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Essay 291 - Colposcopy

COLPOSCOPY Posted by J K.

 

(a) Abnormal cervical smear is associated with anxiety in the woman. I would counselled her regarding the need for colposcopy because of abnormal smear. Moderate dyskaryosis is a pre cancerous lesion, if left untreated, may have potential to become malignant. There is small chance of existing cervical malignancy. Colposcopy involves the examining of the cervix with a colposcope, to identify areas of abnormality. Additional liquid such as acetic acid and Lugol's iodine  will be applied at the cervix to facilitate the detection of abnormal areas. SHe will be advised to avoid sexual intercourse and tampon insertion 24 hours prior to colposcopy. I will also explain to the woman that additional procedures may be carried out during colposcopy of moderate or severe abnormalities are found. These could range from obtaining multiple small cervical biopsies or large loop cervical excision of the transformation zone(LLETZ). Consent will be obtained prior to procedure. I will explain there is poor correlation between cytology, colposcopy and histology findings. Histological examination is important to confirmed the cervical abnormalities and plan for further management and follow up. Procedures such as cervical biopsy and LLETZ are associated with small risk of bleeding and infection. LLETZ is associated with small risk of preterm labour and preterm pre labour rupture of membranes, therefore her fertility wish should be obtained. There is also small risk of cervical stenosis with LLETZ leading to infection. Colposcopy and the additional procedures are usually carried out in the outpatient clinic with the use of local analgesia, but it may have to be carried out in theatre under general anaesthesia if the lesion to be removed is too big or she has severe discomfort. A follow up appointment will be given in 4-6 weeks time to review the result of the biopsy or LLETZ.  Written information and information leaflet will be given to her as well as a telephone contact for further enquiries.
 
(B) I will explained to her that diathermy loop excision was done because of abnormalities seen on the cervix.  SHe may have a little abdominal discomfort which should go away on its own. Analgesia such as paracetamol will be given. She may also experience some brownish black discharge for the next few days due to LUgol's iodine as well as silver nitrate. I will advise her to avoid sexual intercourse and tampon insertion for the next 4 weeks. She should also avoid  swimming until the bleeding has stopped. A 24 hour telephone contact will be given to her as well as written information. She should be advised to see her GP if bleeding becomes more than usual or the presence of foul smelling discharge. Subsequent follow up will depend on the histology, if CIN I, she will need repeat colposcopy in 6 months with smear. If normal, she will go back to routine recall. If CIN II-III, with clear margins in the specimen, she would need repeat smears at 6, 12 and 24 months then annually for a total of ten years before going back to routine recall.
colposcopy Posted by farzana S.

          A)  Woman should be given appropriate  information with contact name,telephone number and     clinic timings. She should also be informed if the clinic provides treatment in the same setting ,called  SEE AND TREAT.  

The smear result and the need for  colposcopy examination will cause anxiety in woman.She should be adequately counseled to allay anxiety and given adequate information about the procedure.She may bring a close relative or friend with her.

Colposcope  is  like a magnifying  glass to see a clear, enlarged and detailed view of cervix.It will not touch or go inside and it will not be painful.

She should be counseled that the examination aims to look for any abnormal areas on cervix which are highly suspicious of  cancer and take biopsy from there for histopathogical  diagnosis.The chance that she has cancer is  low ,but colposcopy will help in early identification  of presense and severity,so that adequate treatment is planned .If necessary  the treatment  may be given at the same time.Any treatment will be given with her consent.

If colposcopy results show CIN 2 or CIN 3 depending on number of abnormal cells and  if there is no invasion to deeper layers she may be advised to have treatment at the same time.

This is usally excision by laser or cone biopsy.It will be done under local anesthesia.The treatment is  nearly 100% successful  in removing abnormal areas.

She may wish to return at a later date for treatment.

If she receives  LLETZ  ,she may have blood stained discharge for 2-4 wks  and periods may be painful.Cone biopsy has risk of preterm birth and premature rupture of membranes.

In case of invasive lesion,which may be found rarely,she would rquire referral to appropriate centre for  further investigations and surgery.

Woman should be given national information leaflet and also  the clinic she is referred to   should give its local information leaflet .

