Colposcopy

Aka: Colposcopy, Colposcopy Protocol

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II. Indications

  1. See Cervical Dysplasia
  2. Decision rules are based on chance of finding CIN3 or worse with >=4% probability
  3. Cervical Intraepithelial Neoplasia (CIN)
    1. Persistent LSIL (or CIN 1)
    2. HSIL (or CIN 2 or CIN 3)
  4. 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)
  5. Atypical Glandular Cells (AGC)
    1. All subtypes except atypical endometrial cells
    2. Endometrial Biopsy for atypical endometrial cells

III. Preparation: Patient

  1. Consent
  2. Questions
  3. Ibuprofen 800 mg, 30 minutes before procedure

IV. Exam: External

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

V. Approach: Low Risk Patients

  1. 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)
  2. 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

VI. Approach: High Risk Patients

  1. 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)
  2. 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

VII. Approach: Very High Risk Patients

  1. Criteria
    1. Age >25 years old AND
    2. HPV 16, HPV 18, HSIL or CIN 3 risk >60%
  2. 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

VIII. Exam: Cervical (without colposcope)

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

IX. Exam: Cervical (Under Colposcopy)

  1. Apply Acetic Acid (5%) with cotton swab every 5 min
  2. Scan entire Cervix at low power (5x)
  3. Observe Vascular patterns at high magnification
    1. Consider use of the green filter
  4. Consider Lugol's Solution to clarify lesion sites
    1. Sharply outlines potential biopsy sites
  5. Mentally Map areas or obtain pictures
  6. 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

X. Technique: Biopsies

  1. 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
  2. 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
  3. 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]

XI. Technique: Coagulation of Bleeding

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

XII. Technique: Ending of Procedure

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

XIII. Education: Post-Procedure instructions

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

XIV. Procedures

  1. See Cervical Intraepithelial Neoplasia Procedures

XV. Resources

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

XVI. References

  1. Brotzman (1994) J Fam Pract 39:271-8 [PubMed]
  2. Coppleson (1993) Obstet Gynecol Clin North Am 20:83-110 [PubMed]
  3. Ferris (1991) J Fam Pract 33:506-15 [PubMed]
  4. Newkirk (1990) J Fam Pract 31:171-8 [PubMed]
  5. Wright (2003) Am J Obstet Gynecol 189:295-304 [PubMed]

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