COLPOSCOPY

Cervical Screening QARC Training School October 2012

Terminology • Dyskaryosis • Cervical Intraepithelial Neoplasia (CIN)

Time

Disease progression

Months Years Normal epithelium HPV infection; koilocytosis CIN I CIN II CIN III Invasive cervical cancer Borderline Mild Moderate Severe Dyskaryosis CIN I 57% CIN II 43% CIN III 32% Approx. likelihood of regression

Indications for Colposcopy • ABNORMAL CYTOLOGY • Moderate or severely dyskaryotic result • • Borderline/mild samples that are high risk (16 & 18) HPV positive Abnormal glandular cells • FINDINGS OR SYMPTOMS • Suspicious appearance to cervix • Symptomatology – post coital bleeding

Examination • • • • • • Cusco Speculum ??repeat LBC sample Acetic Acid +/- Lugols Iodine Colposcope Punch Biopsy Silver nitrate

Treatment • Excisional – LETZ, Knife Cone • Destructive - Cold Coag, Laser Ablation • Rarely - Hysterectomy

Follow-Up prior to HPV testing • • • After Treatment for high grade CIN (or worse) – Cervical sampling 6, 12 then annually for 10 years After Treatment for low grade CIN – 6, 12, 24 then normal recall After hysterectomy (if no Cervix) – no longer part of re-call! Gynaecologist sets intervals

What is HPV test of cure?

• • • • Women who have a normal, borderline or mild cervical screening result six months after treatment for CIN and who also test negative for high-risk HPV have a very low risk of residual disease.

Samples taken six months post treatment that are cytology negative are HPV tested.

Women whose samples show no high-risk HPV will proceed to three year routine recall – avoiding the need for up to 10 years of annual cervical screening.

Women who have an abnormal cervical screening result or whose samples show high-risk HPV six months after treatment will be referred back to colposcopy.

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Letz and pregnancy • • • Knife cone worse than Letz Laser ablation carries no risk Complications • Premature labour (<37/40) 1.7 RR • • • Premature rupture of membranes 2.7 RR Low birthweight 1.8 RR Cervical stenosis – emergency LSCS

Colposcopy in Pregnancy • Aim is to exclude invasive disease • No evidence of more rapid progression in pregnancy • • Avoid treatment but can biopsy Warts more florid • Sampling and colposcopy are easily interpreted despite pregnancy changes • If has invasive disease when pregnant • Treat Ca cx if under 24/40 i.e. terminate pregnancy. After 24/40 deliver by LSCS as soon as baby is viable (32/40)

Colposcopy after the menopause • Transformation zone is usually not visible • With low grade cytology try to repeat ‘sample’ after a course of topical oestrogen

Cervical Dysplasia • Oncogenic virus is the cause of over 99% of cases • Co-factors • • • Smoking Parity Immunocompromise (Transplants & HIV)

HPV triage as an adjunct to LBC & Colposcopy • LBC allows HPV testing • No value in the assessment of women with high grade dyskaryosis – assumption is that they are all HPV +ve • In women with borderline and mild dyskaryosis may allow decision about who needs colposcopy • Follow up after treatment for CIN