Information concerning visit to clinic and results of investigations should be communicated within to referring physician  within 4 wks

B)Post procedure  woman should be informed that  after LLETZ, she may have blood stained discharge for 2-4 wks .It is advisable that she should  use sanitary towels during this time and avoid using tampons.Her menstruation may be sustained and more painful.

She should also abstain from sexual intercourse for 4wks.This will give time for good healing of cervix.

 LLETZ wil not affect her fertility or increase risk of midtrimester miscarriage,but slightly increase risk of preterm birth.

She should avoid swimming for 2 wks.She should avoid heavy exercise but may continue light excercises.Alcohol  may be taken in moderate amounts.

As the procedure is done under local anesthesia she may drive back home,and return to work in a day or two.

Travelling abroad  need not be avoided but overseas medical expenses  for any complications are not covered by insurance.

Follow up will be after 6 months  by cytology ,and  then repeated annually for nine years .If all these smears are normal she will be returned to routine recall.

All information should be given both  in verbal and written  form.Information leaflet should be provided.

colposcopy Posted by ammara M.

A

women's counselling done sensitively as diagnosis is associated with patient anxiety.i will explain that it is a precancerous state which may progress to invasive disease if let untreated.there is a small chance of existing invasive disease. colposcope is a low power binucular microscpetaht allows magnification 4-25 times.it is done in colposcopic clinic under local anesthesia.cervix is visulaized under low magnification(4-6) times.cotton soaked in saline applied to the cervix  which moisten the epithelium and then cervix is seen under high magnification to visulaized the capillaries.then 3-5%acetic acid is appied followed by lugol's iodin test to look for the vessels pattern.pt.explained that there is poor corelation between cytology,colposcopy and histology.definite diagnosis is based on histological findings.additional procedures include multiple small cervical biopies.cone biopsy or LETTZ if needed.consent should be obtained.pt.may experince vaginal bleeding for 2-4 weeks.complications of cone biopsy or LETTZ include pretrem labour.cervical stenosis and haemorrhage.follow up appointment would be given to rewiew histological results.if CIN dignosed she need follow up at 6-12-24 months and then send back to routine recall.if CIN2/CIN3 dignosed she needs follow up for 2-12 months and the yearly for 9 years.

written information given with follow up appointment.information given regarding place ,time for colposcopy and the person who will preform.

 

b

I would explain that laser excision of the transformation zone done.usullay it removes whole of the lesion but if the margins are involved or there is invasive disease she may need further treatment.

she may experince abdominal pain which will settle on its own or she may take simple analgesia.brownish discharge may occur due to lugol's iodine.mild bleed can continue upto 4 wk.she should avoid sexual intercourse ,inserting tampons,swining until bleeding settles.

if bleeding increases or there is foul smelling discharge she should immediately contact her G.P.

short term complications include haemorrhage.infection and pain.long term complications include pre -term labour,cervial stenosis,chronic PID due to asending infections.

women explained that there is poor corelation between cytology ,colposcopy and histology and definite diagnosis can be given after hiatological results.

patient given written information.24 hour hospital no.given.information regarding support groups provided.

Essay 291 - Colposcopy Posted by k H.

A healthy 37 year old woman is due to attend for colposcopy following a cervical smear showing high grade (moderate) dyskaryosis.

(a) Discuss the counselling and information that should be provided before colposcopy [10 marks].

I will start by reviewing the woman's history and notes and previous cervical smear history.i will explain the smear result and that moderate dyskaryosis is not cancer however cancer need to be excluded and more investigations needed part of which is colposcopy.i will explain that the procedure involves positioning her in lithotomy position and examining the cervix by a telescopic camera that gives a magnified view of the tissues allowing proper and closer examination for abnormalities.during the procedure application of some chemical substances as acetic acid and lugol's iodine will help with examining the tissues.i will explain that for this part of the procedure anaesthesia is not required however if we are to proceed for treatment procedure local anaesthesia will be applied otherwise she can opt for having the treatment procedure under general or regional anaesthesia as a day case procedure in a later appointment.i will explain that if abnormalities are detected the further steps will be to obtain a biopsy of the abnormal tissues and sending it for microscopic examination or treatment procedure can be done.treatment options that can be provided are either excision or ablation of abnormal tissues,however for ablation to be done invasive cancer has to be excluded by biopsy.excision options include knife cone biopsy which requires general or regional anaesthesia and can't be offered in the outpatient setting.diathermy loop excision and needle excision can be provided which allows excision of part of the ectocervix and cervical canal and sending the excised tissues for microscopic examination.the procedure will be done under local anaesthesia and complications involve bleeding,infection and cervical stenosis and cervical incompetence.i wll then answer her questions and document the discussion in the notes and obtain a written consent before the procedure.

