Colposcopy

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  • Those of us involved in the healthcare of women have seen a remarkable transformation in screening techniques for cervical cancer and its precursors since the mid 1990s.  The staid old Pap smear technique of scraping cells from the cervix with a wooden spatula and cotton-tipped applicator and smearing them onto a glass slide is a thing of the past in most practices. We now use plastic collection devices to transfer cells from the cervix into a preservative which is sent to the lab for liquidbased cytology and reflex human papillomavirus (HPV) testing.

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  • The speculum should be carefully positioned so the entire cervix is seen. If excess mucus or other secretions obscure the cervix, they should be gently removed using a proctoswab without disturbing the epithelium. Small amounts of blood will not interfere with cytologic evaluation, but large amounts, as occurs during menses, preclude cytologic interpretation by conventional Pap smear. This is considerably less of a problem when liquid based cytology is used.

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  • This book is aimed specifically at medical practitioners in primary care who require a quick guide to help diagnose and manage genital problems. As such this is not a comprehensive text but a prompt to “what to do next” when faced with a patient presenting with a genital complaint. A list of reference textbooks is provided in Further Reading and I would suggest you have at least one of these available for perusing at a more leisurely pace at a later time.

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  • The use of a reference standard consisting of colposcopy and directed biopsy served two purposes. The treatment decision was supposed to be based on colposcopic impression (with lab results coming later to identify any cancers that might have been missed) to reduce the number of visits and the loss to follow-up care. However, district hospital staff usually preferred to wait for the biopsy result to come back before offering treatment. Second, the use of colposcopy allowed comparison to conventional cytology and the evaluation of the proposed triage methods: VIA, VILI, and VIAM.

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  • Of the women screened, results were available for only about 2,200 who attended a particular clinic. These women, who all had positive VIA results, subsequently had repeat VIA by gynecologists at the clinic: only about half of the women were found to have positive VIA results at this second visit. The authors also noted a problem with the treatment of screen-positive women: only half of those with high-grade precancers received treatment.

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  • (The cost-effectiveness analysis was based on the baseline screening results of the Morelos HPV study. 20 ) Results showed that using clinician-HPV testing alone or in combination with Pap is more cost-effective for women aged 30 to 80 years than using the Pap test alone in Mexico. The analysis took into account the cost of false negatives and false positives, colposcopy and biopsy, and treatment for CIN2/3 or cancer, as well as the cost of the screening tests.

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  • The algorithm for programmes to treat women with precancerous lesions should be chosen based on the resources and health systems infrastructure in the country. A screen-and- treat approach with VIA followed by cryotherapy for treatment (by minimizing delay and the number of visits between screening and treatment) may be suitable for most low- resources settings. Screening with VIA can be provided at all levels of health care, including at the primary health care level.

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