Colposcopy and Cervical Treatments

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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Colposcopy is the magnified direct inspection of the surface of a woman's genital area, including the cervix, vagina and vulva (when it may be referred to as vulvoscopy), using a light source and a binocular microscope - a colposcope. It is used to evaluate potentially cancerous areas, typically after an abnormal cervical screening test. A biopsy of an abnormal area may be taken during the procedure. Colposcopy can also be used to detect inflammatory or infectious changes and harmless growths and also to assess traumatic injuries or gather evidence in cases of sexual assault.

Worldwide, cervical cancer is the second most common female malignancy. The national cervical screening programmes in the UK have reduced both incidence of and deaths from the disease. Colposcopy is used within this programme as a secondary tool. Human papillomavirus (HPV) is the main cause of cervical cancer. HPV vaccination against high-risk oncotypes of HPV is expected to reduce the incidence and deaths from cervical cancer still further.

Management of cervical screening test results[1, 2]

  • Investigate and manage any incidental findings (eg, infections).
  • Ensure that the patient is informed of the result.
  • Recall as appropriate for a negative result.
  • Repeat the sample immediately after treating any infection or atrophy, preferably within three months.
  • Repeat the sample as soon as convenient if technically inadequate.
  • If persistent (two consecutive inadequate samples), advise assessment by colposcopy.
Borderline nuclear change in squamous or endocervical cells
  • HPV testing is now being performed on these samples[3].
  • Women who are positive for HPV will be referred for colposcopy.
  • Those women who are negative for HPV will be returned to routine screening.
  • If the HPV test is unreliable or inadequate, repeat the screen, including HPV, after six months. This allows time for resolution of changes. The majority of screening tests will return to normal by this stage.

In the absence of HPV testing:

  • Treat any associated condition and repeat the screen after six months.
  • Refer for colposcopy if there are three screens in a series reported as borderline without the woman being returned to routine recall or three borderline or more severe results in a 10-year period.
  • Three consecutive negative results, six months apart, are required before returning to routine recall.
Mild dyskaryosisHPV testing is now performed on these samples[3]:
  • Women who are positive for HPV, refer for colposcopy.
  • Those women who are negative for HPV will be returned to routine screening.
  • If the HPV test is unreliable or inadequate, refer for colposcopy.

In the absence of HPV testing:

  • Women should be referred for colposcopy after one mild dyskaryotic cervical screening test but it has been acceptable to recommend a repeat test within six months - many will have returned to normal by this stage:
    • 40-67% of women with mild dyskaryosis are subsequently found to have developed high-grade cervical intraepithelial neoplasia (CIN).
    • Immediate colposcopy referral, as opposed to cytological follow-up, reduces non-attendance rates and shortens time to diagnosis but is associated with more adverse events.
  • Always refer for colposcopy after two tests reported as mild dyskaryosis without a return to routine recall.
  • Three consecutive negative results six months apart are required before returning to routine recall.
  • If a single mild dyskaryotic result is obtained after treatment for CIN2 or worse, refer for colposcopy.
  • If in a 10-year period there are three borderline or more severe results, refer to colposcopy.
Moderate dyskaryosisUrgent colposcopy referral for suspected cancer (two-week-wait) unless direct referral by the screening programme is in operation.
Severe dyskaryosisUrgent colposcopy referral for suspected cancer (two-week-wait) unless direct referral by the screening programme is in operation.
?invasive cancer or ?glandular neoplasiaUrgent colposcopy or gynaecology referral for suspected cancer (two-week-wait) unless direct referral by the screening programme is in operation.

