Colposcopy


Continuing Education Activity

Colposcopy is a procedure in which a lighted, magnifying instrument called a colposcope is used to examine the cervix, vagina, and vulva. It is a diagnostic procedure performed to evaluate abnormal cytology results from a screening Pap test. This activity outlines the use of colposcopy and reviews the role of the healthcare team in effectively evaluating and treating patients with an abnormal pap smear.

Objectives:

  • Identify the indications for colposcopy.
  • Describe the equipment, personnel, preparation, and technique in regards to colposcopy.
  • Review the potential complications and clinical significance of colposcopy.
  • Summarize interprofessional team strategies for improving care coordination and communication to enhance the care of patients who need a colposcopy.

Introduction

Colposcopy is a procedure in which a lighted, magnifying instrument called a colposcope is used to examine the cervix, vagina, and vulva. Hans Hinselmen of Germany first described colposcopy in 1925 as a screening tool for cervical cancer. It is a diagnostic procedure performed to evaluate women with an abnormal Papinocalau (Pap) test, women with visual inspection with acetic acid (VIA), women positive for high-risk human papillomavirus (HPV) DNA, or with a suspicious appearing cervix even if the PAP test is normal. It is also performed as a post-treatment follow-up of intraepithelial and invasive carcinoma.

Colposcopy is practiced by a number of different clinicians, including advanced practice clinicians, family medicine physicians, gynecologists, gynecological oncologists, and some internists. There is poor standardization of this process as well as training received or continued development based on daily, monthly, or more infrequently practiced procedures. It is well known that colposcopy has significant variability and poor reliability between colposcopists. The ASCCP (American Society for Colposcopy and Cervical Pathology) published colposcopy standards in 2017 to address these and other concerns.[1] The standardization of terminology was established to simplify and ensure a comprehensive colposcopic exam was performed at every encounter.

Anatomy and Physiology

The Pap test is performed in order to screen for cervical cancer. The cells at the squamocolumnar junction of the endo and ectocervix are susceptible to HPV infection and dysplastic change. HPV is responsible for >90% of cervical cancer. This virus incorporates its DNA into the developing cell and turns off the tumor suppressor gene (p53 and RB) function allowing the cells to become dysplastic. This process is a slow, gradual process that has many stages of development that can be identified before the dysplasia progresses to cervical cancer.

Because there are time and an adequate screening test that allows for sampling these changing cells (the Pap test), the process can be identified early and treated before progressing to cervical cancer. The dysplastic process is not limited to the cervix as the vaginal and vulvar tissue are also susceptible to the HPV virus. Colposcopy of the cervix and vagina are essentially identical, but the vulval tissue has a delayed absorption of the acetic acid, so the procedure is slightly modified.

Indications

The indications for a colposcopy to be performed are risk-based. Women referred for colposcopy have a variety of underlying risks for cervical pre-cancer based on their cytological results, the HPV testing if it was performed, and personal history of cervical dysplasia. Each can be triaged accordingly, but when colposcopy is indicated, it is used to diagnose if dysplasia is present and its severity. 

Indications for colposcopy:[2][3][4]

  • Evaluation of women with an abnormal Pap test:
    • To localize the lesion.
    • To map out the extent of the lesion.
    • To select the biopsy site/s
  • Evaluation of women positive for high-risk HPV DNA
  • Evaluation of VIA positive women
  • Evaluation of a suspicious appearing cervix, and postcoital/postmenopausal bleeding, even if the Pap smear is normal.
  • Unexplained abnormal lower genital tract bleeding.
  • Persistent inflammatory/unsatisfactory cervical cytology despite appropriate treatment, especially with high-risk factors for carcinoma cervix
  • Evaluation of persistent abnormal vaginal discharge or pruritus vulvae
  • Identification and management of subclinical papillomavirus infection
  • History of in utero diethylstilbestrol (DES) exposure
  • Conservative management of intraepithelial neoplasia
  • Identification and management of vaginal extension of cervical neoplasia
  • Post-treatment follow-up
    • After treatment of intraepithelial and invasive carcinoma
    • Post-irradiation follow-up

