Indications for colposcopy

A. Abnormal cytological abnormalities:

1. Persistent atypical squamous cells of undetermined significance (ASCUS) or ASCUS with positive high-risk HPV subtypes.

2. ASCUS suggestive of high-grade lesion (ASCH).

3. Atypical glandular cells (AGC).

4. Low-grade squamous intraepithelial lesion (LSIL).

5. High-grade squamous intraepithelial lesion (HSIL).

B. Evaluation of an abnormal appearing cervix, vagina, or vulva.

II. Contraindications. Active cervicitis should be treated before the examination. Biopsies are relatively contra-

indicated in patients on anticoagulations, who have a known bleeding disorder, or who are pregnant.

III. Procedure. The medical history is obtained, including age, gravity, parity, last menstrual period, use and type of contraception, prior cervical cytology results, allergies, significant medical history including HIV status and history of any immunosuppressive conditions or medications, other medications, prior cervical procedures, and smoking history. If there is any possibility of pregnancy, a pregnancy test is obtained.

A. Repeat cervical cytology. If the patient has not had cervical cytology in the last six weeks, a repeat assessment of cervical cytology is done.

B. Visualization. The cervix and vagina are examined with a bright light, and then with the colposcope. Cotton soaked in saline is used to cleanse the cervix. Pigmented areas and obvious lesions are noted. The cervix is examined for areas of erosion, true leukoplakia, pigmented lesions, or areas of obvious ulceration or exophytic growth. Three to 5 percent acetic acid is applied to the cervix using cotton swabs and the cervix is reexamined. A green-filter examination is performed to accentuate abnormal vasculature. Iodine solution (Lugol's or Schiller's) is used to improve visualization of abnormal areas.

C. The clinician first identifies the squamocolumnar junction or transformation zone (TZ) . The clinician should differentiate between the grey-pink appearing ectocervix and the pink-red appearing endocervix. The region where the two cell types meet, termed the squamocolumnar junction, defines the "transformation" zone. The ability to see the transformation zone dictates whether the colposcopic exam is adequate (ie, the entire squamocolumnar junction is visible circumferentially around the os) or unsatisfactory.

D. The upper one-third of the vagina, in particular the lateral fornices, is also inspected.

E. Biopsies are obtained from the most abnormal appearing areas. Biopsies should be taken from inferior to superior to avoid bleeding over the target sites.

F. Endocervical curettage is performed in patients with HSIL, AGUS, adenocarcinoma in situ (AIS) on the endocervical margin following cone biopsy, LSIL but no visible lesion, and those with an unsatisfactory colposcopic examination. A long straight curette is used to scrape the four quadrants of the endocervical canal and an endocervical brush is employed to remove any exfoliated tissue. Endocervical curettage in not performed in pregnant women.

References: See page 184.

0 0

Post a comment