Overview of Colposcopy
A colposcopy is a procedure that doctors use to closely examine a woman’s cervix, vagina, and vulva by using a special instrument called a colposcope, which is essentially a magnifying glass with a light. This medical procedure was first introduced in 1925 by Hans Hinselmen from Germany, and he used it as a way to check for signs of cervical cancer.
This procedure is typically used when there are abnormal results from a Pap test (which is a test used to detect abnormal cells in the cervix), when someone tests positive for high-risk human papillomavirus (HPV) DNA (that is the virus often linked to cervical cancer), or if the appearance of the cervix appears unusual. It’s also used to monitor the condition of patients who’ve been treated for incidents of abnormal cell growth in the cervix or invasive carcinoma, which is a term for cancer that’s spread from the original site to other parts of the body.
Currently, a variety of healthcare providers can use this procedure, such as advanced practice providers, primary care providers, gynecologists, and gynecological oncologists, among others. Though it’s widely used, there seems to be a lack of consistent training and standards for how the process should be performed. Inconsistency also depends on the healthcare provider doing the process, leading to differing results. To tackle these issues, the American Society for Colposcopy and Cervical Pathology (ASCCP) released standards for colposcopy in 2017. The goal of these standards is to simplify the procedure and ensure it is thorough every time it is performed.
Anatomy and Physiology of Colposcopy
The cells where the inner and outer parts of the cervix meet are vulnerable toHuman Papillomavirus (HPV) infection and abnormal growths or changes. This virus can insert its DNA into these cells, switching off the action of certain genes that regulate cell growth, known as p53 and RB. This allows the cells to grow and change in an abnormal way, a process which is known as dysplasia. This growth is slow and happens in many stages which can be spotted before they develop into cervical cancer. In fact, more than 90% of cervical cancer cases are caused by HPV.
Thankfully, these abnormal cell changes can be picked up through a Pap smear test, a common method of screening for cervical cancer. With this test, the abnormal growth process can be detected early and treated before it evolves into full-blown cervical cancer. But it’s worth keeping in mind that these abnormal growths are not exclusive to the cervix. The HPV virus can also affect vaginal and vulvar tissue, areas of the female reproductive system. Close examination of these areas using a device called a colposcope is more or less the same for both the cervix and vagina. However, for the vulva, the procedure is slightly adjusted due to the delayed absorption of vinegar-like acid that helps in the procedure.
Why do People Need Colposcopy
Colposcopy is a detailed examination of the cervix – the lower part of a woman’s womb – usually done if there are concerns about the woman’s risk of developing cervical precancerous conditions (also known as dysplasia). The need for colposcopy (or the indications) are usually because of certain risk factors such as results from a Pap smear test, testing for human papillomavirus (HPV – a group of viruses that can cause cervical cancer), or a personal history of cervical dysplasia (abnormal cells in the cervix).
The specific reasons why a colposcopy might be done include:
- Examining women who had an abnormal Pap test
- Understanding where the problem area (lesion) is in the cervix
- Determining how large the problem area is
- Choosing where to take a sample (biopsy) for closer examination
- Assessing women who tested positive for high-risk HPV DNA
- Checking women with positive results from a visual inspection with acetic acid test
- Investigating a cervix’s suspicious appearance if there’s bleeding after sex or in postmenopausal women, even if the Pap smear result is negative
- To investigate unusual bleeding from the reproductive organs
- Checking out ongoing inflammation or unsatisfactory results from a cervical screening test, especially in the presence of risk factors for cervical cancer
- Investigating ongoing abnormal vaginal discharge or itching (pruritus vulvae)
- Finding and managing HPV infection that doesn’t show symptoms
- To examine women with a history in-utero diethylstilbestrol (DES) exposure, a medication that was used to prevent miscarriages but has been linked with rare types of cancer.
In some cases, it is also used in conservative management of a condition known as intraepithelial neoplasia where abnormal cells are found on the surface of the skin in certain areas of the body, finding and taking care of vaginal extension of cervical abnormal cells, keeping track of female health after treatment, and post-radiation follow-up.
It’s note-worthy that not all Pap smear tests must be followed up with a colposcopy. In conditions where there is a less risk such as low-grade squamous intraepithelial lesion (a mild abnormal cell change on the surface of the cervix) or atypical squamous cells of undetermined significance (changes in the cervical cells that are unclear) combined with a negative HPV test, the likelihood of finding severe dysplasia through a colposcopy is low. Immediate colposcopy is not necessary in these cases and a repeat Pap smear can be done the following year. Nonetheless, if the Pap test continues to show these abnormal findings and test positive for HPV, a colposcopy is advised.
Findings in a Pap test that are strongly linked to severe cervical abnormal cells such as high-grade squamous intraepithelial lesions (moderate to severe abnormal cell change on the surface of the cervix) and atypical squamous cells require immediate colposcopy. When there are suspicions of these high-grade lesions, there may be a possibility of invasive cervical cancer, which could be threatening to the woman’s health. Immediate colposcopy is crucial in these cases.
