency radio waves to excise tissue. If any of the abnormal tissue is within the cervical canal, a cone biopsy (removal of a conical section of the cervix for inspection) will be needed.
Who Performs the Procedure and Where Is It Performed?
Colposcopy may be performed by a gynecologist or other qualified health care provider in an outpatient setting. A gynecologist specializes in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics. In cases of sexual assault, a nurse practitioner or registered nurse may perform the procedure. If a biopsy is performed, a pathologist examines the tissue samples under a powerful microscope in the laboratory and sends the results to the health care provider who, in turn, informs the patient of the results.
Questions to Ask the Doctor
Why is colposcopy recommended in my case?
Will a biopsy be performed?
How long will the procedure take?
When will I find out the results?
What will happen if the results are positive for cancer or another abnormality?
Definition
Colposcopy is a procedure that allows a physician to examine a woman's cervix and vagina using a special microscope called a colposcope. It is used to check for precancerous or abnormal areas.
Purpose
Colposcopy is used to identify or rule out the existence of any precancerous conditions in the cervical tissue. If a Pap test shows abnormal cell growth, colposcopy is usually the first follow-up test performed. The physician will attempt to find the area that produced the abnormal cells and remove it for further study (biopsy) and diagnosis.
Colposcopy may also be performed if the cervix looks abnormal during a routine examination. It may be suggested for women with genital warts and for diethylstilbestrol (DES) daughters (women whose mothers took the anti-miscarriage drug DES when pregnant with them). Colposcopy is used in the emergency department to examine victims of sexual assault and abuse and document any physical evidence of vaginal injury.
Demographics
It is estimated that 30–44% of women fail to follow-up with colposcopy after an abnormal Pap test. Minority women, teenagers, and those of low socioeconomic status are at a greater risk of this.
Description
Colposcopy is usually performed in a physician's office and is similar to a regular gynecologic exam. An instrument called a speculum is inserted to hold the vagina open, and the gynecologist looks at the cervix and vagina using a colposcope, a low-power microscope designed to magnify the cervix 10–40 times its normal size. Most colposcopes are connected to a video monitor that displays the area of interest. Photographs are taken during the examination to document abnormal areas.
The colposcope is placed outside the patient's body and never touches the skin. The cervix and vagina are swabbed with dilute acetic acid (vinegar). The solution highlights abnormal areas by turning them white (instead of a normal pink color). Abnormal areas can also be identified by looking for a characteristic pattern made by abnormal blood vessels.
If any abnormal areas are seen, the doctor will take a biopsy of the tissue, a common procedure that takes about 15 minutes. Several samples might be taken, depending on the size of the abnormal area. A biopsy may cause temporary discomfort and cramping, which usually go away within a few minutes. If the abnormal area appears to extend inside the cervical canal, a scraping of the canal may also be done. The biopsy results are usually available within a week.
If the tissue sample indicates abnormal growth (dysplasia) or is precancerous, and if the entire abnormal area can be seen, the doctor can destroy the tissue using one of several procedures, including ones that use high heat (diathermy), extreme cold (cryosurgery), or lasers. Another procedure, called a loop electrosurgical excision (LEEP), uses low-voltage, high-frequency radio waves to excise tissue. If any of the abnormal tissue is within the cervical canal, a cone biopsy (removal of a conical section of the cervix for inspection) will be needed.
Diagnosis/Preparation
Women who are pregnant, or who suspect that they are pregnant, must tell their doctor before the procedure begins. Pregnant women may undergo colposcopy if they have an abnormal Pap test; special precautions, however, must be taken during biopsy of the cervix.
Patients should be instructed not to douche, use tampons, or have sexual intercourse for 24 hours before colposcopy. Patients should empty their bladder and bowels before colposcopy for comfort. Colposcopy does not require any anesthetic medication because pain is minimal. If a biopsy is done, there may be mild cramps or a sharp pinching when the tissue is removed. To lessen this pain, the doctor may recommend ibuprofen (Motrin) taken the night before and the morning of the procedure (no later than 30 minutes before the appointment). Patients who are pregnant or allergic to aspirin or ibuprofen can instead take acetaminophen (Tylenol).
Aftercare
If a biopsy was done, there may be a dark vaginal discharge afterwards. After the sample is removed, the doctor applies Monsel's solution to the area to stop the bleeding. When this mixes with blood, it creates a black fluid that looks like coffee grounds. This fluid may be present for a couple of days after the procedure. It is also normal to have some spotting after colposcopy. Pain-relieving medication can be taken to lessen any postprocedural cramping.
Patients should not use tampons, douche, or have sex for at least a week after the procedure (or until the doctor says it is safe) because of the risk of infection.
