Colposcopy

Definition

Colposcopy is a procedure that allows a physician to examine a woman's cervix and vagina using a special microscope called a colposcope. It is used to check for precancerous or abnormal areas.

Purpose

Colposcopy is used to identify or rule out the existence of any precancerous conditions in the cervical tissue. If a Pap test shows abnormal cell growth, colposcopy is usually the first follow-up test performed. The physician will attempt to find the area that produced the abnormal cells and remove it for further study (biopsy) and diagnosis.

Colposcopy may also be performed if the cervix looks abnormal during a routine examination. It may be suggested for women with genital warts and for diethylstilbestrol (DES) daughters (women whose mothers took the anti-miscarriage drug DES when pregnant with them). Colposcopy is used in the emergency department to examine victims of sexual assault and abuse and document any physical evidence of vaginal injury.

Demographics

It is estimated that 30–44% of women fail to follow-up with colposcopy after an abnormal Pap test. Minority women, teenagers, and those of low socioeconomic status are at a greater risk of this.

Description

Colposcopy is usually performed in a physician's office and is similar to a regular gynecologic exam. An instrument called a speculum is inserted to hold the vagina open, and the gynecologist looks at the cervix and vagina using a colposcope, a low-power microscope designed to magnify the cervix 10–40 times its normal size. Most colposcopes are connected to a video monitor that displays the area of interest. Photographs are taken during the examination to document abnormal areas.

The colposcope is placed outside the patient's body and never touches the skin. The cervix and vagina are swabbed with dilute acetic acid (vinegar). The solution highlights abnormal areas by turning them white (instead of a normal pink color). Abnormal areas can also be identified by looking for a characteristic pattern made by abnormal blood vessels.

If any abnormal areas are seen, the doctor will take a biopsy of the tissue, a common procedure that takes about 15 minutes. Several samples might be taken, depending on the size of the abnormal area. A biopsy may cause temporary discomfort and cramping, which usually go away within a few minutes. If the abnormal area appears to extend inside the cervical canal, a scraping of the canal may also be done. The biopsy results are usually available within a week.

If the tissue sample indicates abnormal growth (dysplasia) or is precancerous, and if the entire abnormal area can be seen, the doctor can destroy the tissue using one of several procedures, including ones that use high heat (diathermy), extreme cold (cryosurgery), or lasers. Another procedure, called a loop electrosurgical excision (LEEP), uses low-voltage, high-frequency radio waves to excise tissue. If any of the abnormal tissue is within the cervical canal, a cone biopsy (removal of a conical section of the cervix for inspection) will be needed.

Diagnosis/Preparation

Women who are pregnant, or who suspect that they are pregnant, must tell their doctor before the procedure begins. Pregnant women may undergo colposcopy if they have an abnormal Pap test; special precautions, however, must be taken during biopsy of the cervix.

Patients should be instructed not to douche, use tampons, or have sexual intercourse for 24 hours before colposcopy. Patients should empty their bladder and bowels before colposcopy for comfort. Colposcopy does not require any anesthetic medication because pain is minimal. If a biopsy is done, there may be mild cramps or a sharp pinching when the tissue is removed. To lessen this pain, the doctor may recommend ibuprofen (Motrin) taken the night before and the morning of the procedure (no later than 30 minutes before the appointment). Patients who are pregnant or allergic to aspirin or ibuprofen can instead take acetaminophen (Tylenol).

Aftercare

If a biopsy was done, there may be a dark vaginal discharge afterwards. After the sample is removed, the doctor applies Monsel's solution to the area to stop the bleeding. When this mixes with blood, it creates a black fluid that looks like coffee grounds. This fluid may be present for a couple of days after the procedure. It is also normal to have some spotting after colposcopy. Pain-relieving medication can be taken to lessen any postprocedural cramping.

Patients should not use tampons, douche, or have sex for at least a week after the procedure (or until the doctor says it is safe) because of the risk of infection.