(b) She has diathermy loop excision. Discuss your post-procedure counselling [10 marks].

I will explain the findings of the colposcopic examination and the treatment performed.abnormal tissues were excised and will be sent for microscopic examination.i will explain that she will experience some pain which is usually relieved by simple analgesia.she will also experience vaginal spotting and vaginal discharge.i will explain the warning symptoms that will require medical advice which are bleeding more than spotting,offensive vaginal discharge and inceasing abdominal or pelvic pain and I will provide her with a 24 hours contact number where she can seek medical advice whenever needed.i will explain that further follow up appointments will depend on the results of microscopic tissue examination.however if invasive cancer is excluded and treatment was deemed complete a 6 months test of cure should be performed by obtaining a smear with or without HPV testing.i will explain how the results will be communicated to her and that a letter will be sent to her GP informing him of the procedure and treatment provided.i will provide written information and document the procedure clearly in her notes.

colposcopy Posted by Priyadarshini G.

A)The lady should be informed that cervical smear is a screening test and is aimed to detect any precancerous lesion early.She should be told that as the test is abnormal she needs to undergo a further diagnostic test in the form of colposcopy.She should be informed that moderate dyskaryosis has the potential to progress to cervical malignancy if not treated.She should be told that colposcopy is an office procedure where the cervix is viewed by a machine after staining with certain chemicals and if any abnormality is seen then a directed biopsy can be taken at the same time from that area for histological diagnosis.She should be informed that the other option for her is the see and treat modality where she can be subjected to either knife or laser cone biopsy or large loop excision of the transformation zone along with colposcopy.She must be informed that in that case she will get adequate local anaesthesia.She should be informed that the see and treat system may be associated with side effects like hemmorhage, infection  and cervical stenosis.She should be assured that following this if no abnormality is detected then she can go back to the age related recall system.She should be informed about the need for follow up in case of any cervical intra epithelial neoplasia.She should be given written information and her consent should be taken for colposcopy.     B)After diathrmy loop excision the lady must be informed that there may be slight vaginal bleeding for 2 to 3 weeks.She may have slight lower abdominal pain for which she will be given analgesics.She should be informed that any excessive or foul smelling vaginal discharge should be reported to the health care worker as there is a chance of infection after this procedure.She should be advised against sexual intercourse for the next 4 weeks.She should be told that in case of any abnormality like cervical intra epithelial neoplasia on histology if the margins are clear then usually no further treatment is  needed.She should be told that following the procedure there is a slight chance of cervical stenosis which may lead to secondary dysmenorrhea.As her procedure has been done by diathermy the artefacts may make interpretation of the margins difficult and this may produce erroneous result.She needs to be informed that her histology report will be discussed with her after 1 week and her further management will be discussed then.She needs to be given written information and contact numbers for emergency purposes.

Colposcopy Posted by NAZIA H.

Colposcopy

 A  The patient is counselled carefully as abnormal cancer cells on smear and colposcopy examination is associated with distress. She should be informed that colposcopy is examination of cervix and vaginal walls under low power binocular microscope to detect abnormal areas on the cervix, taking the biopsy and then examination by pathologist under microscope of the sample taken and detecting the type of lesion with subsequent management. She is told it is very unlikely that she has cancer but if it is detected earlier then timely treatment can prevent progression of the lesion. She is given written information and contact number if she has any queries. Written consent is taken. She is advised to come after periods or pregnancy test should be negative before procedure. Vaginal discharge should be treated, she should not have sexual intercourse, and vaginal douching tampons or creams 24 hours before the procedure.  She is given paracetamol/diclofenac 30 minutes to 1 hour before the procedure and bladder should be emptied. She is told to take off clothing below the waist and drape her with cloth given. She will be put in supine position with legs supported on stirrups. Gynaecologist will examine the vulva and put a speculum in vagina, which may cause discomfort. He will examine the cervix and vaginal walls, can use saline swabs to clear cervix. He can use acetic acid (vinegar) and lugols iodine solution on cervix to see abnormal areas. He will take the biopsy of abnormal area or remove a cone of tissue with excisional technique. This can be associated with bleeding, which can be controlled by silver nitrate sticks or electro cautery. Photographs of abnormal areas can be taken for record.

