Editing Colposcopy

{{Short description|Medical examination of the cervix}}
{{distinguish|Colonoscopy}}
{{Infobox medical intervention |
  Name        = Colposcopy |
  Image       = Basic_Female_Reproductive_System_(English).svg |
  Caption     = In this diagram, the [[canal of the cervix]] (or ''endocervix'') is circled at the base of the womb. The [[vaginal portion of cervix|vaginal portion of the cervix]] projects free into the vagina. The [[transformation zone]], at the opening of the cervix into the vagina, is the area where most abnormal cell changes occur |
  ICD10       = |
  ICD9        = {{ICD9proc|67}} |
  MeshID      = D003127 |
  OPS301      = {{OPS301|1-671}} |
  OtherCodes  = |
}}
'''Colposcopy''' ({{langx|grc|κόλπος|kolpos|hollow, womb, vagina}} + ''skopos'' 'look at') is a medical [[medical diagnosis|diagnostic]] procedure to visually examine the [[cervix]] as well as the [[vagina]] and [[vulva]] using a colposcope.<ref name="pmid19375565">{{cite journal |vauthors=Chase DM, Kalouyan M, DiSaia PJ |title=Colposcopy to evaluate abnormal cervical cytology in 2008 |journal=Am. J. Obstet. Gynecol. |volume=200 |issue=5 |pages=472–80 |date=May 2009 |pmid=19375565 |doi=10.1016/j.ajog.2008.12.025 }}</ref>

The main goal of colposcopy is to prevent [[cervical cancer]] by detecting and treating precancerous lesions early.  [[Human Papillomavirus]] (HPV) is a common infection and the underlying cause for most cervical cancers. Smoking also makes developing cervical abnormalities more likely.

Other reasons for a patient to have a colposcopy include assessment of [[diethylstilbestrol]] (DES) exposure in utero, [[immunosuppression]], abnormal appearance of the cervix or as a part of a [[rape kit|sexual assault forensic examination]].

Colposcopy is done using a colposcope, which provides a magnified and illuminated view of the areas, allowing the colposcopist to visually distinguish normal from abnormal appearing tissue, such as damaged or abnormal changes in the tissue ([[lesion]]s), and take directed [[biopsy|biopsies]] for further pathological examination if needed.

Colposcopy has historical roots in the 10th century when [[Abulcasis]], a renowned Arabian physician, pioneered the use of reflected light to inspect internal organs, with the cervix being the first organ examined in this way.<ref>{{Cite journal |last=Spaner |first=S. J. |last2=Warnock |first2=G. L. |date=1997 |title=A brief history of endoscopy, laparoscopy, and laparoscopic surgery |url=https://pubmed.ncbi.nlm.nih.gov/9449087/#:~:text=The%20first%20effective%20open-tube,tools%20in%20their%20medical%20practice. |journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A |volume=7 |issue=6 |pages=369–373 |doi=10.1089/lap.1997.7.369 |issn=1092-6429 |pmid=9449087}}</ref><ref>Frantizides CT (ed): Laparoscopic and Thoracoscopic Surgery. St. Louis: Mosby, 1995.</ref><ref>Graber IN, Schultz LS, Pietrofitta JJ, Hickok DF (eds): Laparoscopic Abdominal Surgery. Chicago: McGraw-Hill,</ref> The modern procedure was developed by the [[Germany|German]] physician Hans Hinselmann, with help from [[Eduard Wirths]].<ref name="urlThe Deadly Origins Of A Life-saving Procedure – Forward.com">{{cite web |url=http://www.forward.com/articles/9946/ |title=The Deadly Origins Of A Life-saving Procedure – Forward.com |date=27 January 2007 |access-date=2010-01-22}}</ref><ref>{{cite book|url=https://books.google.com/books?id=rB0yxE2WhWIC&q=colposcopy+Wirths+hinselmann&pg=PA3|title=Colposcopy of the Cervix, Vagina, and Vulva: A Comprehensive Textbook|first=Michael S.|last=Baggish|date=11 April 2018|publisher=Mosby|access-date=11 April 2018|via=Google Books|isbn=9780323018593}}</ref> The development of colposcopy involved experimentation on Jewish inmates from Auschwitz.<ref name="urlThe Participation of Hans Hinselman in Medical Experiments at Auschwitz">{{cite journal |title= The Participation of Hans Hinselman in Medical Experiments at Auschwitz |journal= Journal of Lower Genital Tract Disease |volume= 14 |issue= 1 |pages= 1–4 |doi= 10.1097/LGT.0b013e3181af30ef |pmid= 20040829 |year= 2010 |last1= Halioua |first1= Bruno |s2cid= 188116 }}</ref>

== Indications ==
[[file:Colposcopy.png|thumb|300px|left|An illustration of a colposcopy procedure.]]
Most women undergo a colposcopy to further investigate an abnormal [[pap test]] result ([[Cytopathology|cytological]]).

