Colposcopy Workup

Updated: Jan 01, 2015
  • Author: Stephen A Metz, MD, PhD; Chief Editor: Michel E Rivlin, MD  more...
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Workup

Laboratory Studies

A report by Castle et al indicates that the Xpert human papillomavirus (HPV) assay is a sensitive and reliable diagnostic tool for detecting high-risk HPV (hrHPV) DNA as well as grade 2 or greater cervical intraepithelial neoplasia (CIN2+) in a colposcopy referral population. [10] The investigators collected 2 cervical specimens from 708 US women and tested the samples with either the Xpert hrHPV DNA assay or the assay in conjunction with the Hybrid Capture 2 and the cobas HPV tests.

They found no statistical difference in positive results between the two specimens for the hrHPV DNA assay. [10] The sensitivity for identifying CIN2+ was 89.0% in the specimens tested only with the Xpert hrHPV DNA assay; in the specimens evaluated with all three tests, the sensitivity was 90.4% each for the Xpert hrHPV assay and the cobas HPV test, and it was 81.6% for Hybrib Capture 2 test.

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Diagnostic Procedures

Colposcopic evaluation of the cervix should be a simple procedure. However, it is associated with high levels of patient anxiety which can have consequences such as pain and discomfort with the procedure and failure to return for followup. Anxiety may be reduced by a variety of interventions including playing music and viewing the procedure on a TV monitor. Providing patients with information leaflets increases knowledge levels and reduces psychosexual dysfunction. [11]

The colposcopic evaluation must be performed thoroughly and accurately. Accomplishing this for every patient is most reliably accomplished if a systematic repeatable routine is developed and followed for each patient. Below is one such protocol.

  • Explain to the patient the indication for and nature of the procedure.
  • Position the patient as comfortably as possible in the lithotomy position.
  • Carefully insert a speculum of the appropriate size. For patient comfort, a water-based lubricant thinly applied to the speculum blades can be of benefit. This substance should not distort the subsequent evaluation in any way. Care should be taken to avoid any trauma to the cervix on insertion or opening of the speculum. Normal columnar epithelium and dysplastic epithelium can be very fragile, and even minor trauma from speculum placement can cause enough oozing of blood to obscure findings.
  • Inspect the vagina and cervix visually with the naked eye. Gently remove any excess mucus or discharge with a large cotton-tipped applicator moistened with saline. Document any clinical findings on this gross inspection.
  • Liberally apply 3-5% acetic acid with a large cotton swab saturated with the solution. This must be in place for at least 60 seconds prior to inspecting for changes. If the evaluation takes more than 3-5 minutes, acetic acid should be reapplied because the cellular effects it creates are transient in nature.
  • Position the colposcope and focus on the cervix with the desired magnification (7X-15X).
  • Inspect carefully to ensure that the entire transformation zone (TZ) can be observed (ie, that the squamocolumnar junction is visible for its entire circumference). If the TZ extends into the cervical canal, the use of an endocervical speculum can aid in visualization. If the entire TZ cannot be observed, or if the full extent of any lesion cannot be visualized, the evaluation must be considered unsatisfactory.
  • Identify and document with drawings and description the presence of any acetowhite lesions and their internal vascular patterns. Use of the green filter at this point can improve the ability to identify lesion margins and vascular patterns. Many expert colposcopists also place Lugol solution (dilute iodine) on the cervix after initial examination and before any biopsies are obtained. This is a rather nonspecific staining process. It can be useful to provide additional information regarding the extent of abnormal epithelial changes.
  • Biopsy samples should be obtained from all abnormal lesions. As noted, the visual appearance of lesions is a poor predictor of degree of dysplastic change. Histologic analysis of all lesions is necessary to optimize sensitivity of the examination and minimize the risk of missing a significant abnormality. With experience, the examiner may become comfortable in determining if 2 locations are identical, and therefore not have to biopsy each location. Biopsy samples can typically be obtained without the need for anesthetic, but its use is not precluded. Biopsy instruments should be of a 2-bladed type (eg, Tischler, Burke, Kevorkian) and kept sharp and in good working condition. Specimens should be removed from the instrument and placed in an appropriate fixative in a labeled container and submitted for histologic evaluation.
  • Cytologic sampling of the endocervix with a cytobrush, or, alternatively, endocervical curettage may be used to evaluate the patient for endocervical pathology. Studies indicate that cytologic endocervical sampling with a cytobrush has increased sensitivity but decreased specificity compared with endocervical curettage. With either technique, the sample is submitted in fixative. Pregnancy is a relative contraindication for such endocervical sampling.
  • A hemostatic agent can be applied to each biopsy site immediately after sample collection. Monsel paste (dehydrated ferric subsulfate) and silver nitrate are effective measures. If multiple biopsies are indicated, initial samples should be taken from the inferior aspect of the cervix to prevent bleeding or chemical application from running down and obscuring adequate visualization.
    • Special precautions should be taken to optimize hemostasis when colposcopy is being performed on a pregnant woman. As is true for nongravid women, biopsy of the cervix should be performed for any lesion suspected of being invasive. Bleeding from even small biopsy sites can be brisk and persistent, so special preparation for this likelihood should be undertaken. While positioning the biopsy forceps to obtain a sample, a cotton swab saturated with Monsel paste should be readied immediately adjacent to the instrument. As soon as the biopsy is taken and before removal of the specimen, the swab should be firmly applied to the wound bed. A large second swab should be ready to put in place after removal of the first. Should this not control bleeding, equipment for placement of a small suture should be immediately available. If proper precautions are taken, bleeding is seldom a significant problem, even in the case of pregnant patients.
  • The speculum is removed, and patient instructions are provided. Spotting and a light discharge can be anticipated. Coitus should be avoided for 7-10 days, and a follow-up examination and discussion of pathologic findings should take place in 1-2 weeks.
  • Results should be reviewed to confirm that they correspond to the cytologic reports. The colposcopic examination should be considered inadequate for any of the following reasons:
    • The biopsy histology is less severe (typically by ≥2 grades) than that predicted from the cytologic sample.
    • The endocervical margin of any abnormal area cannot be visualized completely.
    • The squamocolumnar junction cannot be visualized completely.
    • There is evidence of endocervical disease not visualized at the time of colposcopy.
    • Histologic or cytologic suggestion of invasive disease not confirmed by biopsy.
    • Histologic or cytologic suggestion of adenocarcinoma or adenocarcinoma in situ.
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