Family doctor

Overview:

• A colposcopy is a detailed examined of the cervix by a specialist
• A colposcopy is usually necessary to identify the source of abnormal smears
• A colposcope is a small microscope inserted in the vagina to view the cervix
• A tissue sample is normally taken from the abnormal area and analysed
• Results are available within one week
• Mild abnormalities may be treated at a further appointment or left to see if they spontaneously resolve
• More serious abnormalities are treated at another appointment

What is a colposcopy?

An abnormal cervical smear indicates that there are abnormal cells on the surface of the cervical skin. The smear alone, however, is not sufficiently accurate to act on.

A more detailed examination of the cervix by colposcopy is necessary for persistent low grade abnormal smears, all high grade abnormal smears, any cervix that looks abnormal at the time of taking a smear, even if the smear result is normal, and any woman with abnormal symptoms such as bleeding after sex.

It is important to reassure women, that an abnormal smear in itself, is highly unlikely to signify invasive cancer. Colposcopy is needed to identify the location of any abnormal skin and to take specific samples (biopsies) of affected skin to be sent for laboratory examination (histology), to identify pre-cancerous changes, called cervical intraepithelial neoplasia (CIN). Colposcopy itself is NOT a treatment.

How is colposcopy performed?

Colposcopy is performed by a specialist who uses a small microscope (mounted on a movable stand) to focus on the surface of the cervix which is at the top of the vagina.

The woman is asked to attend when she is not bleeding and lies on a reclining chair or at the end of an examination couch with her legs apart and supported on foot rests. Her lower half is covered with a sheet.

A speculum is gently inserted in the same way as for a smear test. The specialist sits between the woman's feet and the colposcope and its light are directed onto the cervix. The colposcope remains outside the vagina but it can magnify the view of the cervix. A weak solution of acetic acid (similar to vinegar) is wiped onto the cervix and upper vagina. Abnormal areas of skin usually will become white and can be located. Often the specialist will then seek the patient's permission to take one or two small pinches of skin (biopsies) from the white coloured areas. These biopsies will be sent for detailed examination to accurately determine the extent of the abnormal cells.

The discomfort from the biopsy is brief and may feel like a sharp pinch. Afterwards the patient may have a small amount of vaginal spotting for a day or two. The colposcopy examination itself takes about 10 minutes, but extra time is needed to discuss matters before and afterwards.

What happens when the colposcopy results are available?

Results of the biopsies are usually available within a week and it is important the patient and specialist have a clear idea of how the result will be communicated and whether specific treatment is needed or not.

Low grade changes on smear with colposcopic biopsies confirming mild CIN1 or HPV can either be treated at a further appointment, or purposefully not treated. These minor abnormalities can spontaneously disappear in about 50% of women. Those that do not disappear will either remain unchanged or be a higher-grade abnormality. If the patient chooses not to be treated she should be seen in about 6 months for repeat colposcopy and smear to monitor any changes.

High-grade changes of CIN2 or CIN3 confirmed by colposcopic biopsies are generally treated at a further appointment.

Do cervical smears and colposcopy always agree?

In some instances what is seen at colposcopy does not match with the cervical smear report. This may be in a number of ways such as:

1. The colposcopy and biopsies show a higher or lower grade of CIN than the smear. Usually the biopsies are regarded as more accurate and used as the basis for treatment or not.

2. The colposcopy and biopsies may show CIN even when the cervical smear is normal. Again the biopsy results are taken as more accurate as it is known that smears can occasionally not detect CIN.

3. The colposcopy may show NO abnormal areas despite an abnormal smear. It may be decided to repeat the cervical smear and repeat the colposcopy in a month or two for further confirmation and to see if there is consistency in the findings.

4. The colposcopy views may be inadequate if the woman has a small or closed cervical canal (e.g. menopausal women). Abnormal cells may exist within these narrow canals and may not be visible to colposcopy, but the abnormal cells that are shed are picked up on the smear.

In these situations, a repeat colposcopy after a one-week course of oestrogen hormones may help widen the view into the canal. If this is not successful, then a cone biopsy may be suggested. This operation under anaesthesia involves taking a cone shaped section from the centre of the cervix so that part of the central canal is included. This cone of tissue (about the size of 1x2 cms) is sent for laboratory investigation (histology).

Summary

Colposcopy is NOT a treatment, but a means to more accurately assess the significance of an abnormal smear and to plan any treatment if necessary.

Understandably women will be anxious and worried about their smear result. To ensure the colposcopy procedure is as acceptable and comfortable as possible, it is important the patient and colposcopist have fully communicated beforehand and the patient is aware of what is going to happen.