Today, whether or not a woman should get a colposcopy hinges on the risk of HSIL, which can develop into cervical cancer if left untreated. There are instances where if this risk is more than 25% (considering current HPV test results, cytology or cell study results, and past history), immediate treatment may be needed. If there is more than a 4% risk of finding cervical intraepithelial neoplasia of grade 3 or more (which identifies severe abnormal cells in cervix), colposcopy is recommended. These decisions, termed “clinical action thresholds,” take into account the chances of having either CIN3 or invasive cancer currently and for up to five years in the future.
When a Person Should Avoid Colposcopy
A colposcopy, which is a medical examination of the cervix or lower part of the uterus, usually doesn’t have any restrictions. However, if a woman has an untreated infection in the cervix or vagina, the examination should not be conducted. Also, certain parts of the colposcopy procedure are avoided for pregnant patients. An example is the ‘endocervical curettage’ step, which means scraping the inside of the cervix. It is not performed because it can cause harmful effects on the pregnancy without any significant benefit.
Furthermore, a woman’s pregnancy can limit the options for treatment. For instance, procedures that involve cutting away parts of the cervix are not recommended during pregnancy, unless there’s a suspicion of cervical cancer. If cervical cancer is a possibility, then a careful and shallow cut may be the only option to help diagnosis.
Equipment used for Colposcopy
To carry out a thorough colposcopy (a procedure to examine the cervix, vagina, and vulva closely), the following tools are needed: a vaginal speculum (an instrument to open the vagina for examination), a colposcope (a special magnifying device), 5% acetic acid, Lugol’s solution (a type of iodine), biopsy forceps (special tweezers for tissue sampling), an endocervical speculum (another instrument for better visualization of the cervix), a Kevorkian curette or endocervical brush (tools for sample collection), and methods to stop any bleeding after a biopsy.
The colposcope is a sort of microscope that enlarges the view of the tissue in the vagina, cervix, or vulva. Different models of colposcopes come with assorted features such as different lens types, the ability to produce images via computers, various light filters, and even built-in cameras for capturing images or videos. It’s important that a colposcope should let you switch between low and high magnification to closely examine any concerns. Usually, colposcopes can swap between 10x and 18x magnification. They should also have a standard and green light filter to help identify blood vessel patterns, which can be hard to spot with just white light.
There’s also a new method called digital video colposcopy, which uses a camera and a strong light source (LED) to magnify and illuminate the area. This method doesn’t require the traditional binocular eyepieces. Instead, the colposcopic image is shown on a high-resolution video monitor. This method comes with several perks like easy image handling and sharing of images between multiple viewers, including learners and even the patient. On top of that, it keeps a lasting record of the findings in the form of a duplicated image that the examiner is looking at.
In the procedure, 5% acetic acid is applied to the cervix using a cotton ball or a large swab and left to act for 1 to 2 minutes. When this acid is introduced, abnormal cells dehydrate and turn white, a phenomenon known as “acetowhitening”. This change can cause a bit of discomfort to the patient. The whole cervix and the upper part of the vaginal tissue should be inspected in detail. Additionaly, some doctors might use Lugol’s solution on the cervix. This iodine-based substance can be applied to identify abnormal areas. When it doesn’t get absorbed into an area, rendering it yellow, this suggests the presence of abnormal cells. This is called a “Schiller’s test”.
To get a good look at the opening of the cervix (cervical os), an endocervical speculum might be needed. There are different types of biopsy forceps used to get a tissue sample from the cervix. The Tischler cervical biopsy punch forceps or the Burke biopsy forceps are commonly utilized. When a biopsy is taken, bleeding might occur – and it can be stopped using different methods such as applying Monsel’s solution, using silver nitrate, or using a technique called Bovie cauterization.
Who is needed to perform Colposcopy?
A colposcopy is a procedure that requires a skilled medical professional, known as a colposcopist, to carry out accurately and reliably. It would be beneficial to have an assistant during the procedure to handle various tools and specimen containers, but it’s not a must. Because a colposcopy is a procedure that involves examining the inside of your body, it’s important to have another person, often referred to as a chaperone, present in the room at all times for a patient’s comfort and safety.
Preparing for Colposcopy
If a patient is due for a colposcopy, there’s no specific preparation required for the procedure. However, it might be more difficult to perform the colposcopy during a woman’s period because the presence of blood can make things less clear to see. To make the appointment easier and quicker for the patient, the medical room is prepped in advance with all the necessary equipment.
How is Colposcopy performed
The American Society for Colposcopy and Cervical Pathology (ASCCP) has set some guidelines for colposcopy, a procedure that allows doctors to get a close look at the vulva, vagina and cervix. This process helps identify any abnormal conditions. To visualize any potential issues accurately, a 5% acetic acid solution is applied to the area.
