Colposcopy and cervical treatments

What is a colposcopy?

Colposcopy is a test where a doctor or nurse uses a special microscope, called a colposcope, to look at the cells of the cervix in detail.

A liquid is painted on to the cervix to show up any abnormal cells. During colposcopy, a small piece of tissue may be taken from the cervix. This is known as a biopsy. The tissue is then examined in even closer detail in the laboratory to allow further assessment of the cells. Treatment for any abnormal cells can sometimes be given at the same time as the colposcopy examination.

Note: the information below is a general guide only. The arrangements, and the way tests are performed, may vary between different hospitals. Always follow the instructions given by your doctor or local hospital.

What is the difference between colposcopy and cervical screening?

A cervical screening test is offered regularly to all women between the ages of 25 and 64 to prevent cancer of the neck of the womb (cervical cancer). The cervical screening test is looking for a virus called human papillomavirus. If this is found then the sample is studied to look for any early changes (or abnormalities) in the cervical cells, that, if left untreated, might develop into cancer in the future. See the separate leaflet called Cervical Screening (Cervical Smear Test) for more details.

Cervical screening has been proven to reduce the number of cases of cervical cancer. This is why there is a National Screening Programme throughout the UK. A cervical screening test can be performed more quickly than colposcopy so it is a more suitable test to look for changes in the cervix in large groups of people.

Abnormal changes in the cells are found in some women during screening. These abnormal changes are known as dyskaryosis. In the vast majority of cases, an abnormal result does not mean cervical cancer. However, the presence of dyskaryosis indicates that cancer may develop at some time in the future.

Whilst the cervical screening test shows if abnormal cells are present, it does not show enough detail about the cells. Colposcopy allows a closer and more detailed look at these abnormal cells.

About 1 cervical screening test in 20 is abnormal. If the result is not normal, then the advice may be to repeat the test within the following 12 months, or a colposcopy may be recommended. About 1 in 80 women who have a cervical smear have an abnormal result that results in advice to have a colposcopy.

During colposcopy, the extent of the area where the abnormal cells are present is seen. This is done by applying special liquids to the neck of the womb (cervix), which stain the abnormal cells. Colposcopy also allows a sample of tissue (a biopsy) to be taken.

This sample is then sent to the laboratory for further tests. This means that the exact type of abnormality in the cells can be identified.

Why do I need a colposcopy?

Abnormal cervical screening results

The usual reason for needing a colposcopy is because of an abnormal cervical screening test result. This is usually because of a positive test for human papillomavirus (HPV) initially and then, some abnormal cells being seen in the sample when it is studied. HPV is a virus that can be passed on during sex, childbirth or other close skin-skin contact. It does not usually cause any symptoms and is found in the majority of people who have had sex. Cervical cancers are caused by HPV but most women with HPV do not develop cervical cancer. Following the introduction of the HPV immunisation to all teenagers in the UK, it is hoped that the number of cases of cervical cancer will reduce. Abnormal smear results should also reduce. See the separate leaflet called HPV vaccine for more details.

Remember that, in most cases, an abnormal cervical screening test does not mean cancer of the neck of the womb (cervical cancer) but it does mean that further tests are needed.

Inadequate cervical screening results

Sometimes a referral is made to colposcopy because there have been a number of cervical screening tests in a row that were inadequate. This can happen if there was too much blood or mucus present around the cervix at the time of the cervical screening test, or because too few cells were removed during the procedure.

Abnormal appearance

Sometimes a referral will be made because of an abnormal appearance of the cervix during a speculum examination. In some areas of the UK, this will be via a direct referral to colposcopy; in other areas, a general gynaecology referral will be made.

How will I know if I need a colposcopy?

When you have your cervical screening test, you should be told when (and how) to expect your results. You will generally be informed directly, by letter. Your GP surgery will also receive a copy of your results.

The laboratory advises what action is needed for each cervical screening result. In most areas, women who have an abnormality will be referred directly to a colposcopy clinic.

Contact your GP if you know you are waiting for a colposcopy appointment but have not heard anything after a few weeks.

Before having a colposcopy

Written information about the procedure should be provided before the appointment. There should be a number to call if you have any questions about the procedure. There are some things that you should think about before your colposcopy that can help you prepare:

• Some clinics prefer not to perform colposcopy whilst a woman is having her period. This is because it can be difficult to obtain a good view of the neck of the womb (cervix) if there is a lot of blood. Also, some women may prefer not to have an intimate examination whilst bleeding. If your period starts and you think that you will still be bleeding when you have your appointment, it is probably advisable to telephone the clinic for advice. In some cases your appointment may be rearranged.

• You should avoid sex and not wear a tampon for 24 hours before your colposcopy.

