Colposcopy is a vital diagnostic procedure that plays a pivotal role in women's health care, particularly in the early detection and prevention of cervical cancer. This procedure involves using a specialized instrument known as a colposcope to examine the cervix, vagina, and vulva closely. By providing a magnified view of these areas, colposcopy enables healthcare professionals to identify and evaluate abnormalities that may not be visible to the naked eye. Directed biopsies are often performed as part of the procedure.
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Whether as a follow-up to an abnormal Pap smear, in response to high-risk human papillomavirus (HPV) results, or for assessing suspicious cervical appearances, colposcopy plays a crucial role in determining the appropriate course of action to safeguard women's health. This activity outlines the key aspects of the colposcopic procedure along with its significance in clinical practice. It also reviews the role of the interprofessional team in enhancing patient-centered care and ultimately reducing the burden of cervical cancer.
Objectives:
Identify the indications for colposcopy.
Accurately assess and interpret colposcopy findings and effectively communicate the results to patients, providing clear explanations of findings and potential treatment options.
Apply appropriate biopsy techniques during colposcopy to obtain representative tissue samples for histological analysis and understand potential complications of colposcopy.
Collaborate with interprofessional team members, including gynecologists, oncologists, and primary care providers to improve care coordination and communication with patients needing a colposcopy.
Colposcopy is a diagnostic procedure in which a lighted magnifying instrument called a colposcope is used to examine the cervix, vagina, and vulva. Hans Hinselmen of Germany first described colposcopy in 1925 as a screening tool for cervical cancer. The procedure is performed to evaluate patients with an abnormal Papanicolaou (Pap) test, those who test positive for high-risk human papillomavirus (HPV) DNA, or those with a suspicious appearing cervix, even if screening for dysplasia is negative. It may also be performed as a posttreatment follow-up of cervical intraepithelial neoplasia (CIN) and invasive carcinoma.
Although colposcopy is practiced by many clinicians (including advanced practice providers, primary care providers, gynecologists, gynecological oncologists, and others), standardization of the procedural process, necessary training, and continued development and maintenance of colposcopic skills are generally poor. It is also well-documented that colposcopy has significant interperformer variability and poor reliability. In 2017, the American Society for Colposcopy and Cervical Pathology (ASCCP) published colposcopy standards to address these and other concerns.[1] The standardization of terminology was established to simplify and ensure a comprehensive colposcopic exam was performed at every encounter.[2]
The cells at the squamocolumnar junction (SCJ) of the endo- and ectocervix are susceptible to HPV infection and dysplastic change. The virus incorporates its DNA into the developing cell and turns off the tumor suppressor gene (p53 and RB) function, allowing cells to become dysplastic. This is a slow, gradual process with many developmental stages that can be identified before the dysplasia progresses to cervical cancer (>90% of which is caused by HPV).
Given the Pap as an adequate screening test for sampling these changing cells, the dysplastic process can be identified early and treated before progressing to cervical cancer. Dysplasia is not limited to the cervix; the vaginal and vulvar tissue are also susceptible to the HPV virus. Colposcopy of the cervix and vagina are essentially identical; however, because the vulval tissue has a delayed absorption of acetic acid, the procedure is slightly modified.
The indications for a colposcopy are risk-based. Women referred for colposcopy have various underlying risks for cervical precancer based on their cytological results, HPV testing (if it was performed), and sometimes a personal history of cervical dysplasia. Each can be triaged accordingly, but when colposcopy is indicated, it is used to diagnose the presence of dysplasia and its severity.