Therefore, not all Pap tests must be followed by a colposcopy, though many of them are. Low-risk Pap tests, i.e., low-grade squamous intraepithelial lesion (LSIL) or atypical squamous cells of undetermined significance (ASCUS) with negative HPV, are not as likely to have significant colposcopic findings leading to severe dysplasia. Therefore, immediate colposcopy is not indicated, and the patient can follow up the next year with a repeat Pap test. However, if the following year, the Pap test remains abnormal with LSIL again or ASCUS positive for HPV, then colposcopy is recommended. Some Pap test findings are more closely associated with severe cervical dysplasia. These include high-grade squamous intraepithelial lesions (HSIL) and atypical squamous cells– cannot exclude high-grade intraepithelial lesions (ASC-H). When there is suspicion of high-grade lesions being present, there is a possibility that invasive cervical cancer could be present. Immediate colposcopy is the recommendation in patients with initial Pap test findings more closely correlated with severe cervical dysplasia.

Contraindications

There are no specific contraindications to a colposcopy other than an active or untreated cervical or vaginal infection. If a patient is pregnant, certain steps of the colposcopy procedure are excluded. The endocervical curettage component is not performed due to potential risks of adverse effects on the pregnancy without substantial benefit. Furthermore, pregnancy can limit management options due to the fact that cervical excisional procedures are contraindicated during pregnancy.

Equipment

The equipment needed to perform an adequate colposcopy involves a vaginal speculum, a colposcope, 5% acetic acid, Lugol’s solution, biopsy forceps, an endocervical speculum, a Kevorkian curette or endocervical brush, and a solution or method to stem bleeding. The colposcope is a dissecting microscope that can magnify the cervical, vaginal, or vulvar tissue.  There are multiple options for colposcopes with lens types, computer-generated images, light filters, and even cameras to capture images or videos. Colposcopes should have 2 settings, low power and a high power magnification for evaluation of a lesion.

Most scopes have interchangeable magnifications at 10x and 18x. The scope should have a normal light filter as well as a green filter in order to identify vascular patterns that can be difficult to recognize with white light.[5] 5% acetic acid is applied to the cervix with a cotton ball and allowed to soak for 1 to 2 minutes. Cells that are dysplastic dehydrate and turn acetowhite with the application of acetic acid. This can cause the patient some minor discomfort when initially applying. All areas of the cervix and upper vaginal tissue should be thoroughly inspected. Some colposcopists will apply Lugol’s solution (an iodine-containing solution) that will highlight the dysplastic area with the lack of absorption of the brown solution causing it to be a yellow color. This is referred to as a "Schiller's test." A Schiller positive test is an area that is non-staining with iodine.[6] An endocervical speculum may be needed in order to adequately inspect the cervical os. There is a variety of biopsy forceps available for cervical biopsy, the more common ones are Tischler cervical biopsy punch forceps, Burke biopsy forceps, or some variation of these.[5] 

There are different methods to stop the bleeding after a biopsy has been taken, including applying Monsel’s solution, using silver nitrate, or even Bovie cauterization can be employed. There is also a new method called digital video colposcopy, it provides magnification and illumination with the help of an inbuilt camera and strong light source (LED). Binocular eyepieces are not required, and the colposcopic image is viewed on a high-resolution video monitor. It has several advantages such as easy manipulation, co-visualization of images simultaneously by several viewers, including trainees, as well as the patient. It obtains a permanent record of the findings in the form of a replica of the image being seen by the examiner.

Personnel

An experienced colposcopist is of vital importance. It is helpful to have an assistant handling the instruments and specimen containers during the procedure, but they can be handled independently. There should always be a chaperone in the room due to the fact it is an invasive procedure.

Preparation

There is no required preparation for the patient having the colposcopy; however, it can be difficult to perform if she is on her menstrual cycle due to obscuring blood. Having the room with the proper equipment readily available will expedite the patient’s visit.