B   She is told postoperatively the procedure is associated with some discomfort so she can take paracetamol for it. It might be associated with brown discharge or mild bleeding for one week. She is advised to avoid sexual intercourse, vaginal douching, tampons or creams inside vagina while bleeding but she can use sanitary pads. She is advised to report back if she develops offensive vaginal discharge, abdominal pain or feels unwell after the procedure. As she has a diathermy loop excision she is reassured that the abnormal lesion has been treated and she is extremely unlikely to develop cancer after it but she should have more frequent smears annually for at least 9 years before entering in routine 3 or 5 year recall depending upon histopathology report and local protocols. She should be informed about increased risk of miscarriage and preterm delivery in subsequent pregnancies after diathermy loop excision.

colposcopy Posted by Attia R.

 

I will inform the patient about  theabnormal result of smear and explain to her that an abnormal result is not unusual ( about one in 20 women have bnormal results)I will give her detail informationabout  what abnormal result means ,how it happens ,and what will be further management. An abnormal result usually means that small changes{ dyskaryosis} have been found in the cells on the cervix (the neck of the womb .Changes in the cells of the cervix are often associated with the human papilloma virus (HPV), linked with nearly all cases of cervical cancer. HPV is transmitted by sexual intercourse,and often shows no symptoms. Most women are infected with HPV at some point in their lives, but most infections disappear without the need for treatment. Even women with ‘high risk’ HPVs rarely go on to develop cervical cancer. In many cases these changes return to normal by themselves.but in her caseAs her  abnormal result  show moderate (high-grade) dyskaryosis , areas of changed cells are associated with the grades CIN 2 and CIN 3(pre cancerous lesion). these changes are less likely to return to normal by herself and usually need treatment ,because if left untreated ,sometimes the changes become worse and could lead to cancer in the future. I will reassure her that even with CIN 2 or CIN 3 grade changes, it is unlikely that she has  cancer. HoweverIt is important that these changes are checked now, in case they become more serious in the future . To decide whether she need treatment, a colposcopy examination will be carried out to investigate the cervix in detail.. This is a simple examination at a colposcopy clinic which allows the doctor to visulise the cervix and to decide if patient need treatment.An instrument called a colposcope is used. This is a type of microscope or magnifying glass which lets the doctor look more closely at the changes onr cervix. The examination is very similar to the screening test, so she may find it a bit uncomfortable.i will further explain that if she  need treatment following colposcopy she will usually be treated as an outpatient .It is a simple procedure and will be carried out under local anaesthetic and there will be no need to stay in hospital. The area of changed cells will be removed from the cervixand nearly always 100 per cent successful. After treatment, she will be asked to have a follow-up screening test six months afterwards to check that all the abnormal cells have gone. If this test shows that she still have  moderate or severe (high-grade) dyskaryosis, shewill be referred for another colposcopy. If the test is normal or shows borderline changes or mild (low-grade) dyskaryosis, and she  live in an area where HPV testing has started, her sample will be checked for HPV infection.  If HPV is found, she will be referred for another colposcopy.  If negative for HPV, she  will be screened again in three years. If HPV testing not available then she  will have two tests at 6 -12 months. If both these follow-up tests are normal, then she  may be advised to have annual screening for a while.  If either of her  follow-up tests shows abnormalities, she will be referred for colposcopy.   The screening programme will write to advise her of the follow-up that she needs.she can have her sexual activity and it does not make any abnormality worse,and abnormal cells are not transmitted to partner but it is important not to get pregnant until  abnormality is dealt with, as the hormones produced during pregnancy make treatment more difficult. I will provide her written einformation leaflets of colposcopy.

