Colposcopy

WHY Colposcopy is done

If a Pap smear is abnormal, the next step is usually colposcopy. A colposcopy is a microscopic examination of the cervix done in the office. While a Pap smear randomly samples cells, colposcopy allows the gynecologist to inspect the surface of the cervix under magnification so that the area where the abnormality is can be visualized and biopsied.

WHAT you should do to prepare

No special preparation is needed.

WHAT to expect during the procedure

After you are brought to the examination room, you will be asked to undress from the waist down. A speculum is placed in the vagina and acetic acid (vinegar) is placed on the cervix to enhance visualization. This will feel cold and wet and smell like vinegar, but otherwise has no effects.The physician will then look at your cervix through a microscope. If any areas of concerns are detected, a tiny sample of tissue will be removed for analysis. Local anesthetic gel will be applied to your cervix prior to a biopsy.

Most women are aware of a momentary pinch or cramp, but some women feel nothing. Medication will then be applied to the cervix to prevent bleeding. The entire procedure takes about 10 minutes.

WHAT to expect after the procedure

Most women feel fine immediately after the procedure and can return to their daily routine. Some women experience cramping, but it is unusual for the cramping to be severe. Some bleeding is expected, but it is usually minimal. You may use a tampon or a pad. The medication applied to your cervix is called Monsels paste and looks like dark mustard or peanut butter. It may come out at a day or two after the procedure and is sometimes blood tinged or dark and crusty.

RESULTS

If a biopsy is not required, the results of the colposcopy will be discussed with you immediately after the procedure. If a biopsy is taken, results take approximately one week. Your doctor will call you as soon as results are received. If you have not heard in one week, please contact us.

Possible results are as follows:

1. Normal tissue
   • Frequently the cervical cells are normal which indicates that the cells reverted back to a normal growth pattern. Occasionally, abnormal cells are present, but are high up in the canal and beyond the view of the colposcope. Therefore a follow-up Pap smear is recommended. We will tell you when to schedule your next Pap smear.
2. HPV changes
   • Human Papilloma Virus is the virus that is responsible for almost all dysplasia and cervical cancers. Sometimes cellular changes indicate the presence of the virus, but there are no actual pre-cancerous cells.
   • CIN refers to Cervical Interepithelial Neoplasia and indicates a growth pattern that does not appear normal. There are 3 categories of CIN. They are:
     • CIN I (mild dysplasia or low grade squamous intraepithelial lesions)
     • CIN II (moderate dysplasia or high grade squamous intraepithelial lesions)
     • CIN III (severe dysplasia, or high grade squamous intraepithelial lesions, also known as carcinoma in situ)
3. Invasive Cancer (true cancer which as infiltrated surrounding tissue and has the ability to spread)

Treatment Options
Treatment is never based on a Pap smear alone. A colposcopy is required to determine the appropriate course of action. Treatment recommendations are then determined by the extent and severity of the dysplasia.

• Expectant Management (No treatment other than a repeat Pap)
  The most common outcome of a colposcopy is that you will have no precancerous cells or mild dysplasia and no treatment is required other than a follow-up Pap smear. Low-grade abnormalities, (CIN I) have minimal potential for progression to cancer and will almost always go away on their own. There is generally no need to treat CIN I unless it is persistent. In the event that CIN I is destined to progress to cancer, it is a progression that generally takes years, not months. The appropriate treatment of a CIN I, therefore, is repeat Pap smears at close intervals. If a Pap is persistently abnormal, repeat colposcopy is also required. Some women choose to treat a CIN I to relieve anxiety, or if follow-up is unlikely or inconvenient.
• Cryotherapy
  Cryotherapy is a technique in which the cervix is frozen using nitrous oxide or carbon dioxide. The frozen tissue (including the abnormal tissue), then dies and sloughs off.
  
  Cryotherapy was commonly done through the 1980s, but is now rarely done since the LEEP procedure is far superior. The downside to cryotherapy is that since tissue was not removed, it was impossible to know if all abnormal cells were treated. Patients also complain about the smelly, copious, watery discharge that lasted for up to two weeks. Recurrence rates from cryotherapy are higher than seen in other treatments. Some physicians still recommend cryotherapy for low-grade dysplasia.
• Laser Ablation
  Laser ablation had a short popular run in the late 1980s when physicians were trying to find an alternative to cryotherapy and new uses for laser. The advantage to laser ablation done under colposcopic guidance is that it is very precise in its ability to vaporize the abnormal area while not harming healthy tissue. The disadvantage is that it is very expensive, no tissue is obtained for analysis, the procedure is potentially dangerous, and it requires significant training. It is rarely done.
• Cone Biopsy (cold knife conization)
  Prior to the development of LEEP, cone biopsy was the treatment of choice for women with dysplasia. A cone biopsy is a surgical procedure requiring general anesthesia in which a cone shaped segment of cervix is removed using a scalpel (hence "cold knife"). The major disadvantage to cone biopsy is the need for general anesthesia and the risk of complications such as bleeding, infection, and damage to the cervix, which might complicate future pregnancies. Currently, cold knife cones are only recommended in specific, rare situations.
• LEEP (loop electrosurgical excision procedure), also known as LLETZ (large loop excision of the transformation zone)
  LEEP is the treatment of choice for women with persistent mild dysplasia, moderate, or severe dysplasia. LEEP procedures are almost always done in the office using local anesthesia.

FAQ

How long does colposcopy take?
The procedure usually takes 10-15 minutes.

What if I am bleeding at the time of the procedure?
This procedure should be done when you are not menstruating. If you are having continuous bleeding or spotting (non-menstrual), check with your doctor about the best time to have your colposcopy.

What if I have a tendency to pass out?
Some women do get light headed or pass out during any gynecologic procedure. If this is the case, please be sure to EAT PRIOR TO YOUR ARRIVAL. Inform your doctor that you have a tendency to faint. If, during the procedure, you feel light headed, nauseated, or ill, tell your doctor immediately.

How did I get dysplasia?
Dysplasia is almost always the result of infection with a virus known as Human Papilloma Virus, or HPV. HPV is a sexually transmitted virus, which is why cervical cancer is considered to be a sexually transmitted disease.

Keep in mind that that an HPV exposure could have occurred years before dysplasia shows up and may have nothing to do with a current partner.

Almost all women with cancer have HPV, but most women with HPV never get dysplasia or cancer. HPV is extremely common; some studies show that it is present in the cervixes of almost 80% of sexually active women. There are over 100 subtypes of HPV, and some types are more likely to progress to cancer than other subtypes. It is increasingly common to check the HPV subtype of women with abnormal Pap smears to determine their risk of progression to a more serious condition. The vast majority of women with HPV don't get significant dysplasia or cancer.

High-risk HPV subtypes are more likely to progress than low risk groups. Cigarette smoking significantly increases the risk that women will have dysplasia in the presence of HPV. Breakdown products of cigarette smoke such as nicotine, have been found in cervical mucous, and are considered to be carcinogens.