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Home > Professional Reference > Colposcopy

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Colposcopy

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Colposcopy is the direct magnified inspection of the surface of a woman's genital area, including the cervix, vagina and vulva, using a light source and a binocular microscope - a colposcope. It is used to evaluate potentially cancerous areas, typically after an abnormal cervical smear. A biopsy of an abnormal area may be taken during the procedure. Colposcopy also can be used to detect inflammatory or infectious changes, harmless growths and assess traumatic injuries or gather evidence in cases of sexual assault.

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. More than 120,000 women are referred annually to colposcopy in the UK but currently about a quarter do not attend (DNA) their appointment.1

Indications for referral

Management of cervical smear results2

Result

Action
Negative
  • Investigate and manage incidental findings (e.g. infections).
  • Ensure that the patient is informed of the result.
  • Recall as appropriate for a negative result.
Inadequate
  • Repeat sample immediately after treating any infection or atrophy, preferably within 3 months.
  • Repeat sample as soon as convenient if technically inadequate.
  • If persistent (3 inadequate samples), advise assessment by colposcopy.2
Borderline
  • Borderline nuclear change in endocervical cells - refer for colposcopy.
  • Borderline nuclear change in squamous cells:
    • Treat any associated condition and repeat the screen at no more than 6 months (particularly important where there
      is an association with HPV).
      The majority of smears will return to normal by this stage.
    • Refer for colposcopy if there are 3 smears in a series reported as borderline nuclear change in squamous cells) without the woman being returned to routine recall, or 3 borderline or more severe results in a 10-year period.
    • 3 consecutive negative results, 6 months apart, are required before returning to routine recall.
    • Repeat sample in 3-6 months when the differential diagnosis is between benign/reactive changes and higher
      degrees of dyskaryosis or possible glandular neoplasia.
    • The laboratory may recommend a repeat screening in a shorter interval, or that gynaecological referral should be considered.
Mild dyskaryosis
  • Ideally, women should be referred for colposcopy after 1 mild dyskaryotic smear, but it remains acceptable to recommend a repeat test within 6 months - many will have returned to normal by this stage.2
  • Always refer for colposcopy after 2 tests reported as mild dyskaryosis without a return to routine recall.
  • Three consecutive negative results, 6 months apart, are required before returning to routine recall.
  • If a single mild dyskaryotic result is obtained after treatment for carcinoma in situ stage 2 or worse, refer for colposcopy.
  • If, in a 10-year period, there are 3 borderline or more severe results, refer to colposcopy.
Moderate dyskaryosis Refer for colposcopy.
Severe dyskaryosis Refer for colposcopy.

After a referral to colposcopy for a single mild dyskaryotic result, 60% of follow-up smears subsequently became negative. Treatment was only required in 19% of patients, with 11% prevalence of high-grade cervical intra-epithelial neoplasia (CIN). Outcome was not related to age.3 Some argue, however, that recommending surveillance to allow spontaneous regression to occur, may also put some women at risk of developing invasive disease, as protracted attendance for cytological follow-up decreases over time;4 hence the current guidance.

Colposcopy preparation

  • The patient should not have the examination if they are menstruating.
  • Sexual intercourse, vaginal medications and tampons should be avoided for 24 hours before the examination.
  • Recommend simple analgesia 1 hour before the procedure. Paracetamol, aspirin or ibuprofen may be used, but NSAIDs may increase bleeding from the procedure due to these drugs' antiplatelet effect.
  • Sometimes sedation or even general anaesthetic (most often due to patient choice) is required.5

Procedure

  • The patient sits in a reclining chair in lithotomy position. A speculum is inserted to visualise the cervix.
  • The cervix is stained with acetic acid in the area of the transformation zone (TZ) to identify the site, grade and shape of the abnormal area of cells. The solution is applied using a long-handled cotton bud. Abnormal dyskaryotic/dysplastic cells will stain white; generally, the more dense the white area becomes, the higher the grade of abnormality.
  • A water-based solution of iodine is then gently applied to the rest of the cervix to identify the complete area of abnormality. With iodine, the normal cells stain jet black and the abnormal cells stain yellow.
  • There is usually good correlation between the abnormality suggested by the cervical smear and the appearances seen through the colposcope.6,7 In cases of doubt, a small biopsy can be taken from the worst-looking area for analysis, having first applied local anaesthetic. Special biopsy forceps remove a small fragment of tissue with minimal discomfort.
  • Women who have an obvious abnormality at colposcopy, or who have a positive biopsy result, will proceed to treatment. The most common form of treatment in the UK is called large loop excision of the transformation zone (LLETZ). Treatment by LLETZ can take place at the end of the colposcopy examination during the same clinic visit, or treatment may be carried out at a later visit.