 . B)

Diathermyloop procedure usuallys cuccessful treatmentand most widely used .Specimen is available for histology although diathermy artefacts makes the margin acessment difficult.i will inform her that she might have bleeding (secondary heamrhage 4.5% risk).She should be informed that she may experience vaginal dischargesupto six weeks.There is risk of cervical stenosis (narrowing of opening) is 1.3%,and because of that she may feel reduced menstrual flow ,pain with menstruation.RISK of infection .There is evidence that diathermy loop procedure is associated with pre term deleivery  20-25%.she may need close observation for next pregnancy .Risk of cervical dystocia that is cervix may not dilate and she may need abdominal deleivery.

councelling colposcopy Posted by ghazala A.

a)      Colposcopy is an examination of neck of womb (cervix) using special microscope (colposcop) that allows to look at  your cervix  more closely.  .You are being referred to colposcopy because you had an abnormal smear. Having abnormal smear does not mean that you have a cancer, but in a small percentage of  women over the years it can progress to cancer or rarely cancer may already exist  .Colposcopy is done to detect early abnormal changes in the cervix and monitor these changes until they return to normal. Your   pap smear reports  severe dyskaryosis. If there is a strong evidence of an area of moderate to severe abnormality at your first colposcopy examination you may be offered  treatment at the same visit. If examination shows less severe changes decision regarding repeat smear or to do a biopsy before treatment will be taken. During the procedure you will lie   comfortably on examination couch and colposcopist will gently insert an instrument in your vagina (same as used for smear).This allows to open your virginal walls to allow good view of cervix. The colposcopist will look at cervix through colposcope.We may take pictures of your cervix which may be of benefit if you are seen by a different colposcopist at a future visit. We need a concent for this procedure. During the examination colposcopist may apply acetic acid or logo’s iodine to facilitate detection of abnormal areas . You may feel slight burning sensation during application of these . Depending on your findings if treatment is required it is not usually painful but you may feel slightly discomfort .In your case moderate to severe  dyskaryosis on  pap smear you may require a treatment by removing a small part of cervix that is called LLETZ.The procedure usually takes 15 t0 20  minutes and is  usually done under local anaesthesia but if you request or view is not clear than you will be requiring general anaesthesia. During the procedure there is small risk of bleeding and very small risk of infection and vaginal burns. Rarely opening of cervix may become tightly close that may cause painful periods   but very unlikely fertility problems. This may weaken the cervix and there is some evidence of preterm delivery in future pregnancies. We will need your  consent for the whole procedure. You need to contact us if you need to change an appointment or you have periods during  these days s( although  procedure can be carried out during periods) .If you are using OCPS for contraception take them without break so that you should not have the periods .If you are using IUCD for contraception, please avoid sexual intercourse or use condoms before one week of the procedure as we may need to remove IOCD if treatment is required. Please do not have sexual intercourse 24 hours before procedure if no contraception is being used . If you have bleeding problems, heart disease or allergies that bring your emergency medication with you.

I will give you written information   regarding procedure and  24 hours contact numbers  for any queries.

 

b)    You may experience some pain and slight bleeding after the procedure, we will give pain killers for pain but if you feel that the pain is severe or bleeding is heavy then report to your nearest emergency department. Some discharge is normal after the procedure for a few days but if you feel discharge is becoming smelling then report to you GP.After the procedure you will be able to go home same day. We recommend not to drive by yourself back to home because a small no of women faint after the procedure .Don’t use tampons for four weeks and avoid sexual inter course 6 to 8 weeks to decrease risk of infection. Do not   do swimming until bleeding is stopped.  Histological result of your biopsy will be mailed to you with in 6-8 weeks. Your   further follow  up depends on result of histopathology and will be scheduled at your  subsequent visit . . If you have any queries then you can call our contact no  123 or visit our web site  www.abc.com.

