What is colposcopy?
Worldwide, cervical cancer is the second most common female malignancy. The national cervical screening programmes have reduced both incidence and deaths from the disease. Colposcopy is used within this programme as a secondary tool.
Colposcopy is a procedure for examining the cervix, the vagina or vulva in order to try and detect abnormal cells. The cervix is the area of the genital tract most commonly examined with a colposcope, a specialised microscope that is used to magnify the view. A ‘white’ light is used for most of the examination, however a green light can also be used when trying to assess the vascular pattern. The magnification can be varied to allow for a more generalised examination and a much more detailed examination. Whilst the cervix is the area mainly examined by colposcopy, the vaginal walls and vulva are also examined as the primary indication if there is a lesion noted in these areas such as lichen sclerosus and precancerous changes of the vagina and vulva.
Main indications for colposcopy
Abnormal Pap smear results:
- Persistent low grade changes
- High grade change
- Presence of high risk HPV strain
- Atypical squamous cells
- Atypical glandular cells
Other indications for colposcopy
- Followup after treatment
- Suspicious looking cervical polyp
- Suspicious looking lesion of genital tract (mainly vagina and vulva)
- Documentation of sexual abuse
Preparation for colposcopy
Colposcopy is usually done without any anaesthesia, thus, unless otherwise advised, you will be able to eat and drink normally prior to the investigation. Some women will choose to use some simple analgesia the night before and a couple of hours beforehand. There is no evidence that this is beneficial for all. Although colposcopy is not a very invasive procedure, women not uncommonly report high levels of anxiety. This may be because they are awake for the procedure or concern that it may reveal evidence of cancer. You may be asked to sign a consent form. Whether you do or not you will have an ‘informed consent’ process where your doctor has explained why you are having the test, how it will be performed, possible risks and the plan for followup. If you think that you will be menstruating at the time of your colposcopy then reschedule the appointment. If you believe you may be pregnant then discuss this with your doctor. You should have had a recent Pap smear, but if you have not then the doctor may proceed to do one prior to the colposcopy. A bimanual pelvic examination will be performed prior to colposcopy if this has not already been done.
How colposcopy is done
You will be positioned on an examination couch or chair with your feet up and supported in stirrups. The doctor will sit with the colposcope in front of them. A speculum will be passed into the vagina and opened so that the cervix can be seen. The speculum is then locked into position so that it does not move. The doctor looks through the colposcope and will then apply a solution of 5% acetic acid (dilute vinegar) to the cervix. Abnormal cells will stain white. Generally, the more dense the white area becomes, the higher the grade of abnormality. Some women will feel a tingling sensation but this is not painful. Because the effects of the acetic acid are short, the doctor may need to apply more solution after about 5 minutes. The doctor will need to be able to examine the transformation zone of the cervix, the area right in the centre. Sometimes, in order to view this area, a special type of manipulator will be passed through the speculum, into the cervix and the cervix opened up. This is usually not painful and your doctor will tell you before doing this.
In some cases, an iodine solution needs to be applied to the cervix. Let the doctor know if you are allergic to iodine. The doctor will map out any abnormal areas of the cervix and record them as a drawing or a digital image. Areas of ‘acetowhite change’ or ‘iodine deficiency’ may represent abnormal cells. The doctor will change from a white light to a green light to examine the vascular architecture of the cervix. These areas will be biopsied and the tissue sent for histological analysis. Bleeding will usually occur from the site of the biopsy. This is controlled by the application of a coagulant.
In some cases the doctor will use a fine curette to obtain some cells from the endocervical area. This is called an endocervical biopsy.
The procedure is completed with removal of the speculum and you will be allowed to get dressed in private.
Following the colposcopy, the patient should wear a sanitary pad. Spotting and a light discharge may occur for 3-5 days.
Dark fluid-like material, sometimes green, or resembling coffee grounds, may be seen on the pad. The fluid is that used during the exam. Avoid sexual intercourse, vaginal medications or use of tampons for about a week to allow the cervix to heal and reduce the risk of infection.
In most cases you should be able to return to work later the following day. Make sure you have a followup appointment with your doctor to discuss the results of your investigations and the plans for further management if required. Tissue biopsy results are usually available within 2 weeks of the procedure.
The procedure is relatively safe. The most commonly occurring risks include bleeding (persistent, fresh red loss that does not settle), infection (presenting as an offensive vaginal discharge) and abdomino-pelvic pain. Inform your doctor should any of these occur.
Women who have an obvious abnormality at colposcopy, or who have a positive biopsy result, will proceed to treatment. The nature and timing of any recommended treatment will be discussed with you.
The purpose of colposcopy during pregnancy is to detect severe precancerous changes or cancer. Unless invasive cancer is identified, treatment is unacceptable. Lesions that do not appear severe in nature need not be biopsied. Endocervical biopsies are contraindicated in pregnancy. Serial Pap smears and colposcopy should be performed throughout pregnancy with biopsy of worsening lesions or with Pap smears indicating invasive disease. It is important that patients return for a colposcopy at least 6 weeks after delivery.
After the menopause
Because of hormonal changes, many postmenopausal women will have an unsatisfactory colposcopy. A colposcopy is considered unsatisfactory if the entire transformation zone cannot be visualized and if the distal end of a lesion extending into the endocervical canal cannot be visualized. In postmenopausal women, the former is often true. If this occurs your doctor may prescribe some local oestrogen treatment as this will often cause enough ectropion of the endocervical cells to result in a satisfactory examination.
Ectropion surrounded by dysplasia