Risks
Patients may have bleeding or infection after biopsy. Bleeding is usually controlled with a topical medication prescribed by the physician or health care provider. If colposcopy is performed on a pregnant patient, there is a risk of premature labor.
A patient should call her doctor right away if she notices any of the following symptoms:
heavy vaginal bleeding (more than one sanitary pad an hour)
If visual inspection shows that the surface of the cervix is smooth and pink, this is considered normal. Areas that look abnormal may actually be normal variations; a biopsy will indicate whether the tissue is normal or abnormal.
Abnormal conditions that can be detected using colposcopy and biopsy include precancerous tissue changes (cervical dysplasia), cancer, and cervical warts caused by human papilloma virus.
Morbidity and Mortality Rates
Complications associated with colposcopy are extremely rare. There is a risk that the procedure will miss precancerous or cancerous tissues and thus prolong treatment until the cancer has become advanced. Of the 12,800 women who are diagnosed in the United States each year with cervical cancer, approximately 37.5% will die as a result of the disease.
Alternatives
While the Pap test is an effective screening test for abnormal cell growth of the cervix, it is an inadequate diagnostic alternative to colposcopy because of the potential for false negative results (10–50%). In some instances, a repeat Pap test may be recommended before performing colposcopy (e.g., in the case of inflammation or no previous abnormal Pap test).
Resources
Books
Ryan, Kenneth J., Ross S. Berkowitz, and Robert L. Barbieri. Kistner's Gynecology, 7th ed. St. Louis: Mosby, 1999.
Periodicals
McKee, M. Diane, Joseph Lurio, Paul Marantz, William Burton, and Michael Mulvihill. "Barriers to Follow-up of Abnormal Papanicolaou Smears in an Urban Community Health Center." Archives of Family Medicine 8 (March/April 1999): 129–34.
Organizations
American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. http://www.acog.org.
American Society for Colposcopy and Cervical Pathology. 20 W. Washington St., Ste. #1, Hagerstown, MD 21740. (301) 733-3640. http://www.asccp.org.
Association of Women's Health, Obstetric, and Neonatal Nurses. 2000 L St., NW, Ste. 740, Washington, DC 20036. (800) 673-8499. http://www.awhonn.org.
DES Action USA. 610 16th St., Ste. 301, Oakland, CA 94612. (510) 465-4011. http://www.desaction.org.
Society of Gynecologic Oncologists. 401 North Michigan Ave., Chicago, IL 60611. (312) 644-6610. http://www.sgo.org.
Other
"Colposcopy (Position Paper)." American Academy of FamilyPhysicians, [cited March 11, 2003]. http://www.aafp.org/x6665.xml.
None, unless a biopsy is performed at the same time (see below).
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Other names
None.
Purpose
To evaluate the cervical tissue following an abnormal Pap smear.
Routinely to monitor women who are at increased risk of reproductive system cancers, such as women whose mothers took DES (diethylstilbestrol) during pregnancy.
How it works
The colposcope, a specially lit microscope on a stand, allows the doctor to look directly at the abnormal tissue of the cervix. Sometimes a biopsy is done at the same time.
Preparation
You remove all clothing from the waist down and don a hospital gown.
Test procedure
You lie on your back on the examination table with your feet in the stirrups.
The doctor will insert a speculum into your vagina (see the description of a pelvic exam) and may perform a Pap smear before using the colposcope, which is positioned about a foot from your body.
If a biopsy is indicated, the doctor will remove a sample of cervical tissue (see the description of a cervical biopsy).
After the test
The speculum is removed, and you are free to dress and return to normal activities, or follow the postbiopsy restrictions if you had a combined procedure.
Factors affecting results
Creams or other obstructions in the vaginal area.
Interpretation
Direct visualization may determine if there is abnormal tissue.
Advantages
It's relatively noninvasive.
It allows physician to view directly the tissue in question.
Disadvantages
It does not allow for laboratory analysis of the tissue unless a biopsy is performed.
The next step
If the results of the colposcopic exam are normal, the test is considered conclusive, but you may be scheduled for Pap tests at closer intervals than persons with normal Pap test results.
If your doctor notices any abnormalities, a cervical biopsy may be done.
In this diagram, the canal of the cervix (or endocervix) is circled at the base of the womb. The vaginal portion of the cervix projects free into the vagina. The transformation zone, at the opening of the cervix into the vagina, is the area where most abnormal cell changes occur
Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix and the tissues of the vagina and vulva. Many premalignant lesions and malignant lesions in these areas have discernible characteristics which can be detected through the examination. It is done using a colposcope, which provides an enlarged view of the areas, allowing the colposcopist to visually distinguish normal from abnormal appearing tissue and take directed biopsies for further pathological examination. The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early and treating them. The procedure was developed in 1925 by the German physician Hans Hinselmann.