Indications for colposcopy are as follows:
To localize the lesion
To map the extent of the lesion
To select the biopsy site or sites
Evaluation of women with an abnormal Pap test
Evaluation of women testing positive for high-risk HPV DNA
Evaluation of women with positive visual inspection with acetic acid test results
Evaluation of a suspicious appearing cervix with postcoital or postmenopausal bleeding, even if the Pap smear is negative
Unexplained abnormal lower genital tract bleeding
Persistent inflammatory or unsatisfactory cervical cytology despite appropriate treatment, especially with high-risk factors for carcinoma of the cervix
Evaluation of persistent abnormal vaginal discharge or pruritus vulvae
Identification and management of subclinical papillomavirus infection
History of in-utero diethylstilbestrol (DES) exposure
Conservative management of intraepithelial neoplasia
Identification and management of vaginal extension of cervical neoplasia
After treatment of intraepithelial neoplasia and invasive carcinoma
Postradiation follow-up [3] [4] [5]
Posttreatment follow-up
Not all Pap tests must be followed by colposcopy, though many are. Low-risk Pap tests (ie, low-grade squamous intraepithelial lesion [LSIL] or atypical squamous cells of undetermined significance [ASCUS] with negative HPV) are not as likely to have significant colposcopic findings, including severe dysplasia. Therefore, immediate colposcopy is not indicated, and the patient can follow up the following year with a repeat Pap test. However, if the Pap test remains abnormal with LSIL or ASCUS positive for HPV, a colposcopy is recommended.
Some Pap test findings are more closely associated with severe cervical dysplasia. These include high-grade squamous intraepithelial lesions (HSIL) and atypical squamous cells and cannot exclude high-grade intraepithelial lesions (ASC-H). When there is suspicion of high-grade lesions, a possibility exists that invasive cervical cancer could be present. Immediate colposcopy is recommended in patients with initial Pap test findings more closely correlated with severe cervical dysplasia.
Current guidelines for colposcopy depend on the risk of HSIL. In certain instances, if the risk is greater than 25% (based on current HPV and cytology results combined with past history), immediate treatment may be acceptable. If the risk of finding CIN grade 3 or greater (CIN3+) is above 4%, colposcopy is indicated. These "clinical action thresholds" consider the immediate risk of CIN3 or invasive cancer. Five-year risks are used for longer-term surveillance guidelines.[6]
There are no specific contraindications to a colposcopy except an active or untreated cervical or vaginal infection. Certain steps of the colposcopy procedure are excluded if a patient is pregnant. The endocervical curettage component is not performed due to potential risks of adverse effects on the pregnancy without substantial benefit. Furthermore, pregnancy can limit management options given that cervical excisional procedures are contraindicated during pregnancy unless cervical cancer is suspected. In that case, a shallow excisional procedure may be necessary.[7]
The equipment needed to perform an adequate colposcopy includes a vaginal speculum, a colposcope, 5% acetic acid, Lugol's solution, biopsy forceps, an endocervical speculum, a Kevorkian curette or endocervical brush, and solutions or methods to stem bleeding. The colposcope is a dissecting microscope that can magnify the cervical, vaginal, or vulvar tissue. Colposcopes differ in their optional features. Variation occurs with respect to lens types, computer-generated images, light filters, and even cameras to capture images or videos. Colposcopes should have 2 settings—low power and high power magnification—to evaluate a lesion. Most scopes have interchangeable magnifications at 10x and 18x. The scope should have a normal and green light filter to identify vascular patterns that can be difficult to recognize with white light.[8]
There is a new procedural method called digital video colposcopy, which provides magnification and illumination with the help of a built-in camera and a strong light source (LED). Binocular eyepieces are not required, and the colposcopic image is viewed on a high-resolution video monitor. This procedure has several advantages, such as easy manipulation and visualization of images by several viewers simultaneously, including trainees and the patient. Additionally, it obtains a permanent record of the findings in the form of a replica of the image being seen by the examiner.