Technique

The ASCCP (American Society for Colposcopy and Cervical Pathology) has published standardization guidelines for the performance of colposcopy. The ASCCP makes recommendations for extensive and minimum requirements for a colposcopy. The colposcopist should examine the vulva, vagina, and cervix grossly in the natural state and also after the application of 5% acetic acid.[7] The entire cervix and SCJ (squamocolumnar junction) must be visualized for adequacy. Both white light and a red-free (blue or green) filter should be applied to the visual field in order to identify any lesions.[7] 

Directed biopsies of lesions should be taken of each abnormal finding. Documentation in a minimum of text format should comment on the visibility extent, size, location, and description of each lesion (color/contour/border/vascular changes), presence or absence of acetowhitening, complete or incomplete visibility of the SCJ, documentation of biopsies and locations, if an endocervical curettage was performed, and finally the impression of the colposcopy (benign-normal/low grade/high grade/cancer).[7] Application of Monsel’s solution or silver nitrate should be applied after the colposcopy is completed, and all biopsies are taken. 

Documentation

Grade of cytological abnormality, colposcopic adequacy, visibility, and type of SCJ should be documented. The location of lesion, size, and extent of lesion, endocervical, or vaginal extension of the lesion should also be clearly documented. Abnormal colposcopic findings should be described location wise in detail, and colposcopic impression should be made in terms of low grade or high-grade lesion along with Reid’s/ Swede score. Histopathologic diagnosis should never be made on colposcopy only.

2011 IFCPC Nomenclature[8]

General assessment

·         Adequate/Inadequate for the reason (e.g., Cervix obscured by inflammation, bleeding, scar)

·         Squamocolumnar Junction visibility: completely visible, partially visible, not visible

·         Transformation zone types 1,2 and 3

 

Normal colposcopic findings

Original squamous epithelium:

· Mature

· Atrophic Columnar epithelium

· Ectopy

Metaplastic squamous epithelium

· Nabothian cysts

· Crypt (gland) openings

Abnormal colposcopic findings

General principles

Location of the lesion:

Inside or outside the T-zone, Location of the lesion by clock position.

Size of the lesion:

Number of cervical quadrants the lesion covers, Size of the lesion in the percentage of the cervix,

 

Grade 1 (Minor)

Thin aceto-white epithelium Irregular, geographic border

Fine mosaic, Fine punctation

 

Grade 2 (Major)

Dense aceto-white epithelium, Rapid appearance of acetowhitening, Cuffed crypt (gland) openings

Coarse mosaic, Coarse punctuation, Sharp border, Inner border sign, Ridge sign

 

Non-specific

Leukoplakia (keratosis, hyperkeratosis), Erosion Lugol’s staining (Schiller’s test): stained/non-stained

Suspicious for invasion

Atypical vessels Additional signs: Fragile vessels, Irregular surface, Exophytic lesion, Necrosis, Ulceration (necrotic), tumor/gross neoplasm

Miscellaneous finding

Congenital transformation zone, Condyloma, Polyp (Ectocervical/ endocervical) Inflammation,

Stenosis, Congenital anomaly, Post-treatment consequence, Endometriosis

The Swede score is used to score the colposcopic findings and to have uniformity in the reporting system. The total score is 10.[9]

Score

0

1

2

Aceto uptake

Zero or transparent

Shady, Milky (not transparent; not opaque)

Distinct, opaque white

Margins/Surface

Diffuse

Sharp but irregular, jagged, ‘geographical’ satellites

Sharp and even, the difference in surface level, including ‘cuffing.’

Vessels

Fine, regular

Absent

Coarse or atypical

Lesion size

<5mm

5-15mm or 2 quadrants

>15mm or 3-4 quadrants/ endocervical undefined

Iodine staining

Brown

Faintly or patchy yellow

Distinct yellow

Overall Swede score

Colposcopic prediction of probable histology

0-4

Low grade/normal

CIN 1

5-6

High grade/non-invasive cancer

CIN 2+

7-10

High grade/suspected invasive cancer

CIN 2+

Complications

Complications from colposcopy are likely to be related to an obscured visual field, severe atrophy, or scarring present based on the patient’s history. Overall procedural risks of significant bleeding, infection, and long-term morbidity are low.[10] Anxiety and patient discomfort are significant complications associated with the procedure that should not be ignored, but it can be difficult to ascertain if the negative feelings about the procedure are related to the idea of HPV infection or the procedure. There is potential harm in the performance of colposcopy by an unskilled clinician.[10]