Other reasons for a patient to have a colposcopy include:
* assessment of [[diethylstilbestrol]] (DES) exposure in utero,
* [[immunosuppression]] such as [[HIV]] infection, or an organ transplant patient
* an abnormal appearance of the cervix as noted by a primary care provider
* as a part of a [[rape kit|sexual assault forensic examination]] using a specialized colposcope equipped with a camera<ref>{{Cite web |url=http://samfe.dna.gov/examination_process/exam_evidence_collection_procedures/conducting/ |title=Sexual Assault Medical Forensic Examinations |access-date=2010-02-25 |archive-url=https://web.archive.org/web/20091222172726/http://samfe.dna.gov/examination_process/exam_evidence_collection_procedures/conducting/ |archive-date=2009-12-22 |url-status=dead }}</ref>

Many physicians base their current evaluation and treatment decisions on{{cn|date=February 2020}} the report "Evidence-Based Consensus Recommendations for Colposcopy Practice for Cervical Cancer Prevention in the United States", developed by the American Society for Colposcopy and Cervical Pathology, most recently in 2017.<ref>{{Cite journal|title=Evidence-Based Consensus Recommendations for Colposcopy Practice for Cervical Cancer Prevention in the United States|journal=Journal of Lower Genital Tract Disease|language=en-US|volume=21|issue=4|pages=216–222|doi=10.1097/LGT.0000000000000322|pmid=28953109|issn=1526-0976|year=2017|last1=Wentzensen|first1=Nicolas|last2=Massad|first2=L. Stewart|last3=Mayeaux|first3=Edward J.|last4=Khan|first4=Michelle J.|last5=Waxman|first5=Alan G.|last6=Einstein|first6=Mark H.|last7=Conageski|first7=Christine|last8=Schiffman|first8=Mark H.|last9=Gold|first9=Michael A.|last10=Apgar|first10=Barbara S.|last11=Chelmow|first11=David|last12=Choma|first12=Kim K.|last13=Darragh|first13=Teresa M.|last14=Gage|first14=Julia C.|last15=Garcia|first15=Francisco A.R.|last16=Guido|first16=Richard S.|last17=Jeronimo|first17=Jose A.|last18=Liu|first18=Angela|last19=Mathews|first19=Cara A.|last20=Mitchell|first20=Martha M.|last21=Moscicki|first21=Anna-Barbara|last22=Novetsky|first22=Akiva P.|last23=Papasozomenos|first23=Theognosia|last24=Perkins|first24=Rebecca B.|last25=Silver|first25=Michelle I.|last26=Smith|first26=Katie M.|last27=Stier|first27=Elizabeth A.|last28=Tedeschi|first28=Candice A.|last29=Werner|first29=Claudia L.|last30=Huh|first30=Warner K.|s2cid=24933665|url=https://escholarship.org/content/qt2pp0r8f2/qt2pp0r8f2.pdf?t=qgpjja}}</ref>

Colposcopy is not generally performed for people with pap test results showing low-grade [[squamous intraepithelial lesion]] (LSIL) or less. SILs are an abnormal growth of [[Epithelium|epithelial]] cells, known as a lesion, on the surface of the [[cervix]]. Unless the person has a visible lesion, colposcopy for this population does not detect a recurrence of cancer.<ref name="SGOfive">{{Citation |author1 = Society of Gynecologic Oncology |author1-link = Society of Gynecologic Oncology |date = February 2014 |title = Five Things Physicians and Patients Should Question |publisher = Society of Gynecologic Oncology |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/society-of-gynecologic-oncology/ |access-date = 19 February 2013}}, which cites
* {{Cite journal | doi = 10.1097/AOG.0b013e3182271fdd| pmid = 21860282| title = Cervicovaginal Cytology in the Detection of Recurrence After Cervical Cancer Treatment| journal = Obstetrics & Gynecology| volume = 118| issue = 3| pages = 548–53| year = 2011| last1 = Rimel | first1 = B. J.| last2 = Ferda | first2 = A. | last3 = Erwin | first3 = J. | last4 = Dewdney | first4 = S. B. | last5 = Seamon | first5 = L. | last6 = Gao | first6 = F. | last7 = Desimone | first7 = C. | last8 = Cotney | first8 = K. K. | last9 = Huh | first9 = W. | last10 = Massad | first10 = L. S. | s2cid = 2465459}}
* {{Cite journal | doi = 10.1016/j.ygyno.2013.05.037| pmid = 23747836| title = Cost analysis of colposcopy for abnormal cytology in post-treatment surveillance for cervical cancer| journal = Gynecologic Oncology| volume = 130| issue = 3| pages = 421–5| year = 2013| last1 = Tergas | first1 = A. I. | last2 = Havrilesky | first2 = L. J. | last3 = Fader | first3 = A. N. | last4 = Guntupalli | first4 = S. R. | last5 = Huh | first5 = W. K. | last6 = Massad | first6 = L. S. | last7 = Rimel | first7 = B. J. }}</ref>