Use of HPV testing

  • In 2011, HPV testing triage of borderline or mildly abnormal cervical screening tests was introduced in England and Northern Ireland[3]:
    • Women who are positive for HPV are directly referred for colposcopy. Those who are negative continue with routine (three-year or five-year) follow-up.
    • Triaging these women with HPV testing allows around a third of women to return immediately to routine recall and a substantial proportion to be referred for colposcopy without repeat cytology being necessary[4].
    • HPV triage is under consideration in Scotland and Wales
  • HPV 'test of cure' at six months for all women treated for CIN has been introduced across the UK to effectively identify women at risk of serious recurrent disease in the future[5].
  • In 2016 the UK National Screening Committee (NSC) recommended that the NHS cervical screening programme should adopt HPV testing for primary screening, as it is more sensitive than cytology and its use will reduce the number of women going on to have cytology screening[6].
  • There is compelling evidence that many women become very anxious when they are called to attend for colposcopy. Accurate and clear information is important to allay anxiety.
  • Simple analgesia one hour before the procedure is sometimes recommended. Paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) may be used but NSAIDs may increase bleeding from any procedure, due to the antiplatelet effect of these drugs.
  • Sometimes sedation or (rarely) general anaesthetic (most often due to patient choice) is required.
  • Consider that any woman who appears unusually anxious or upset may be a survivor of childhood or adult sexual assault[7].
  • Some colposcopists prefer not to colposcope a woman who is menstruating but this isn't a contra-indication to the procedure.
  • The patient sits in a reclining chair in lithotomy position. A speculum is inserted to visualise the cervix.
  • The cervix is stained with acetic acid in the area of the transformation zone (TZ) to identify the site, grade and shape of any abnormal area of cells. The solution is applied using a long-handled cotton bud. Abnormal dyskaryotic/dysplastic cells will stain white, referred to as 'aceto-white'; generally, the more dense the white area becomes, the higher the grade of abnormality.
  • A water-based solution of iodine is then gently applied to the rest of the cervix to identify the complete area of abnormality. With iodine, the normal cells stain jet black and the abnormal cells stain yellow.
  • There is usually good correlation between the abnormality suggested by the cervical screening test and the appearances seen through the colposcope.
  • A small biopsy can be taken for analysis from the worst-looking area, having first applied local anaesthetic. Special biopsy forceps remove a small fragment of tissue with minimal discomfort.
  • A punch biopsy has been shown to have a high sensitivity (81%) although it is not clear whether this may be due to confirmation bias[8].

Women who have an obvious abnormality at colposcopy, or who have a positive biopsy result, will proceed to treatment. Women at a 'see and treat' clinic are more likely to be anxious unless it has previously been explained to them that they may be treated at their first visit.

  • Large loop excision of the transformation zone (LLETZ) is the most common form of treatment in the UK:
    • LLETZ can take place at the end of the colposcopy examination during the same clinic visit, referred to as 'see and treat', or treatment may be carried out at a later visit.
  • Cryotherapy: freezing the affected area of the cervix, which destroys the abnormal cells.
  • Laser treatment: destroying or excising the abnormal area.
  • Cold coagulation: a heat source is used to destroy and remove the abnormal cells.

Intracervical injection of local anaesthetic with a vasoconstrictor appears to be the most effective from of pain relief for colposcopy treatments[9].

When an area of abnormality extends into the cervical canal beyond the area that can be seen with the colposcope, a cone biopsy is indicated. This is usually undertaken under general anaesthetic.