 

Colposcopy Posted by Julie A.
a)I would adopt a sensitive approach to the women as the result can cause extreme anxiety.Explain that moderate dyskaryosis   means abnormal cells in the cervix  and doesnot mean cancer. It needs  further investigation   by colposcopy and treatment based on findings to prevent progression to cancer.Colposcopy is  detailed  examination of the cervix under  light and magnification.It should be done within two weeks of referral.It is done by trained specialists and written consent will be obtained prior to the procedure .The procedure usually takes 20-30 minutes and is associated with only a minimal discomfort.  Women should lie in lithotomy position.5% acetic acid is applied to the cervix.Abnormal cells will be seen as acetowhite areas . Iodine shillers’ test  is also done which shows  low uptake.Biopsy will be obtained from suspicious areas of the cervix under local anaesthesia.Further treatment will be based on histopathological diagnosis of the biopsy specimen.Some centres offer ‘see and treat’ policy where procedures like cryotherapy and LargeLoopExcision of Transformation Zone(LLETZ) are done at the same time under local anaesthesia.Complications of the procedure include bleeding,pain ,infection and trauma to the cervix.
Patient can be discharged  soon after the procedure with contact numbers to use in  emergency.Followup appointment to discuss the results will be provided 2-4 weeks later. At the end of the counselling ,I will check her understanding and answer  further querries.Also I will provide written information and leaflets to the patient.
 
b)‘Large LoopExcision of Transformation Zone’  can cause bleeding,pain ,infection ,cervical stenosis and cervical trauma.It  doesnot cause cervical incompetence and  preterm delivery.
Minimal amount of pain and bleeding is expected following the procedure.I would provide her with emergency contact numbers  and  advise her to attend hospital if heavy bleeding,offensive discharge,fever and feeling unwell.I would advise her to avoid tampons  and sexual intercourse for 6 weeks.She can return to work after a couple of days,if she is feeling  well.She will have a follow up ‘test of cure’ cytology in 6 months time.If it is negative, mild and borderline ,HPV testing will be done.If HPV is  negative ,recall is advised in 3 years for cervical smear.If HPV positive  is  positive,referral  for  further colposcopy is needed.
If moderate /severe dyskaryosis is present , referral to colposcopy should be done. 
I will provide written information  and leaflets to the patient and offer her follow up appointment in 2-4 weeks time.
 
colposcopy Posted by A H.

 

This patient will most be very anxious and worried.  Counseling will take place in a sensitive manner.  I will reassure her that her results do not indicate that she has cancer. She will need further examination to exclude cancer.  This will be done as an outpatient under local anaesthesia using a colposcope. This is a binocular microscope, which will magnify the surface of the cervix so that it can be closely examined for abnormalities. Any abnormal areas can be treated at the same time according to local protocol once she agrees. Colposcopy will be arranged in 2 to 4 weeks. She will also be advised that if she declines follow up, there is a significant risk of developing cancer.

Colposcopy involves placing her in the lithotomy position on a special couch.  A bivalve speculum is passed to allow visualization of the cervix in the same manner as doing the pap smear.  The cervix will be cleaned with a cotton ball soaked in saline, and examined at low magnification.   Dilute acetic acid will be applied using another cotton ball. Lugol’s iodine will be applied after and the cervix examined carefully at higher magnification. Abnormal areas can be treated by either ablation after punch biopsy, or by excision, depending on the equipment available. The main advantages of excision are that tissue can be sent for histological diagnosis, and it can be used to confirm that the margins are clear of disease. Complications include haemorrhage in about eight percent, and infection in less than five percent. In the longer term there is a small risk of cervical stenosis, cervical incompetence and preterm delivery. Cure rates are similar for the different procedures. She will be given the time frame for collecting the results and for follow up. If the histology shows pre invasive disease with clear margins, she will be followed up with repeat smear in six months. If invasive disease  (which is very unlikely) is found, she will be referred for further treatment by the oncology team. Enough time will be allowed for all her concerns and questions can be addressed. Consent will be taken for local anaesthesia if she agrees for treatment. She would be given written information. Proper documentation will be recorded in the notes. She will be given contact numbers.

 

b) After the procedure she will be advised that she may experience cramping abdominal pain. Paracetamol or co-dydamol is usually effective pain relief. If the pain is not relieved by simple analgesia, she should contact the gynaecology ward.