A specialized colposcope equipped with a camera is used in examining and collecting evidence for victims of rape and sexual assault.
Most women undergo a colposcopic examination to further investigate a cytological abnormality on their pap smears. Other indications for a woman to have a colposcopy include:
an abnormal appearance of the cervix as noted by a physician.
Many physicians base their current evaluation and treatment decisions on the report "Guidelines for the Management of Cytological Abnormalities and Cervical Cancer Precursors", created by the American Society for Colposcopy and Cervical Pathology, during a September 2001 conference.[1]
The procedure
Colposcope
During the initial evaluation, a medical history is obtained, including gravidity (number of prior pregnancies), parity (number of prior deliveries), last menstrual period, contraception use, prior abnormal pap smear results, allergies, significant past medical history, other medications, prior cervical procedures, and smoking history. In some cases, a pregnancy test may be performed before the procedure. The procedure is fully described to the patient, questions are asked and answered, and she then signs a consent form.
A colposcope is used to identify visible clues suggestive of abnormal tissue. It functions as a lighted binocular microscope to magnify the view of the cervix, vagina, and vulvar surface. Low power (2× to 6×) may be used to obtain a general impression of the surface architecture. Medium (8× to 15×) and high (15× to 25×) powers are utilized to evaluate the vagina and cervix. The higher powers are often necessary to identify certain vascular patterns that may indicate the presence of more advanced precancerous or cancerous lesions. Various light filters are available to highlight different aspects of the surface of the cervix. Acetic acid solution and iodine solution (Lugol's or Schiller's) are applied to the surface to improve visualization of abnormal areas.
Colposcopy is performed with the woman lying on her back, legs in stirrups, and buttocks at the lower edge of the table (a position known as the dorsallithotomy position). A speculum is placed in the vagina after the vulva is examined for any suspicious lesions.
Three percent acetic acid is applied to the cervix using cotton swabs. The transformation zone is a critical area on the cervix where many precancerous and cancerous lesions most often arise. The ability to see the transformation zone and the entire extent of any lesion visualized determines whether an adequate colposcopic examination is attainable.
Areas of the cervix which turn white after the application of acetic acid or have an abnormal vascular pattern are often considered for biopsy. If no lesions are visible, an iodine solution may be applied to the cervix to help highlight areas of abnormality.
After a complete examination, the colposcopist determines the areas with the highest degree of visible abnormality and may obtain biopsies from these areas using a long biopsy instrument. Some doctors consider anesthesia unnecessary, however, many colposcopists now recommend and use a topical anesthetic such as lidocaine or a cervical block to diminish patient discomfort, particularly if many biopsy samples are taken.
Following any biopsies, an endocervical curettage (ECC) is often done. The ECC utilizes a long straight curette to scrape the inside of the cervical canal. The ECC should never be done on a pregnant woman. Monsel's solution is applied with large cotton swabs to the surface of the cervix to control bleeding. This solution looks like mustard and becomes black in color when exposed to blood. After the procedure this material will be expelled naturally: women can expect to have a thin coffee-ground like discharge for up to several days after the procedure.
Complications
Significant complications from a colposcopy are not common, but may include bleeding, infection at the biopsy site or endometrium, and failure to identify the lesion. Monsel's solution and silver nitrate interfere with interpretation of biopsy specimen, so these substances should not be applied until all biopsies have been taken. Most patients experience some degree of pain during the curettage, and almost all experience pain during the biopsy.
Adequate follow-up is critical to the success of this procedure. Human Papilloma Virus (HPV) is a common infection and the underlying cause for most cervical dysplasia. Women should be counseled on the benefits of safe sex for reducing their risks of contracting and spreading the HPV virus.[2] One study suggests that prostaglandin in semen may fuel the growth of cervical and uterine tumours and that affected women may benefit from the use of condoms.[3][4]
Smoking predisposes women to developing cervical abnormalities. A smoking cessation program should be part of the treatment plan for women who smoke.
Without proper treatment, minor abnormalities may develop into cancerous lesions. Various treatments exist for significant lesions, most commonly cryotherapy, loop electrical excision procedure (LEEP), and laser ablation.
Future technologies
Colposcopy is the "gold standard" tool in the United States for diagnosing cervical abnormalities after an abnormal pap smear. The procedure requires many resources and can be expensive to perform, making it a less-than-ideal screening tool.
Newer visualization techniques on the horizon utilize broad-band light (e.g., direct visualization, speculoscopy, cervicography, and colposcopy) and electronic detection methods (e.g., Polarprobe and in-vivo Spectroscopy). These techniques are less expensive and can be performed with significantly less training. At this point, these newer techniques have not been validated by large-scale trials and are not in general use.