Five percent acetic acid is applied to the cervix with a cotton ball or large swab and allowed to soak for 1 to 2 minutes. Cells that are dysplastic dehydrate and turn acetowhite with the application of acetic acid. This process can cause the patient some minor discomfort. All areas of the cervix and upper vaginal tissue should be thoroughly inspected. Some colposcopists will apply Lugol's solution (an iodine-containing solution) that will highlight the dysplastic area with the lack of absorption of the brown solution, causing it to be more yellow. This is referred to as a "Schiller's test." A positive Schiller test is an area that is nonstaining with iodine.[9]
An endocervical speculum may be needed to inspect the cervical os adequately. There is a variety of biopsy forceps available for cervical biopsy; the more common ones are Tischler cervical biopsy punch forceps, Burke biopsy forceps, or some variation of these.[8] There are different methods to stop the bleeding after a biopsy has been taken, including applying Monsel's solution, using silver nitrate, or even Bovie cauterization.
An experienced colposcopist is paramount to performing a reliable and accurate colposcopy. An assistant handling the instruments and specimen containers during the procedure is helpful but not required. A chaperone should always be in the room since colposcopy is an invasive procedure.
There is no required preparation for the patient having a colposcopy; however, it can be challenging to perform if she is on her menstrual cycle due to obscuring blood. Preparing the room with readily available equipment will expedite the patient’s visit.
ASCCP has published standardization guidelines for the performance of colposcopy and makes recommendations for extensive and minimum requirements for a colposcopy. The colposcopist should examine the vulva, vagina, and cervix grossly without and with the application of 5% acetic acid.[10] The entire cervix and SCJ must be visualized for procedure adequacy. Both white light and a red-free (blue or green) filter should be applied to the visual field to identify any lesions.[10]
Directed biopsies of lesions should be taken of each abnormal finding. Documentation should include the visibility extent, size, location, and description of each lesion (color/contour/border/vascular changes), presence or absence of acetowhitening, complete or incomplete visibility of the SCJ, documentation of biopsies and locations (if an endocervical curettage was performed), and finally the impression of the colposcopy (benign normal/low grade/high grade/cancer).[10] Application of Monsel’s solution or silver nitrate should be applied to the biopsy sites if persistently bleeding upon completion of the colposcopy.
In 2011, the International Federation for Cervical Pathology and Colposcopy (IFCPC) introduced nomenclature and terminology to standardize colposcopic procedures performed by healthcare professionals (see Table 1. 2011 IFCPC Nomenclature).[11] Its use in general clinical practice was recommended and subsequently adopted.
The Swede scoring system is used to score the colposcopic findings and to have uniformity in the reporting system (see Table 2. Swede Scoring System). The total possible score is 10.[12] The performance and accuracy of colposcopic scoring are highly dependent upon the training and experience of the colposcopist.
The original study by Strander et al reported the sensitivity to predict CIN grade 2 and higher (CIN2+) with a Swede score ≥5 was 100%, and the specificity was 90% with a score ≥8. It was recommended that biopsy be reserved for a Swede score ≥5 (see Table 3. Use of Swede Score to Predict Histology).[13]
Table 1. 2011 IFCPC Nomenclature
Adequate or inadequate If inadequate, a reason must be given (eg, cervix obscured by inflammation, bleeding, scar) If inadequate, a reason must be given (eg, cervix obscured by inflammation, bleeding, scar)
Table 2. Swede Scoring System
Score 0
Table 3. Use of Swede Score to Predict Histology
Overall Swede Score Colposcopic Prediction of Probable Histology
Colposcopy complications are most often related to an obscured visual field, severe atrophy, or scarring present. Procedural risks are low, including significant bleeding, infection, and long-term morbidity. There is potential harm in the performance of colposcopy by an unskilled clinician.[14] Anxiety and patient discomfort associated with the procedure can be significant and should not be underestimated. It can be challenging to ascertain if patients' negative feelings about colposcopy are related to the idea of HPV infection or the procedure itself.
Professional training and continued experience in colposcopy are necessary for competency. The false-negative rate (missed high-grade squamous intraepithelial/invasive cancer) for colposcopy ranges from 13% to 69%.[15][16] Today, there are improved screening tests with cytology, molecular testing for HPV, and risk-based assessments. Therefore, there is less need for diagnostic testing with colposcopy, which creates less opportunity for ongoing training and experience for newly trained clinicians. This fuels an even greater need for experienced, skilled colposcopists.