Different types of light (white and a red-free filter which is either blue or green) are used to identify any lesions, or abnormal areas. If any are found, small tissue samples, or biopsies, are taken for further analysis. Details about the visibility, size, location, and description of each lesion are noted down, along with any changes like color or blood flow, presence or absence of any whitening effect after the application of acetic acid, visibility of the transformation zone, and so on.
If any bleeding occurs after the biopsy, a substance called Monsel’s solution or silver nitrate is applied to stop it. Also, the colposcopist makes an impression of the colposcopy, which could range from benign (or harmless) to a potential indication of cancer.
In order to standardize what is noted down during a colposcopy, the International Federation for Cervical Pathology and Colposcopy (IFCPC) in 2011 introduced some terminology and it’s now widely used. They also introduced a scoring system called the Swede scoring system to standardize the reporting of colposcopic findings.
These scores can range from 0 to 10, with each score indicating different findings and their severity. The training and experience of the colposcopist play a crucial role in the scoring accuracy. For example, according to a study by Strander et al, a Swede score of 5 or more suggests a strong likelihood of a high-grade cervical lesion. Therefore, a biopsy is recommended when the Swede score is 5 or higher.
The IFCPC provided additional information on the categorization of findings during colposcopy which needs to be documented. These details give information about the health of cervical tissues, including abnormalities. They also have a grading system for abnormal findings and a scoring system which helps to categorize lesion characteristics, their size and specific appearances like the way they take up acetic acid, characteristics of their edges and the nature of vessels in and around them.
Possible Complications of Colposcopy
Colposcopy is a procedure done mainly to check for diseases in the cervix, and the complications from it are usually minor. These complications can include emotional issues like anxiety and discomfort caused by the procedure. Additionally, they can be affected by the quality of the colposcopy. The person performing this procedure needs to have the right training and experience to reduce false-negative results, which means missing signs of serious disease. A lack of experience could result in missing between 13% to 69% of high-grade or invasive cancers.
Despite improved screening tests for detecting Human Papillomavirus (HPV) and assessing risk, there is still a need for diagnostic testing by colposcopy. The reduced use of colposcopy due to these improved screening techniques means that newly trained doctors might not have as many opportunities to gain experience and proficiency. However, even when a colposcopy doesn’t find any signs of disease, studies have found that patients can still develop serious conditions later. Therefore, continuous monitoring based on individual disease risk, HPV testing, and past history is essential.
Making an mistake during a colposcopy mainly involves incorrectly identifying signs of disease in the tissue being examined. For example, a mild white patch (lesion) on the surface of the cervix might be mistaken for a sign of disease, when it’s really due to normal processes, like tissue regeneration or a subclinical HPV infection. If there’s any doubt, a biopsy should be taken of suspicious areas. Also, colposcopy should be avoided during periods when the cervix’s surface is regenerating, such as after certain treatments or injuries. Other situations that might lead to mistakes include not being able to see the entire cervix due to an obstruction, or when the cervix’s opening (the os) is narrowed.
Doing a colposcopy during pregnancy can be challenging due to changes in the cervix, which may result in an exaggerated appearance of certain tissue patterns. However, these changes can be taken into account, and certain methods like taking a tissue sample (biopsy), or swabbing the cervix for cells (cytology), are safe during pregnancy.
Finally, colposcopy can be more difficult in women who have gone through menopause. About 25% of these women may have an unsatisfactory result because their cervix couldn’t be fully examined or due to thinning tissues in the vagina (vaginal atrophy). To improve the likelihood of a successful examination, these women may be advised to use a vaginal estrogen treatment before the colposcopy.
What Else Should I Know About Colposcopy?
A colposcopy is a medical procedure that is performed if your routine cervical screening test comes back abnormal, or if there is an unusual spot or growth seen on your cervix during an exam. This process helps doctors decide the best course of action depending on your biopsy results. This can follow established medical guidelines, which evidence has shown to be effective.
If you have lower risk abnormal cells, your doctor can keep an eye on it and decide how to manage it based on a step-by-step plan from professional medical groups like the American Society for Colposcopy and Cervical Pathology (ASCCP). If you have higher risk abnormal cells, the treatment will depend on your personal factors such as your age and whether you want to have children in the future.
If a colposcopy does not give enough information, your doctor may have to do a more invasive procedure to take a larger sample of the unusual area on your cervix to figure out exactly what is going on. If the growth or spot is an invasive (potentially dangerous) one, you may be sent to a cancer doctor (gynecological oncologist) who specializes in exploring further treatment options.
If you are pregnant and have an abnormal colposcopy result, your treatment may be put on hold until you deliver your baby, unless there’s a risk that the unusual spot on your cervix is invasive. Your doctor will always consider your and your baby’s safety when deciding the next steps.