She will be advised that a dark brown vaginal discharge is common but not serious. Vaginal bleeding may occur. Usually this is light spotting for about 2 weeks. It may start soon after the procedure or after 24 hours. If she experiences heavy bright red bleeding, she should contact the hospital.

She will be advised to use sanitary napkins and avoid the use of tampons for about 4 weeks. She will also be advised to avoid intercourse and douching.

She will be given emergency telephone numbers and written information.

An appointment for follow up in 4 to 6 weeks will be given.

A letter will be sent to the GP.

Colposcopy Posted by Francina S.

A) The patient should be sent/given written information about colposcopy, the reason the referral, what the procedure entails and that it is usually a "see and treat" clinic so treatment may be offered on the same day. The patient should be encouraged to bring a friend with for support if she wishes. At consultation the purpose of cervical screening, of which colposcopy is a part, should be explained - that is to screen for pre-cancer changes and therefore, in most cases, prevent the occurance of cancer by treating them. Her smear result is therefore indicative of a possible pre-cancer change in the neck of the womb (cervix) and this needs to be confirmed by closer examination which is colposcopy. It should be explained that the cause is the wart virus (human papilloma virus, HPV) of which certain types are associated with cervical cancer (16, 18, 32). The wart virus is carried by most sexually active people, most of who are able to clear the virus. However in some cases the virus is not cleared properly and a process begins in the cervix which can progress to cancer if not treated.

The procedure of colposcopy involves an internal vaginal examination very similar to the smear test itself. However, at colposcopy, the cervix is looked at with a microscope to identify any changes. Two types of solution are applied to help to find areas that need treatment: iodine and acetic acid. This should be a painless procedure but may be uncomfortable. Depending on what is seen at colposcopy either some samples may be taken, called biopsies, or treatment may be offered at the same appointment which involves removing a thin layer of the cervix. This procedure, called LLETZ, can be done under local anaesthetic and, in the majority of cases, also provides treatment. The biopsy or sample taken by LLETZ will be sent to the laboratory for confirmation of the type of change found and further colposcopy or treatment required will be determined by this. Written consent should be given prior to performing a large loop excision of transformation zone (LLETZ) with an explanation of the risks of the procedure (bleeding, infection, cervical stenosis and preterm delivery). It is possible that no abnormality is seen and the patient does not require any further testing and can return to routine screening by 3 yearly smears.

B) Written information should be provided about after care following a LLETZ procedure with contact numbers and advice to regarding who to contact in the event of any complications. It is important to explain common effects of the procedure: mild cramping pain that can be treated with paracetamol and should resolve in the next few days; light bleeding that should settle over the next 1-2 weeks; clear discharge may be seen for the next 6 weeks. The patient should be advised to avoid the use of tampons, douching or sexual intercourse for the next 2 weeks to reduce the risk of infection. She should seek medical help if she has heavy bleeding, abnormal smelling or coloured discharge, abdominal pain or fevers.

It should be explained that she will be seen in clinic in the next 4-6 weeks to discuss the results of the procedure based on the sample sent to the laboratory. In the majority of cases no further treatment will be required. However, in some cases a repeat LLETZ or a larger biopsy (knife cone biopsy) will need to be taken. The follow-up protocol will depend on whether the centre is using HPV for triage and test of cure. If HPV testing is done then the following protocol is used: for CIN 1 with negative HPV the patient returns to routine recall (3 yearly smear); for CIN 1 with positive HPV then for 6 month smear; for CIN 2-3 for 6 month smear. If HPV is negative at 6 month smear then patient can be returned to routine recall, if positive then for repeat colposcopy. If 6 month smear is normal following CIN 2-3 then for yearly smears for 9 years. If HPV testing is not done then all cases except normal histology for 6 month smear and then routine recall for CIN 1 or 9 year follow up for cases of CIN 2-3.

colposcopy Posted by vinivee S.

 

a .)Recognise the fact that smear report of moderate dyskaryosis can be a matter of anxiety and concern for the woman. I will counsel her in a sensitive reassuring manner. Explain to her that though the abnormal cells suggest a precancerous condition which can progress to the invasive cancer if left untreated, it is not cancer presently. The need for a colposcopy examination to rule out the invasive cancer will be stressed, especially since in rare cases it can coexist.

