What is colposcopy?
Colposcopy is a simple medical diagnostic procedure done in a gynecological practice by a certified OB/GEN physician in the American college of obstetricians and gynecologists for detailed examination of cervical and vaginal epithelium and sub epithelial vasculature if your cervical screening (pap smear) reveals abnormal cells so the colposcope is used to determine whether these cells are precancerous or if it’s a simple condition like polyps or cysts and may aid in their treatment using various excisional methods .
A colposcope is a low power binocular microscope with bright illumination and magnification of ×5:40 times that provides your doctor with a better look into the cells of the cervix and vagina to identify any sort of dysplasia as (dyskaryosis , increased mitotic figures, pleomorphism in shape , size and staining characteristics of the cells )
It also provides higher magnification and green light to evaluate the different vascular patterns of the sub epithelial vasculature that supplies the cervix to diagnose any abnormal vasculature that indicating the presence of malignancy.
› There are special colposcopies used for the examination of rape and sexual assault victims.
Why you need colposcopy?
Colposcopy may be indicated to be done by your physician in case of :
- Abnormal cells in your pap smear.
- A suspicious lesion in the cervix.
- If you test positive for HPV (human papillomavirus) also called Genital warts .
- To identify the cause of abnormal vaginal bleeding (post sexual intercourse bleeding).
- To check an abnormal looking cervix during a pelvic exam.
- To obtain a biopsy for definitive diagnosis of CIN.
- For follow up after conservative treatment of CIN.
What to expect?
A lot of females have anxiety before getting their colposcopy done as it can be an invasive procedure but it is very important to try and calm down and get over these worries as it is only the fear of the unknown and it is very crucial to get it done for early identification of precancerous lesions that are easier to treat and almost get completely cured by the simple removal of these parts of the cervix instead of being left undiagnosed and turning over the years into cancerous and invasive conditions that then lead to more serious issues like spreading to the bladder and rectum and then metastasizing to distant organs making the condition not easily treatable as precancerous ones and with far more serious life threatening complications and sequelae.
So you may need to take someone you trust with you to that appointment to give you the support you need, and make sure to ask your doctor during your visit any questions and inquiries you have concerning the procedure , your condition , different treatment modalities, prognosis and follow up after treatment .
Many people also cancel their appointments for fear of the procedure being painful but it is not supposed to be very painful _only slightly uncomfortable _ as it is only for visualizing your cervix .
your doctor may apply a local anesthetic if you need a tissue sample taken (biopsy), all you can expect is a little discomfort and pressure from the device introduced into the cervix (speculum) and a burning sensation if the doctor applied a solution to wash the cervix or to perform diagnostic tests or to apply topical medication.
Your doctor may give you an over the counter pain reliever (ibuprofen, acetaminophen ) before the procedure starts by 20 minutes to make you feel more comfortable and the procedure less painful.
What is the Importance of colposcopy?
Cervical cancer is one of the most common types of cancer in women worldwide especially in developing countries due to the lack of screening but it is considered a preventable type of cancer as Regular cervical screening tests like pap smears , colposcopies and biopsies regularly done in developed countries have markedly increased the amount of cases that are diagnosed early in the precancerous stage making it easier to treat them and lowered the amount of women who present later on with advanced cancers and metastases that require more intensive treatment and have higher morbidity and mortality rates.
How to prepare?
- It is best to schedule the appointment in advance making sure you won’t be on your monthly period because the bleeding obscures the visual field making it difficult to properly carry out the examination of the lesion.
- You should avoid using tampons or apply any creams ,medications, lubricants or douches to your vagina before the examination.
- You should also avoid having vaginal intercourse before the procedure for a couple of days so as not to cause tenderness in the vagina.
- You should tell your doctor if you’re using any blood thinners like aspirin as it could lead to heavier bleeding in case a biopsy is taken .
- Tell your doctor if you have any allergies like allergy to latex or any medications like anesthetics.
- Tell your doctor if you are pregnant as she/he’ll probably postpone the biopsy.
What is the procedure?
1. You should sign a consent forum before the procedure begins after discussing it with your doctor.
2. You will get undressed from the waist down , put on a hospital gown and settle on the examination chair in a dorsal lithotomy position.
3. Your doctor will start by inspecting your external genital organs (vulva , vagina) for any apparent abnormal lesions before the beginning of the examination.