Training and continued experience in colposcopy are necessary for competency. The false-negative rate (missed high grade squamous intraepithelial/invasive cancer) for colposcopy ranges from 13% to 69%.[11][12] There are improved screening tests now with cytology, molecular testing for HPV, and risk-based assessments. Therefore, there is less need for diagnostic testing with colposcopy, which creates an even greater need for an experienced, skilled colposcopist. 

Sources of Error in Colposcopy

Every colposcopic image is a reflection of a specific tissue pattern resulting from the interaction of surface epithelium and stroma. Misinterpretation of patterns is the most common error in colposcopy. A flat, mild acetowhite grade 1 lesion is more likely to be over-diagnosed as they mimic immature or active metaplastic epithelium in young women, regenerative epithelium, subclinical HPV infection, and congenital transformation zone. If in doubt, such lesions must be biopsied. Colposcopy should be avoided during the regenerative period of epithelium following CO2 laser ablation, cryosurgery, or trauma. Another common error is making a diagnosis without completely visualizing the cervix in cases where it is obscured by an endocervical polyp or large retention cyst, or there is a stenosed internal os, and in cases of incomplete visibility of the squamocolumnar junction.

Colposcopy can be difficult in postmenopausal women, with an unsatisfactory colposcopy in 25% of women due to the incomplete visibility of the squamocolumnar junction and vaginal atrophy. Errors may occur in association with pregnancy due to its physiological and morphological changes. Vasodilatation and congestion during pregnancy produce accentuated colposcopic patterns with more pronounced mosaics and punctations and enhanced acetic acid effect, which may mimic paraneoplastic lesions. These may be minimized by the use of a large speculum covered with a condom, quadrant wise interpretation, and remembering that colposcopic changes in pregnancy are one grade higher than the non-pregnant cervix. The colposcopic biopsy is safe if indicated in pregnancy, but endocervical curettage is contraindicated. However, the use of an endocervical brush for cytology is safe.

Clinical Significance

Colposcopy is a diagnostic procedure done due to an abnormal cervical screening test or a visible lesion seen on the cervix during an exam. This diagnostic procedure assists with the formulation of a management plan based on the results of the biopsied pathology or lack of results. In general, all results can either be observed or treated and are based on evidence-based guidelines. Low-grade lesions can be followed up and managed according to ASCCP guideline algorithms. High-grade lesions are treated depending on the patient’s age and fertility status.[13] 

A patient that is pregnant will have their treatment deferred until after delivery unless there is a specific concern for an invasive lesion. A colposcopy that is considered inadequate for a variety of reasons may lead to a more aggressive sampling of the cervical tissue with an excisional procedure of the cervix in order to attain the diagnosis. Invasive lesions should be referred to a gynecological oncologist for treatment options.

Enhancing Healthcare Team Outcomes

Colposcopy is a dying art but is a necessary step in the fight to prevent cervical cancer from ever developing. This procedure can be learned by multiple types of clinical practitioners. In the US, colposcopic services are delivered in diverse practice settings, including academic and non-academic referral settings, primary care environments in urban and rural communities, and funded by private and public resources.[14] 

The training of the variety of practitioners should be fostered and continued as there are fewer patients available due to improved screening techniques and risk-based recommendations and consolidation of information by organizations like the ASCCP. Clinicians should adhere to recommended standardization of the procedure as well as documentation in order to improve patient care. Just as standardization of terminology for the pathologist has enhanced communication between practitioner and pathologist, standardization of procedure and documentation will do the same. Enhancements in technology may continue to improve the reliability and validity of the colposcopy procedure.


Article Details

Article Author

Danielle Cooper

Article Editor:

Manjeet Goyal

Updated:

1/29/2021 10:16:26 AM

PubMed Link:

Colposcopy

References

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