COLPOSCOPY
Cervical Screening QARC
Training School
October 2012
Terminology
• Dyskaryosis
• Cervical Intraepithelial Neoplasia
(CIN)
Disease progression
Months
Time
Normal
epithelium
HPV infection;
koilocytosis
Borderline
CIN I
Mild
Years
CIN II
Moderate
CIN III
Invasive
cervical cancer
Severe
CIN I 57%
CIN II 43%
CIN III 32%
Approx. likelihood of regression
Dyskaryosis
Indications for Colposcopy
• ABNORMAL CYTOLOGY
• Moderate or severely dyskaryotic result
• Borderline/mild samples that are high
risk (16 & 18) HPV positive
• Abnormal glandular cells
• FINDINGS OR SYMPTOMS
• Suspicious appearance to cervix
• Symptomatology – post coital bleeding
Examination
•
•
•
•
•
•
Cusco Speculum
??repeat LBC sample
Acetic Acid +/- Lugols Iodine
Colposcope
Punch Biopsy
Silver nitrate
Treatment
• Excisional – LETZ, Knife Cone
• Destructive - Cold Coag, Laser
Ablation
• Rarely - Hysterectomy
Follow-Up prior to HPV testing
• After Treatment for high grade CIN
(or worse) – Cervical sampling 6,
12 then annually for 10 years
• After Treatment for low grade CIN –
6, 12, 24 then normal recall
• After hysterectomy (if no Cervix) –
no longer part of re-call!
Gynaecologist sets intervals
What is HPV test of cure?
• Women who have a normal, borderline or mild cervical
screening result six months after treatment for CIN and
who also test negative for high-risk HPV have a very low
risk of residual disease.
• Samples taken six months post treatment that are
cytology negative are HPV tested.
• Women whose samples show no high-risk HPV will
proceed to three year routine recall – avoiding the need
for up to 10 years of annual cervical screening.
• Women who have an abnormal cervical screening result or
whose samples show high-risk HPV six months after
treatment will be referred back to colposcopy.
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Letz and pregnancy
• Knife cone worse than Letz
• Laser ablation carries no risk
• Complications
• Premature labour (<37/40) 1.7 RR
• Premature rupture of membranes 2.7
RR
• Low birthweight 1.8 RR
• Cervical stenosis – emergency LSCS
Colposcopy in Pregnancy
• Aim is to exclude invasive disease
• No evidence of more rapid progression in
pregnancy
• Avoid treatment but can biopsy
• Warts more florid
• Sampling and colposcopy are easily interpreted
despite pregnancy changes
• If has invasive disease when pregnant
• Treat Ca cx if under 24/40 i.e. terminate
pregnancy. After 24/40 deliver by LSCS as soon
as baby is viable (32/40)
Colposcopy after the menopause
• Transformation zone is usually not
visible
• With low grade cytology try to
repeat ‘sample’ after a course of
topical oestrogen
Cervical Dysplasia
• Oncogenic virus is the cause of over
99% of cases
• Co-factors
• Smoking
• Parity
• Immunocompromise (Transplants & HIV)
HPV triage as an adjunct to LBC & Colposcopy
• LBC allows HPV testing
• No value in the assessment of women
with high grade dyskaryosis –
assumption is that they are all HPV +ve
• In women with borderline and mild
dyskaryosis may allow decision about
who needs colposcopy
• Follow up after treatment for CIN