4. The doctor or nurse will open your cervix using a device called the speculum that separates the walls of your vagina keeping it open to inspect the cervix just like the one used before in obtaining your pap smear .
5. The doctor will apply a cleaning solution like vinegar (acetic acid) to clear out the mucus secretions in the cervix and help him visualize abnormal cells by the naked eye as these cells turn into white patches on the cervix after washing the tissue with the acetic acid solution .
6. The colposcopy will be illuminated and used by your doctor to inspect the cervix it will not enter your vagina but he may use a cotton swab to manipulate the cervix in order to see the inner margins better and assess the consistency of the lesion .
7. Another solution may be added like iodine to perform what is known as a (Schiller’s test )that helps identify the non staining abnormal areas of the cervix as the normally mature squamous epithelial cells contain abundant glycogen that stains dark brown with iodine while dysplastic ones don’t contain the same amount of glycogen needed to take the color of the iodine dye so any cell that doesn’t take the stain is considered to be an abnormal dysplastic cell.
8. If you need a biopsy the doctor will tell you in the same setting and take it using the different techniques according to the type of biopsy needed to obtain a proper sample of the lesion.
9. It should take up to 15-30 minutes to finish the entire
10. Then your biopsy will be taken to the pathology lab for further tests to be performed on the sample to get to a specific diagnosis.
11. the results would take up to 1-4 weeks in average till you receive them and discuss them with your doctor and go through the different modalities of treatment.
What to expect after colposcopy?
You should be able to go back home right after the procedure is over .
You can also get back to your normal activities and work and drive normally unless you would prefer to get some rest for a day but if you get a biopsy it’s recommended to stay away from strenuous activities like jumping and swimming.
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- You may experience cramps for 2:3 days after the procedure just like your normal period cramps.
- You may feel some pelvic pain but it should go away in a few days and it shouldn’t be severe.
- You may also find brown to black vaginal discharge resembling grounded coffee beans but it should end in a couple of days .
- You can have bleeding but it shouldn’t last for more than 7 days you should wear a pad to catch the blood and not use a tampon .
Discharge after colposcopy:
You may have a brownish to blackish discharge after the procedure and that’s mostly from the bleeding and the tenderness in your cervix or it can be from the topical medication applied by your doctor to help healing of the wound that changes color into black when exposed to blood after a biopsy is taken .
Bleeding after colposcopy:
There tends to be bleeding for a few days after the procedure from the introduction of the speculum into the vagina but it’s not supposed to be heavy bleeding or last longer than a week as this might be a sign of infection through contaminated medical equipment or the physician not using proper antiseptic techniques.
The bleeding may last longer in case of a biopsy as it takes time for the wound to heal after the sample is taken depending on the type of biopsy which the doctor used and the extent of tissue excised.
Sex after colposcopy:
It’s best to avoid having vaginal intercourse before and after the procedure for at least a week to avoid causing further tenderness and bleeding and so as not to open the wound if a biopsy was taken.
When to call your doctor?
If you feel any of these side effects you should call your doctor or go to the nearest hospital:
- High grade fever
- Chills
- Heavy bleeding
- Yellow colored , foul smelling vaginal discharge
- Severe abdominal pain
As this means you may have gotten an infection from the procedure and that requires prompt treatment with the recommended antibiotics to avoid further complications and spread of infection to other body parts.
What are the normal colposcopic findings?
Your doctor must be able to:
- Find a smooth pink lustrous surface of the cervix and vagina during the primary inspection.
- visualize the transformation zone or (TZ) also called the (squamocolumnar junction ) suited near the external os between the cervix and vagina to its upper limit and into the endocervix for a cm or so because it is the most common site for finding cancer bearing cells in the cervix in almost 90%of the cases as it’s a place where metaplasia occurs frequently.
- Find normal subepithelial vascular pattern consisting of healthy looking vessels ending in smooth branching and no signs of bleeding on touch.
Patients with normal colposcopic findings are assured and asked to come back later after one year for annual screening to detect any problems early.
What are the abnormal colposcopic findings?
The doctor may see :
- Irregular friable cauliflower Like growths from the cervix with areas of hemorrhage and necrosis ( most probably cancerous).
- Focal white lesions on administering acetic acid with well defined borders and outward extension from the cervix which could be precancerous cells that require further investigation.