  • A cone biopsy does not reduce subsequent fertility. A meta-analysis and systematic review in 2014 demonstrated no difference in fertility outcomes for women following treatments for cervical pre-cancer, including following cone biopsy. It did, however, suggest a significant increase in the rate of mid-trimester miscarriages, although they are still rare[10].
  • A cone biopsy increases the risk of perinatal mortality, severe preterm delivery and low birth weight in subsequent pregnancy[11].
  • Cervical stenosis is a rare side-effect, leading to haematocolpos and possible reduced fertility.
  • Cervical treatment is relatively safe. The most commonly occurring risks include:
    • Bleeding.
    • Infection.
    • Pelvic or abdominal pain.
  • Colposcopy during pregnancy is safe, the aim being to exclude invasive disease. Treatment, including biopsy, may be delayed until three months following delivery unless invasive disease is suspected[1].
  • Cervical biopsy should be avoided during pregnancy unless a malignancy is suspected; the risk of haemorrhage is 25%.
  • Psychological morbidity is common: women's levels of anxiety before and during colposcopy are high, frequently higher than for a surgical procedure.
  • Although providing information leaflets prior to the procedure does not actually decrease anxiety, it can improve knowledge about the procedure and also increase quality of life by reducing psychosexual dysfunction[12].
  • The use of music during the procedure and being able to view the procedure on a TV monitor have both been shown to reduce anxiety levels[13].
  • Following the colposcopy, the patient should wear a sanitary pad.
  • Spotting and a light discharge may occur for 3-5 days.
  • Dark fluid-like material, sometimes green, or resembling coffee grounds, may be seen on the pad. This is the fluid that was used during the examination.
  • The patient should avoid sexual intercourse, vaginal medications or use of tampons until the bleeding stops.
  • If treatment has been required, a blood-stained discharge may continue for 2-4 weeks.
  • The appearance of the cervix is altered by cervical surgery, especially a cone biopsy. The healed area may be mistaken for a cervical polyp.
  • Between 2% and 5% of women with treated CIN have recurrence of abnormalities for which further treatment is required[14].

Further reading and references

  1. Colposcopy and Programme Management; Guidelines for the NHS Cervical Screening Programme, May 2010

  2. Cervical screening; NICE CKS, August 2017 (UK access only)

  3. NHS Cervical Screening Programme Screening Protocol Algorithm for HPV Triage and TOC; Public Health England

  4. Kelly RS, Patnick J, Kitchener HC, et al; HPV testing as a triage for borderline or mild dyskaryosis on cervical cytology: results from the Sentinel Sites study. Br J Cancer. 2011 Sep 27105(7):983-8. doi: 10.1038/bjc.2011.326. Epub 2011 Sep 6.

  5. Legood R, Smith M, Lew JB, et al; Cost effectiveness of human papillomavirus test of cure after treatment for cervical intraepithelial neoplasia in England: economic analysis from NHS Sentinel Sites Study. BMJ. 2012 Oct 31345:e7086. doi: 10.1136/bmj.e7086.

  6. The UK NSC recommendation on Cervical Cancer screening in women; UK National Screening Committee (Jan 2016)

  7. Cadman L, Waller J, Ashdown-Barr L, et al; Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study. J Fam Plann Reprod Health Care. 2012 Oct38(4):214-20. doi: 10.1136/jfprhc-2012-100378.

  8. Underwood M, Arbyn M, Parry-Smith W, et al; Accuracy of colposcopy-directed punch biopsies: a systematic review and meta-analysis. BJOG. 2012 Oct119(11):1293-301. doi: 10.1111/j.1471-0528.2012.03444.x. Epub 2012 Aug 13.

  9. Gajjar K, Martin-Hirsch PP, Bryant A; Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment. Cochrane Database Syst Rev. 2012 Oct 1710:CD006120. doi: 10.1002/14651858.CD006120.pub3.

  10. Kyrgiou M, Mitra A, Arbyn M, et al; Fertility and early pregnancy outcomes after treatment for cervical intraepithelial neoplasia: systematic review and meta-analysis. BMJ. 2014 Oct 28349:g6192. doi: 10.1136/bmj.g6192.

  11. Arbyn M, Kyrgiou M, Simoens C, et al; Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ. 2008 Sep 18337:a1284. doi: 10.1136/bmj.a1284.

  12. Swancutt DR, Greenfield SM, Luesley DM, et al; Women's experience of colposcopy: a qualitative investigation. BMC Womens Health. 2011 Apr 1311:11. doi: 10.1186/1472-6874-11-11.

  13. Galaal K, Bryant A, Deane KH, et al; Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database Syst Rev. 2011 Dec 7(12):CD006013. doi: 10.1002/14651858.CD006013.pub3.

  14. Kitchener HC, Walker PG, Nelson L, et al; HPV testing as an adjunct to cytology in the follow up of women treated for cervical intraepithelial neoplasia. BJOG. 2008 Jul115(8):1001-7. doi: 10.1111/j.1471-0528.2008.01748.x. Epub 2008 May 22.