Even after a negative colposcopic examination, studies have reported subsequent high-grade disease. In a large trial for low-grade abnormalities, the sensitivity of initial colposcopy to detect high-grade disease in the subsequent 2 years was only 53%.[17] Studies have shown a low level of agreement between the colposcopic impression of disease and final histology.[18][19] The use of multiple biopsies increases the accuracy of colposcopic diagnoses.[20] Endocervical evaluation with a curette or brush may also be helpful.[21] These studies highlight the need for continued observation based on the personalized risk of cytology, HPV testing, and past history.
Sources of Error in Colposcopy
Every colposcopic image reflects a specific tissue pattern resulting from the interaction of surface epithelium and stroma. Misinterpretation of patterns is the most common error in colposcopy. A flat, mild acetowhite grade 1 lesion is more likely to be overdiagnosed as these findings mimic immature or active metaplastic epithelium in young women, regenerative epithelium, subclinical HPV infection, and congenital transformation zone. If in doubt, such lesions must be biopsied. Colposcopy should be avoided during the regenerative period of epithelium following CO2 laser ablation, cryosurgery, or trauma. Another common error is making a diagnosis without completely visualizing the cervix in cases where it is obscured by an endocervical polyp or large retention cyst, or there is a stenosed internal os, and in cases of incomplete visibility of the SCJ.
Errors may occur in association with pregnancy due to physiological and morphological changes. Vasodilatation and congestion during pregnancy produce accentuated colposcopic patterns with more pronounced mosaics and punctations and enhanced acetic acid effect, which may mimic paraneoplastic lesions. These findings may be minimized by using a large speculum covered with a condom, quadrant-wise interpretation, and remembering that colposcopic changes in pregnancy are 1 grade higher than those in the nonpregnant population. Colposcopic biopsy and the use of an endocervical brush for cytology are safe if indicated during pregnancy, while endocervical curettage is contraindicated.
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Colposcopy can be difficult in postmenopausal women. An unsatisfactory colposcopy occurs in 25% of postmenopausal women due to the incomplete visibility of the SCJ and vaginal atrophy. Prior to colposcopy, it may be advisable to recommend these patients use vaginal estrogen to enhance the likelihood of achieving a satisfactory colposcopic examination.
Colposcopy is a diagnostic procedure performed due to an abnormal cervical screening test or a visible lesion seen on the cervix during an examination. This diagnostic procedure assists with formulating a management plan based on the biopsy results. Generally, all results can be observed or treated based on evidence-based guidelines. Low-grade lesions can be followed up and managed according to ASCCP guideline algorithms. High-grade lesions are treated depending on the patient’s age and fertility status.[22]
A colposcopy considered inadequate for various reasons may lead to a more aggressive sampling of the cervical lesion with an excisional procedure of the cervix to attain the diagnosis. Invasive lesions should be referred to a gynecological oncologist for treatment options.
Pregnant patients will have treatment deferred until after delivery unless there is a specific concern for an invasive lesion.
Colposcopy is necessary to prevent cervical cancer from developing, but colposcopic expertise is not commonplace. Health professionals involved in colposcopy, including physicians, nurses, and pharmacists, must possess specialized skills. In the US, colposcopic services are delivered in diverse practice settings, including academic and nonacademic referral settings, primary care environments in urban and rural communities, and clinics funded by private and public resources.[23]
Multiple types of clinical professionals can master this procedure. The training of various clinicians should be encouraged and ongoing. Developing a standardized approach to colposcopy is vital. Clinicians should adhere to recommended standardization and documentation of the procedure to improve patient care. Establishing clear protocols, guidelines, and clinical pathways ensures a consistent patient evaluation and management strategy. Future technological enhancement may continue to improve the reliability and validity of the colposcopic results.