- Leukoplakia which are also white lesions raised above the surface that don’t need acetic acid to be seen and require a biopsy.
- Atrophic areas that are wasted away.
- Any abnormal vascular pattern of punctate or mosaic shapes and any abnormally branching vessels like comma shaped or cork screw shaped branches that are suggestive of micro invasion of the sub epithelium.
- Poor iodine staining cells in Schiller’s test that are dysplastic in nature.
Your physician has to describe the lesions shapes and sizes and margins whether it’s taking up all of the four quadrants of the cervix and the direction of its extension into the cervix or away from the cervix and he can also take some images of the lesion to reassess them later.
The doctor may also get unsatisfactory results like the inability to visualize the transformation zone (TZ) to its upper limit as it could be shifted upward to the endocervix normally as in menopausal women by the effect of different hormones.
Then your doctor will ask for either endocervical curettage or a biopsy to be taken in the same setting if the lesion requires further investigations but if the lesion is diagnosed easily he may try to treat it by excision or may decide to take time for following its progression.
When is a biopsy indicated?
- If the colposcopy results are unsatisfactory .
- If there is suspicion of CIN, micro invasion or invasive cervical cancer.
- If there are multifocal abnormally shaped lesions.
- If there is discrepancy between your pap smear ,colposcopy and biopsy.
What is a biopsy?
It is a minimal surgical procedure in which your doctor will remove a small amount of tissue from the cervix and send it to a pathology lab to get it thoroughly examined histologically and pathologically to give a definitive diagnosis of CIN ,micro invasion or invasion cervical cancer .
It can also be used for treatment of certain conditions like the removal of small polyps and genital warts.
What are the different types of biopsies?
- Endocervical curettage (ECC): in which the doctor removes a small amount of cells using a curette that looks like a peeler .
- Punch biopsy: in which the doctor using a small forceps punches out a small amount of tissue.
- Cone biopsy: in which the doctor uses a scalpel or a cold knife to remove a large cone shaped piece of tissue And a part of the underlying cervical tissue in order to get a deeper look into the cervix and estimate the extent of the invasion into the cervix to be able to grade it .
There are many other methods used than a scalpel for obtaining a cone biopsy for example :
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- using laser excision conization by co2 laser .
- Using loop electro-excisional procedure (LEEP) by a thin wire loop.
The doctor may give you a general anesthetic in case of a cone biopsy to make it less painful as it penetrates deeper into the tissue irritating the nerves in the area.
After the biopsy is taken your doctor will cauterize the area or apply sutures if the biopsy is big to minimize the bleeding but if it’s a small biopsy he will only apply some topical medication over the wound and it will heal on its own in approximately the following 4-6 weeks.
What are the complications of a biopsy?
1) bleeding for a couple of days.
2) cervical stenosis that may lead to dystocia (obstructed labor) if your pregnant or to secondary infertility only if done excessively or using wrong technique.
3) cervical incontinence that may lead to habitual abortion.
But these complications are rare and you can discuss with your doctor if you want to get pregnant and have kids in the future
What are the results of the biopsy?
It will confirm if you have:
- HPV infection or genital warts
- Simple polyps
- (CIN ) cervical intra epithelial neoplasia which is a precancerous condition.
- (CGIN) cervical glandular intra epithelial neoplasia which is less common than (CIN) but more severe and detected only in the glandular cells of the cervix.
- Cervical cancer.
Grading of CIN:
- Grade 1: low grade intra epithelial lesion (LSIL)
- Grade 2: high grade intra epithelial lesion (HSIL) in which the dysplastic cells are seen in more than 1/3 of the lining of the cervix .
- Grade 3: high grade intra epithelial lesion (HSIL) in which the dysplastic cells are seen in more than 2/3 of the lining of the cervix.
- Carcinoma in situ (CIS): in which the dysplastic cells are seen all over the epithelial lining of the cervix but not extending to the basement membrane.
What is the cost of colposcopy in the USA?
Colposcopy without biopsy done in an office in the USA prices usually range from 100$ to 500$ depending on the place, with additional 200$ to 300$ laboratory fees if multiple biopsies were taken to be tested ,it differs depending on the type and number of biopsies taken .
Those who have insurance or on different health plans can find lower prices with 10%-50% copay of the procedure’s cost.