Risks

Patients may have bleeding or infection after biopsy. Bleeding is usually controlled with a topical medication prescribed by the physician or health care provider. If colposcopy is performed on a pregnant patient, there is a risk of premature labor.

A patient should call her doctor right away if she notices any of the following symptoms:

• heavy vaginal bleeding (more than one sanitary pad an hour)
• fever, chills, or an unpleasant vaginal odor
• lower abdominal pain

Normal results

If visual inspection shows that the surface of the cervix is smooth and pink, this is considered normal. Areas that look abnormal may actually be normal variations; a biopsy will indicate whether the tissue is normal or abnormal.

Abnormal conditions that can be detected using colposcopy and biopsy include precancerous tissue changes (cervical dysplasia), cancer, and cervical warts caused by human papilloma virus.

Morbidity and mortality rates

Complications associated with colposcopy are extremely rare. There is a risk that the procedure will miss precancerous or cancerous tissues and thus prolong treatment until the cancer has become advanced. Of the 12,800 women who are diagnosed in the United States each year with cervical cancer, approximately 37.5% will die as a result of the disease.

Alternatives

While the Pap test is an effective screening test for abnormal cell growth of the cervix, it is an inadequate diagnostic alternative to colposcopy because of the potential for false negative results (10–50%). In some instances, a repeat Pap test may be recommended before performing colposcopy (e.g., in the case of inflammation or no previous abnormal Pap test).

Resources

BOOKS

Ryan, Kenneth J., Ross S. Berkowitz, and Robert L. Barbieri. Kistner's Gynecology, 7th ed. St. Louis: Mosby, 1999.

PERIODICALS

McKee, M. Diane, Joseph Lurio, Paul Marantz, William Burton, and Michael Mulvihill. "Barriers to Follow-up of Abnormal Papanicolaou Smears in an Urban Community Health Center." Archives of Family Medicine 8 (March/April 1999): 129–34.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. http://www.acog.org .

American Society for Colposcopy and Cervical Pathology. 20 W. Washington St., Ste. #1, Hagerstown, MD 21740. (301) 733-3640. http://www.asccp.org .

Association of Women's Health, Obstetric, and Neonatal Nurses. 2000 L St., NW, Ste. 740, Washington, DC 20036. (800) 673-8499. http://www.awhonn.org .

DES Action USA. 610 16th St., Ste. 301, Oakland, CA 94612. (510) 465-4011. http://www.desaction.org .

Society of Gynecologic Oncologists. 401 North Michigan Ave., Chicago, IL 60611. (312) 644-6610. http://www.sgo.org .

OTHER

"Colposcopy (Position Paper)." American Academy of Family Physicians, [cited March 11, 2003]. http://www.aafp.org/x6665.xml .

Garcia, Agustin. "Cervical Cancer." eMedicine, April 17, 2002 [cited March 11, 2003]. http://www.emedicine.com/med/topic324.htm .

Mayeaux, E. J. "Colposcopy Atlas." Louisiana State University Health Sciences Center Medical Library, [cited March 11, 2003]. http://lib-sh.lsumc.edu/fammed/atlases/colpo.html .

Pattan, Charles. "Colposcopy." eMedicine, July 15, 2002 [cited March 11, 2003]. http://www.emedicine.com/med/topic 3298.htm .

Jennifer E. Sisk, MA Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Colposcopy may be performed by a gynecologist or other qualified health care provider in an outpatient setting. A gynecologist specializes in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics. In cases of sexual assault, a nurse practitioner or registered nurse may perform the procedure. If a biopsy is performed, a pathologist examines the tissue samples under a powerful microscope in the laboratory and sends the results to the health care provider who, in turn, informs the patient of the results.

QUESTIONS TO ASK THE DOCTOR

• Why is colposcopy recommended in my case?
• Will a biopsy be performed?
• How long will the procedure take?
• When will I find out the results?
• What will happen if the results are positive for cancer or another abnormality?