Surgical Therapy and Follow-up
Following complete colposcopic evaluation of the cervical lesion and histologic confirmation of the diagnosis, an appropriate treatment regimen can be developed. This should be based on the extent and degree of the pathologic findings, taking into account, insomuch as possible, the individual patient’s desire for future childbearing.
Regardless of the treatment modality chosen, patients undergoing therapy for preinvasive cervical lesions are at risk for recurrence. Follow-up algorithms are available from various sources, such as the American Society for Colposcopy and Cervical Pathology.
For patient education resources, see Cancer Center and Women's Health Center, as well as Colposcopy, Cervical Cancer, and Pap Smear.
Complications
Complications from colposcopic procedures are exceedingly rare. Occasionally, bothersome bleeding can occur following biopsy. This tends to be problematic only with procedures performed during pregnancy or with large excisional procedures. Infection of biopsy sites is also exceedingly rare, although it can occur following laser ablation or loop electrosurgical excision procedures. The most worrisome complication is inadequate or inaccurate evaluation leading to the missed diagnosis of invasive cancer. This obviously can lead to treatment delays and poorer outcomes. Another complication is the overestimation of lesion severity by inexperienced practitioners. This can put the patient on a treatment course that may not be necessary and has the potential for adverse sequelae. Many of these sequelae center around future fertility limitations such as cervical stenosis or incompetence.
The infrequent but preventable lack of adequate evaluation is the only real controversy surrounding the procedure today. Questions concern who should perform the examination and what training requirements must be met before instituting the procedure on patients. Because of the prevalence of HPV disease and the frequency of abnormal findings on Papanicolaou tests, this becomes both an economic issue and a quality issue. Some have recommended as many as 200 supervised procedures to gain competence followed by regular performance of at least 25 procedures a year to maintain competence. The learning curve undoubtedly is practitioner-dependent, and, currently, no adequate studies have identified minimum criteria for certification. All practitioners performing this procedure should put mechanisms in place to ensure their own competence and safety.
Future and Controversies
The colposcope can also be helpful in evaluating lesions of the vagina or vulva. The vaginal epithelium is a nonkeratinizing squamous epithelium similar to that of the exocervix. Acetowhite changes and vascular patterns can be observed that are similar to those found on the cervical portio. Because vaginal lesions do not originate in metaplastic tissue, vascular patterns previously described are not diagnostically reliable. When premalignant changes are suspected, all acetowhite lesions should be biopsied.
The vagina is more sensitive to pain than the cervix, so prebiopsy injection of local anesthesia should be considered. However, in a study involving 214 women with abnormal cervical cytologic findings that required colposcopy and directed cervical punch biopsy with/without endocervical curettage, Oz et al found no significant differences in pain scores after the colposcopic cervical biopsies with endocervical curettage between women who received 10% topical lidocaine spray and those who received placebo. [14]
The vulva is also a potential site for development of preinvasive disease. These tissues also can show acetowhite changes, but, because of the thickness of the epithelium and its keratin surface, acetic acid should be applied for a greater length of time and in a higher concentration (eg, 5%) to be effective in bringing about this change. Altered vascular patterns are uncommon on the vulva; but, when they are observed, biopsies should be performed liberally. Again, because of the sensitivity of these tissues, all biopsies should be obtained under local anesthetic.
Another use of the colposcope is in the evaluation of a victim of sexual assault. This has gained popularity, especially in the evaluation of children suspected of being assaulted. At low magnification, the colposcope can assist in identifying tissue trauma that might be too subtle to be detected by the naked eye. Careful, thorough, and gentle examination, especially of hymenal tissues, can usually be accomplished with minimal discomfort. Attached cameras for recording findings can be helpful from an evidentiary perspective.
An exploratory study by Mueller et al reported that cervix images from the low-cost point-of-care tampon colposcope (POCkeT) were comparable to a standard-of-care colposcope. [15]
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Early metaplastic change of columnar epithelium.
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Normal squamocolumnar junction. Tissue response to applied light.
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Dysplastic epithelium with increased reflectance of applied light.
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Human papilloma virus (HPV)–infected epithelium with increased light reflectance.
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Punctation in cervical lesions. Left is fine, right is coarse (likely high grade or invasive).
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Mosaicism in cervical lesions; left is fine, right is coarse (likely high grade or invasive).
