Colposcopy

1. See Also
   1. Cervix Anatomy
   2. Colposcopy Findings
   3. Colposcopy Protocol
2. Indications
   1. See Cervical Dysplasia
   2. Abnormal Pap Smear (ASC-US x2, ASC-H, LSIL, HSIL)
3. Preparation: Patient
   1. Consent
   2. Questions
   3. Ibuprofen 800 mg 30 minutes before procedure
4. Exam: External
   1. Bimanual
      1. Uterus size and pain on palpation
      2. Cervix position
      3. Cervical Motion Tenderness (CMT)
   2. Vulva
      1. Obvious condyloma
      2. Apply Acetic acid after cervical exam
      3. Avoid acetic acid before performing Pap Smear
5. Exam: Cervical (without colposcope)
   1. Warmed Speculum
   2. Vaginal stint indications
      1. Obese patient
      2. Multiparous patients
   3. Cervical Exam without microscopy
      1. Signs of obvious inflammation
      2. Gonorrhea and Chlamydia testing
      3. Pap Smear
      4. ViraPap (Tests for Human Papilloma Virus 16 and 18)
6. Exam: Cervical (Under Colposcopy)
   1. Apply Acetic Acid (5%) with cotton swab every 5 min
   2. Scan entire Cervix at low power (5x)
   3. Observe Vascular patterns at high magnification
      1. Consider use of the green filter
   4. Consider Lugol's Solution to clarify lesion sites
      1. Sharply outlines potential biopsy sites
   5. Mentally Map areas or obtain pictures
   6. Is Colposcopy Adequate?
      1. Is Entire Squamocolumnar Junction (SCJ) visualized?
         1. Consider Kogan endocervical speculum
      2. Any visualized lesions seen in entirety
      3. Endocervical curettage (ECC) is negative
      4. Colposcopy and biopsies agree with Pap Smear
7. Technique: Biopsies
   1. Endocervical Curettage (ECC)
      1. Consider topical benzocaine on swabs
         1. Leave in endocervical canal for 30 seconds
      2. Kevorkian curette rotated 360 degrees twice
      3. Contraindicated in pregnancy
   2. Cervical Punch Biopsy
      1. Obtain 3 mm samples
      2. Start with inferior sites and work upwards
         1. Less blood interference from other biopsy sites
      3. Not necessary to include normal margins in biopsy
      4. Do not use Monsel's until after all biopsies taken
   3. Ectocervical Brush (experimental)
      1. New stiff bristled brush designed for Colposcopy
      2. More effective than cervical Punch Biopsy
         1. Brush correlation with loop excision: 76-79%
         2. Punch Biopsy correlation with loop excission: 53%
      3. Significantly less pain than with Punch Biopsy
      4. References
         1. Monk (2002) Obstet Gynecol 100:1276-84
8. Technique: Coagulation of Bleeding
   1. Monsel's Solution
      1. Should be thickness of toothpaste
      2. Swab out excess Monsel's and Bloody debris
   2. Silver Nitrate
      1. For isolated bleeders
9. Technique: Ending of Procedure
   1. Observe vaginal walls while removing speculum
      1. Use a dental mirror pre-heated in warm water
   2. Patient rests supine for several minutes
   3. Diagram exam
      1. Document cervical os
      2. Document Squamocolumnar junction (SCJ)
      3. Document biopsy sites
10. Education: Post-Procedure instructions
    1. No intercourse or tampons for 7 days
    2. Return to clinic
       1. Foul vaginal odor or discharge
       2. Pelvic Pain
       3. Fever
    3. Follow-up for histology results in 2 weeks
11. Precautions
    1. Perform LEEP procedure during Follicular Phase
       1. Luteal Phase associated with heavy bleeding
       2. Paraskevaidis (2002) Obstet Gynecol 99:997-1000
    2. LEEP histology has a high false negative rate
       1. Follow all dysplasia closely regardless of histology
       2. Livasy (2004) Obstet Gynecol 104:250-4
12. References
    1. Brotzman (1994) J Fam Pract 39:271-8
    2. Coppleson (1993) Obstet Gynecol Clin North Am 20:83-110
    3. Ferris (1991) J Fam Pract 33:506-15
    4. Newkirk (1990) J Fam Pract 31:171-8