All team members share the responsibility for patient safety and well-being. Healthcare professionals must collaborate to ensure seamless transitions and a comprehensive care plan for patients with abnormal findings. Enhancing patient-centered care in colposcopy involves honing skills, developing a clear strategy, fostering interprofessional communication, and coordinating care effectively. By prioritizing these aspects, healthcare professionals involved with colposcopy procedures can improve patient safety, outcomes, and overall team performance.
Disclosure: Danielle Cooper declares no relevant financial relationships with ineligible companies.
Disclosure: Charles Dunton declares no relevant financial relationships with ineligible companies.
Colposcopy is an exam that looks closely at the cervix. It uses a special magnifying instrument to do this. The instrument also may be used to look at the vagina and vulva.
Colposcopy is an exam that looks closely at the cervix. It uses a special magnifying instrument to do this. The instrument also may be used to look at the vagina and vulva.
Colposcopy, which is pronounced kol-POS-kuh-pee, looks for signs of disease. A colposcopy may be recommended if a Pap test result shows something concerning. If your healthcare team finds a suspicious area of cells during your colposcopy procedure, a sample of tissue can be collected for testing.
It's common to feel anxious before a colposcopy exam. Knowing what to expect during your colposcopy may help you feel more comfortable.
The ovaries, fallopian tubes, uterus, cervix and vagina (vaginal canal) make up the female reproductive system.
The vulva is the outer part of the female genitalia, including the labia majora, labia minora and clitoris.
A healthcare professional may recommend colposcopy if a Pap test or pelvic exam finds something concerning.
Colposcopy can help diagnose:
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Colposcopy is a safe procedure that has very few risks. Rarely, complications from biopsies taken during colposcopy can happen. A biopsy is a procedure to remove a sample of tissue for testing in a lab. Biopsy complications may include:
To prepare for your colposcopy, your healthcare team may recommend that you:
It is common to feel anxious before a colposcopy appointment. Being anxious can make you feel generally uncomfortable. You may find it hard to concentrate. You also may have difficulty sleeping.
People who are very anxious about colposcopy may have more pain during the procedure than people who find ways to cope with and manage their feelings.
Things that can help with feeling anxious about colposcopy include:
Colposcopy is usually done in a healthcare professional's office. The procedure typically takes 10 to 20 minutes. You'll lie on your back on a table with your feet in supports, just as during a pelvic exam or Pap test.
A metal or plastic speculum is placed in your vagina. The speculum holds open the walls of your vagina so that your healthcare professional can see your cervix.
The special magnifying instrument, called a colposcope, is placed a few inches away from your vulva. Your healthcare professional shines a bright light into your vagina and looks through the lens of the colposcope, as if using binoculars.
Your cervix and vagina are swabbed with cotton to clear away any mucus. A solution of vinegar or another type of solution may be applied to the area. This may cause a burning or tingling sensation. The solution helps highlight any areas of suspicious cells.
If your healthcare professional finds a suspicious area, a small sample of tissue may be taken for lab testing. To collect the sample, a sharp biopsy instrument is used to remove a small piece of tissue. If there are multiple suspicious areas, your healthcare professional may take multiple biopsy samples.
A chemical solution may be applied to the biopsy area to limit bleeding.
If your healthcare professional didn't do a biopsy during your colposcopy, you won't have any restrictions on your activity once your exam is complete. You may experience some spotting or very light bleeding from your vagina in the next day or two.
If you had a biopsy sample taken during your colposcopy, you may experience:
Use a pad to catch any blood or discharge. Avoid tampons, douching and vaginal intercourse for a week after your biopsy, or for as long as you're instructed.
Contact your healthcare team if you have any lasting symptoms that worry you.
Symptoms that may indicate complications include:
Before you leave your colposcopy appointment, ask your healthcare professional when you can expect the results. Also ask for a phone number you may call if you don't hear back within a specified time.
The results of your colposcopy will determine whether you'll need any further testing and treatment.
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