• You should not use any vaginal creams or pessaries for 24 hours before your colposcopy. This includes lubricants, thrush treatments, douches and spermicides.

• Some people find the colposcopy examination a little uncomfortable. For this reason, you may choose to take some paracetamol about an hour before your appointment.

• You may want to wear a loose, full skirt on the day of your colposcopy so that you do not have to remove all of your lower clothing.

• It is often a good idea to bring someone with you who can take you home after your colposcopy. This is especially important if the clinic has told you that you may have treatment, as well as the colposcopy, at your first appointment. They do not have to come into the examination room with you. (However, if you do want a friend or relative with you during your examination this is also possible.)

What should I expect when I have my colposcopy?

The whole procedure normally takes about 15-20 minutes. It may be longer if you have treatment at the same time (see below). It is best to allow an hour for the whole visit:

• The doctor or nurse will usually start by asking you some questions. These may include information about your periods, the date of your last period, what contraception you use and your general health.

• You will then be asked to remove your clothing from the waist down. (You can usually keep a loose skirt on.)

• You will be asked to lie in a reclining chair, or on a couch, in the same position as during a cervical screening test. This is with your knees bent and your legs apart. In some clinics you may be able to place your legs apart in padded supports called stirrups.

• An instrument called a speculum (the same instrument that is used during a cervical screening test) will be inserted into your vagina. It is gently opened to show the neck of the womb (cervix), at the top of the vagina.

• The doctor or nurse will then look through the colposcope to obtain a good view of your cervix. The colposcope itself does not go inside your vagina. It is essentially like a big pair of binoculars on a stand that can be moved around. There is also a light to help see inside your vagina. Sometimes, the colposcope can be attached to video equipment so that the examination can be viewed more clearly on a TV screen.

• A long swab (like a fat cotton bud) is used to dab liquids on to the cervix. These liquids stain any abnormal cells that may be present. Two different liquids are normally used - weak vinegar (acetic acid) and iodine.

• A small sample of tissue (a biopsy) from your cervix may also be taken. This will be sent to the laboratory for further examination. The biopsy is only about the size of a pinhead; sometimes this can be painful. If this is expected, local anaesthetic is usually used to numb the neck of your womb first.

• Sometimes it is suggested that you have treatment at your first colposcopy visit (see below). However, often, you may be asked to return for treatment once the biopsy results are back.

• It is worth bringing a sanitary towel or panty liner with you, to use after your colposcopy. It is unlikely you would have much bleeding. However, you might have some discharge or staining from the iodine used in the examination. There is more likely to be discharge or bleeding if you have had a biopsy or treatment. You should not use a tampon.

After the colposcopy

After your colposcopy, you can usually return to work or carry on with your normal day. You are likely to have a small amount of bleeding, especially if you have had a sample of tissue taken (a biopsy).

This can last for three to five days and you should wear a sanitary pad. Do not use tampons. You should not have sex or use vaginal creams or pessaries until the bleeding has stopped. Generally you should wait for five days.

You may notice a dark fluid-like material on the pad. It is sometimes green or looks like coffee granules. This is normal and is the liquid that has been dabbed on to the neck of your womb (cervix) during the examination.

What are the risks or complications of colposcopy?

Colposcopy is generally safe. Some women find that it is a little uncomfortable. Rarely, complications can occur. These can include heavy bleeding and infection. If you experience any heavy bleeding, smelly vaginal discharge or severe lower abdominal pain, you should seek medical advice as soon as possible. You should have the number of the colposcopy clinic so you can contact them directly about any complications.

The biopsy results

When a small sample of tissue (a biopsy) has been taken, it is sent to the laboratory for further examination under a microscope. The cell abnormality that can be seen is called cervical intraepithelial neoplasia (CIN). There is a scale from 1 to 3 according to the number of cells in the biopsy sample affected by CIN. In CIN1, only a few (1 in 3) cells are abnormal. In CIN2, up to two thirds of the cells are abnormal.

In CIN3, all of the cells are abnormal. Rarely, a biopsy can show changes in the cells that have already developed into cancer. About 7 in 10 cases of CIN1 return to normal without treatment, but 1 in 10 progresses to CIN3. Only 1 in 100 cases of CIN1 become cancer (and this is over a long time).

CIN2 and CIN3 still mean it is very unlikely that cervical cancer will develop. However, these changes are much less likely than CIN1 to get better on their own without treatment. So, if CIN2 or CIN3 were to be found on a biopsy, you treatment is likely to be needed to remove or destroy these abnormal cells on the neck of the womb (cervix).

Remember that the whole point of cervical screening (and subsequent examination/treatment of abnormal cells at colposcopy) is to prevent cervical cancer. This is by detection and treatment of early changes in the cells, which, if left untreated or unchecked for some years, could develop into cancer.

How will I know if I need any treatment?

