Colposcopy

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

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 can also be used to detect inflammatory or infectious changes, and harmless growths and to 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.

Management of cervical smear results[1]

Result

Action

Negative
  • Investigate and manage incidental findings (eg, infections).
  • Ensure that the patient is informed of the result.
  • Recall as appropriate for a negative result.
Inadequate
  • Repeat the sample immediately after treating any infection or atrophy, preferably within three months.
  • Repeat the sample as soon as convenient if technically inadequate.
  • If persistent (three inadequate samples), advise assessment by colposcopy.
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 six months (particularly important where there is an association with human papillomavirus (HPV). The majority of smears will return to normal by this stage.
    • Refer for colposcopy if there are three smears in a series reported as borderline nuclear change in squamous cells) without the woman being returned to routine recall, or three borderline or more severe results in a 10-year period.
    • Three consecutive negative results, six months apart, are required before returning to routine recall.
    • Repeat the sample in three to six 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.
    • HPV testing will be performed on these samples.
    • Women who are positive for HPV will be referred for colposcopy.
    • Those women who are negative for HPV will be returned to routine screening every 3 or 5 years depending on their age.
Mild dyskaryosis
  • Ideally, women should be referred for colposcopy after one mild dyskaryotic smear, but it remains acceptable to recommend a repeat test within six months - many will have returned to normal by this stage.
  • Always refer for colposcopy after two tests reported as mild dyskaryosis without a return to routine recall.
  • Three consecutive negative results, six 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 three borderline or more severe results, refer to colposcopy.
  • HPV testing will be performed on these samples.
  • Women who are positive for HPV will be referred for colposcopy.
  • Those women who are negative for HPV will be returned to routine screening every 3 or 5 years depending on their age.
Moderate dyskaryosis Refer for colposcopy.
Severe dyskaryosis Refer for colposcopy.
  • After a referral to colposcopy for a single mild dyskaryotic result, 70-80% of follow-up smears subsequently became negative.[2]
  • In April 2011, HPV testing triage of borderline or mildly abnormal cervical smears was introduced.[3]
  • Women who are positive for HPV are directly referred for colposcopy. Those who are negative continue with routine (three-year or five-year) follow-up.
  • Triaging these women with HPV testing allows around a third of women to return immediately to routine recall and a substantial proportion to be referred for colposcopy without repeat cytology being necessary.[4]

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  • 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 giving simple analgesia one hour before the procedure. Paracetamol, aspirin or ibuprofen may be used, but non-steroidal anti-inflammatory drugs (NSAIDs) may increase bleeding from the procedure, due to the antiplatelet effect of these drugs.
  • Sometimes sedation or, rarely, general anaesthetic (most often due to patient choice) is required.
  • 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.
  • In cases of doubt, a small biopsy can be taken for analysis from the worst-looking area, having first applied local anaesthetic. Special biopsy forceps remove a small fragment of tissue with minimal discomfort.
  • A punch biopsy has been shown to have a high sensitivity (81%).[5]
  • 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 a 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.
  • The procedure is relatively safe. The 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.[1]
  • However, cervical biopsy should be avoided during pregnancy unless a malignancy is suspected and endocervical sampling is contra-indicated.[6]
  • Psychological morbidity is common: women's levels of anxiety before and during colposcopy are high, frequently higher than for a surgical procedure.
  • Although providing information leaflets prior to the procedure does not actually decrease anxiety, it can improve knowledge about the procedure and also increase quality of life by reducing psychosexual dysfunction.[7]
  • The use of music during the procedure has been shown to reduce anxiety levels.[8]
  • 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.
  • The patient should avoid sexual intercourse, vaginal medications or use of tampons until the bleeding stops.

Further reading & references

  • Metz SA; Colposcopy, Medscape, Jan 2012.
  1. Colposcopy and Programme Management: Guidelines for the NHS Cervical Screening Programme; NHS Cancer Screening Programme (2010)
  2. Wright TC Jr, Massad LS, Dunton CJ, et al; 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ. J Low Genit Tract Dis. 2007 Oct;11(4):223-39.
  3. NHS Cervical Screening Programme, HPV Triage and Test of Cure Protocol; NHS Cancer Screening Programmes
  4. Kelly RS, Patnick J, Kitchener HC, et al; HPV testing as a triage for borderline or mild dyskaryosis on cervical cytology: results from the Sentinel Sites study. Br J Cancer. 2011 Sep 27;105(7):983-8. doi: 10.1038/bjc.2011.326. Epub 2011 Sep 6.
  5. Underwood M, Arbyn M, Parry-Smith W, et al; Accuracy of colposcopy-directed punch biopsies: a systematic review and meta-analysis. BJOG. 2012 Oct;119(11):1293-301. doi: 10.1111/j.1471-0528.2012.03444.x. Epub 2012 Aug 13.
  6. Fleury AC, Birsner ML, Fader AN; Management of the abnormal Papanicolaou smear and colposcopy in pregnancy: an evidenced-based review. Minerva Ginecol. 2012 Apr;64(2):137-48.
  7. Swancutt DR, Greenfield SM, Luesley DM, et al; Women's experience of colposcopy: a qualitative investigation. BMC Womens Health. 2011 Apr 13;11:11. doi: 10.1186/1472-6874-11-11.
  8. Galaal K, Bryant A, Deane KH, et al; Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD006013. doi: 10.1002/14651858.CD006013.pub3.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Hayley Willacy
Current Version:
Peer Reviewer:
Dr Hannah Gronow
Document ID:
4177 (v4)
Last Checked:
01/03/2013
Next Review:
28/02/2018