Risks

  • The procedure is relatively safe. Most commonly occurring risks include:
    • Bleeding
    • Infection
    • Pelvic or abdominal pain 
  • Colposcopy during pregnancy may cause complications, although a pregnant woman meeting the criteria for colposcopy still requires the procedure.2,8
  • Psychological morbidity is common: women's levels of anxiety before and during colposcopy are high, frequently higher than for a surgical procedure. This can increase their experience of pain and discomfort during the procedure and may contribute to the high DNA rate. Interestingly, providing information leaflets prior to the procedure does not decrease anxiety, though other methods (the use of music or video during the procedure or providing video information beforehand) may help.9
  • False positive or negative results: inadequate or inaccurate evaluation can lead to a missed diagnosis of invasive cancer, or the overestimation of lesion severity may lead to unwarranted treatment.

The procedure is inevitably operator-dependent and, whilst training can alleviate inter-operator variability, the use of digital technologies and spectroscopy may, in the future, allow a more automated analysis and interpretation of the colposcopic image.10

After the procedure

  • 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 may be seen on the pad, sometimes green, or resembling coffee grounds. The fluid is that used during the exam.
  • The patient should avoid sexual intercourse, vaginal medications or use of tampons until the bleeding stops.

Document references

  1. Swancutt DR, Greenfield SM, Wilson S; Women's colposcopy experience and preferences: a mixed methods study. BMC Womens Health. 2008 Jan 14;8:2. [abstract]
  2. Colposcopy and Programme Management: Guidelines for the NHS Cervical Screening Programme, NHS Cancer Screening Programme (2004)
  3. Ahmed AS, Goumalatsos G, Akbar N, et al; Outcome analysis of 4 years' follow-up of patients referred for colposcopy with one smear showing mild dyskaryosis. Cytopathology. 2008 Apr;19(2):94-105. Epub 2007 Oct 12. [abstract]
  4. Kyrgiou M, Koliopoulos G, Martin-Hirsch P, et al; Management of minor cervical cytological abnormalities: a systematic review and a meta-analysis of the literature. Cancer Treat Rev. 2007 Oct;33(6):514-20. Epub 2007 Jul 20. [abstract]
  5. Swancutt DR, Luesley DM, Eastaugh JL, et al; Anaesthetic choice in the colposcopy clinic: a retrospective analysis of routinely collected data. BJOG. 2008 Apr;115(5):646-52. [abstract]
  6. Jones MH, Jenkins D, Singer A; Regular audit of colposcopic biopsies from women with a mildly dyskaryotic or borderline cervical smear results in fewer cases of CINIII. Cytopathology. 1996 Feb;7(1):17-24. [abstract]
  7. Errington CA, Roberts M, Tindle P, et al; Colposcopic management of high-grade referral smears: a retrospective audit supporting 'see and treat'? Cytopathology. 2006 Dec;17(6):339-47. [abstract]
  8. Hunter MI, Monk BJ, Tewari KS; Cervical neoplasia in pregnancy. Part 1: screening and management of preinvasive disease. Am J Obstet Gynecol. 2008 Jul;199(1):3-9. [abstract]
  9. Galaal KA, Deane K, Sangal S, et al; Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006013. [abstract]
  10. Louwers JA, Kocken M, ter Harmsel WA, et al; Digital colposcopy: ready for use? An overview of literature. BJOG. 2009 Jan;116(2):220-9. [abstract]

Internet and further reading

  • Metz SA, Colposcopy eMedicine, Aug 2008.

Acknowledgements

EMIS is grateful to Dr Chloe Borton for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
Document ID: 4177
Document Version: 3
Document Reference: bgp26045
Last Updated: 22 Jul 2009
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