Colposcope is a binocular microscope instrument which provides a detailed ,magnified view of the cervix  to note any  abnormal or suspicious areas .Explain her that Colposcopy  is an outpatient procedure done under local anaesthesia usually  in half an hour  preferably  within 2-4 weeks of the referral to the centre. She will be given an appointment after periods or once pregnancy test is negative, advised to avoid sexual intercourse, vaginal douching, tampons or vaginal creams 24-48 hrs before the procedure.

 Dyskaryosis of moderate to severe type is associated with CIN 2-CIN 3 changes in 80-90% of women and with invasive lesion in  5% .Colposcopy directed biopsy of the abnormal area will provide the histological diagnosis. Given the malignant potential of CIN 3 to progress onto invasive disease, I will counsel her and take  the written consent to proceed with  “see and treat” policy  at the same time  if the examination  is suggestive.

She will be examined in lithotomy position which could be uncomfortable for some, an instrument called speculum will be used to visualise cervix. Acetic acid 5% will be applied to the cervix that demarcates the abnormal areas as acetowhite patches.Lugol’s iodine can also be used to show low uptake and a magnified view of cervix can be saved as a photographic image in the camera.

Biopsy of the suspicious area is taken once consented under local anaesthesia, usually by the large loop excision of the transformation zone (LLETZ ) to confirm the histological diagnosis. Explain that this is a treatment  most widely used  for CIN with fewer complications than knife or laser cone biopsy. Mention about the complications like bleeding, vaginal discharge, infection in some women. The risk of preterm delivery in subsequent pregnancy and cervical stenosis will also be discussed.

She will be discharged after the procedure, to report back for the histology results which are usually ready in 2-3 weeks time. Explain that further treatment and follow-up plan will be made after the histology. Written information will be provided along with contact numbers of the hospital services for emergency. Adequate documentation done in the notes.

b.)She will be explained that LLETZ  has been done as its  the recommended  treatment for CIN . Minimal discomfort or pain can be expected for which she will be prescribed paracetamol or codydramol.There is risk of vaginal bleeding (4-5%) and dark brown discharge lasting for a few days for which she must report to her GP if it becomes heavy or associated with fever and foul smell. She should avoid sexual intercourse and tampons for about 4 weeks, also swimming if there is heavy vaginal bleeding. She can resume her work if well within two days. 

    Explain that further treatment will be decided after histology results.Once Invasive cancer is excluded, in case of CIN 1, she will need repeat smear with HPV test of cure after 6 months and if it is normal she will be sent back to normal age recall. If CIN 2 or CIN 3 with clear margins repeat smears at 6, 12, 24 months with HPV test of cure, to be followed annually for a ten year period. Repeat colposcopy will be advised   if HPV test comes positive, (adequately treated CIN has a recurrence rate of 5% at two years). A letter to her GP will be sent. She will also be provided with written   information leaflets 

colposcopy Posted by ghada S.
  1. I have to explain the procedure to the woman in simple language. It is an outpatient  procedure under local or regional analgesia. An examination of the cervix is done by colposcope which can magnify cervix up to 40 times. This enables identification of abnormal areas to be biopsied & examined in the lab. I will explain the need to treat  abnormalities if detected by a large loop  diathermy excision. I will provide the woman with written information and I will obtain a consent. I will inform her that definite diagnosis is by histology report of the excised part(s) & further follow up &management  will depend on it.
  2. I will advise her to avoid tampons application, bathing & sexual intercourse for  one month. I will prescribe her prophylactic antibiotic & analgesic as she may develop some discomfort. I will inform her that she may have some spotting or discharge. I will advise her to seek medical advice if she thinks that excessive bleeding or offensive discharge. Contact  phone number should be provided. Follow up appointment should be arranged. The woman should know the pathway of management  with the result of histology. If results show invasive disease referral to oncologist & in case of cervical intraepithelial neoplasia CIN repeated smear after 6 months. If smear shows moderate or severe dyskariosis referral to colposcopy again. If smear results shows normal, mild or borderline, HPV triage should be done which if +ve referral to colposcopy& if – ve  3 year recall .