The results of the colposcopy and the small sample (biopsy) taken will show if any treatment is needed. Sometimes, the doctor or nurse may suggest that you have treatment at the first visit for colposcopy. However, they may suggest that they wait for the results of the biopsy before deciding on treatment. It can take a few weeks for the biopsy results.

Not everyone who has a colposcopy needs treatment. If only a mild abnormality is found, a repeat colposcopy in 12 months might be suggested. The changes in the neck of the womb (cervix) may return to normal by themselves and they may just need monitoring.

What are the treatment options available?

There are a number of different treatments available for CIN. The aim of the treatment is to destroy or remove all the abnormal cells on the neck of the womb (cervix) without affecting too much normal tissue. Most treatments can be done at colposcopy, as an outpatient. The treatment may cause a little discomfort, perhaps similar to a period pain.

The treatment will depend on the extent of the abnormality as well as what treatment the clinic has available and the preference of the doctor or nurse. Treatment options include:

• Loop diathermy: a thin wire loop cuts through and removes the abnormal area of cells. This is also known as a large loop excision of the transformation zone (LLETZ). It is the most common form of treatment used in the UK.

• Cryotherapy: freezing the affected area of the cervix, which destroys the abnormal cells.

• Laser treatment: this destroys or cuts away abnormal cells.

• Cold coagulation: a heat source is used to burn away and remove the abnormal cells.

A local anaesthetic is usually given before any treatment, to numb the neck of the womb. The treatment is normally very straightforward and quick. There is a small risk of bleeding at the time of treatment.

Occasionally, one of the following procedures might be suggested as a treatment for CIN:

• A cone biopsy (described later).

• Very rarely, removal of your womb and cervix (a hysterectomy).

If this is the case, you will need to be admitted to hospital.

What should I expect after my treatment?

You may have some mild discomfort, like a period pain, after your treatment. Painkillers such as paracetamol may help to ease the pain.

You are likely to have some bloody vaginal discharge. This can last up to six weeks. It is like the bleeding you have during a period. If you are worried that it is too heavy, or if it becomes smelly, see your doctor. You should use sanitary pads and not tampons. You should avoid sex and not do any heavy exercise or swim until your discharge has gone back to normal.

Will I need any follow-up?

This depends on the results of the colposcopy and whether any treatment was needed. Some women may need a follow-up colposcopy examination. Other women may just need a follow-up cervical screening test, usually after six months. This test can be carried out by the usual clinic or GP surgery. The doctor or nurse who performs the colposcopy will advise what follow-up is needed

If the follow up smear shows no abnormal cells and is negative for HPV, a routine cervical screening test will be advised (in 3 years).

What is the prognosis if I need treatment?

Treatment of CIN is usually almost 100% effective. The outlook (prognosis), in the vast majority of treated women, is that it is unlikely that CIN will come back.

Cone biopsy

What is a cone biopsy?

Sometimes, some of the abnormal cells cannot be seen during colposcopy because the cells go further up into the neck of the womb (cervix). If this happens, the doctor or nurse will usually suggest a minor operation called a cone biopsy. In this procedure, a cone-shaped piece of tissue is removed from the cervix so that it can be examined under the microscope in the laboratory.

This is usually performed under a general anaesthetic and often requires a hospital stay overnight. This will be booked separately to the colposcopy.

What happens after a cone biopsy?

After a cone biopsy, there may be some gauze packed into the vagina to help control any bleeding. Some women also have a tube to drain urine (a catheter) inserted into their bladder at the time of the operation.

The gauze and the catheter will be removed before leaving hospital.

Most women notice a bloody discharge for up to four weeks after a cone biopsy. You should wear sanitary pads and not tampons. You should seek medical advice (ideally from the hospital who performed the biopsy) if:

• The bleeding is too heavy.

• The discharge becomes smelly.

• Abdominal pain develops.

After a cone biopsy, you should rest for a few days. You should not have sex or do any heavy exercise for four to six weeks.

If all the abnormal cells are removed during your cone biopsy and there is no sign of any cancer, no more treatment is usually required. However, regular cervical screening tests are always advised to make sure that no more abnormal cells develop.

Colposcopy and pregnancy

Colposcopy can be done safely in pregnancy. However, women who are pregnant should discuss this with the doctor or nurse before having a colposcopy. Any treatments are usually delayed until after having the baby - unless the abnormality is very severe and it is thought to be dangerous to wait until after the baby is born. Colposcopy in pregnancy does not affect the delivery of the child, nor does it affect future fertility.

Women who become pregnant after a previous treatment to their cervix, such as a cone biopsy or a loop excision, should mention this to their midwife at their first booking appointment. This is because some treatments to the cervix can make problems such as a preterm (early) delivery slightly more likely. This can be monitored to try and prevent any problems.