== Procedure ==
[[Image:Colposcope.jpg|250px|right|thumb|Colposcope]]
[[File:Transformation zone types.png|thumb|240px|Transformation zone types:<ref>International Federation for Cervical Pathology and Colposcopy (IFCPC) classification. References:<br>-{{cite web|url=https://www.rcpa.edu.au/Library/Practising-Pathology/Structured-Pathology-Reporting-of-Cancer/Docs/Transformation_zone|title=Transformation zone (TZ) and cervical excision types|website=[[:en:Royal College of Pathologists of Australasia|Royal College of Pathologists of Australasia]]}}<br>- {{cite journal|last1=Jordan|first1=J.|last2=Arbyn|first2=M.|last3=Martin-Hirsch|first3=P.|last4=Schenck|first4=U.|last5=Baldauf|first5=J-J.|last6=Da Silva|first6=D.|last7=Anttila|first7=A.|last8=Nieminen|first8=P.|last9=Prendiville|first9=W.|title=European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1|journal=Cytopathology|volume=19|issue=6|year=2008|pages=342–354|issn=0956-5507|doi=10.1111/j.1365-2303.2008.00623.x|pmid=19040546|s2cid=16462929|doi-access=free}}</ref><br>Type 1: Completely ectocervical (common under hormonal influence).<br>Type 2: Endocervical component but fully visible (common before puberty).<br>Type 3: Endocervical component, not fully visible (common after menopause).]]

During the initial evaluation, a medical history is obtained. The procedure is fully described to the patient. In some cases a [[pregnancy]] test may be performed before the procedure and the patient then signs a consent form.{{citation needed|date=September 2020}} Colposcopy is performed with the woman lying back, legs in [[Stirrup (disambiguation)|stirrups]], and buttocks at the lower edge of the table (a position known as the [[Anatomical terms of location#Dorsal and ventral|dorsal]] [[lithotomy position]]). A [[speculum (medical)|speculum]] is placed in the vagina after the [[vulva]] is examined for any suspicious [[lesion]]s.{{citation needed|date=September 2020}}

A colposcope is used to identify visible clues suggestive of abnormal tissue. It functions as a lighted binocular or monocular [[microscope]] to magnify the view of the cervix, vagina, and vulvar surface. <ref>{{cite book|author=Kelly M. Pyrek|title=Forensic Nursing|url=https://books.google.com/books?id=-eDKBQAAQBAJ&pg=PA157|date=2006-01-13|publisher=CRC Press|isbn=978-1-4200-0291-1|pages=157–}}</ref><ref>{{cite book|author=Margaret M. Stark|title=Clinical Forensic Medicine: A Physician's Guide|url=https://books.google.com/books?id=bAAhI7jUZ1IC&pg=PA103|date=2011-09-22|publisher=Springer Science & Business Media|isbn=978-1-61779-258-8|pages=103–}}</ref>

Low magnification (2× to 6×) may be used to obtain a general impression of the surface architecture. 8× to 25× magnification are utilized to evaluate the vagina and cervix. High magnification together with green filter is often used to identify certain vascular patterns that may indicate the presence of more advanced pre-cancerous or cancerous lesions.{{cn|date=March 2023}}

The squamocolumnar junction, or "transformation zone", is a critical area on the cervix where many precancerous and cancerous lesions most often arise. The ability to see the transformation zone and the entire extent of any lesion visualized determines whether an adequate colposcopic examination is attainable.{{citation needed|date=September 2020}}

[[Acetic acid]] solution is applied to the surface of the cervix using cotton swabs to improve visualization of abnormal areas.{{citation needed|date=September 2020}}. Areas of the cervix that turn white (acetowhiteness) after the application of acetic acid or have an abnormal [[Blood vessel|vascular]] pattern are often considered for [[biopsy]]. If no lesions are visible, an [[iodine]] solution may be applied to the cervix to help highlight areas of abnormality.{{cn|date=March 2023}}

After a complete examination, the colposcopist determines the areas with the highest degree of visible abnormality and may obtain biopsies from these areas using a long biopsy instrument, such as a punch forceps, [[Instruments used in obstetrics and gynecology|SpiraBrush CX]] or [[Instruments used in obstetrics and gynecology|SoftBiopsy]]. Most doctors and patients consider [[anesthesia]] unnecessary; however, some colposcopists now recommend and use a [[topical anesthetic]] such as [[lidocaine]] or a [[Anesthesia|cervical block]] to decrease patient discomfort, particularly if many biopsy samples are taken.{{citation needed|date=September 2020}}

Following any biopsies, an endocervical [[curettage]] (ECC) is often done. The ECC utilizes a long straight [[curette]], a [[Instruments used in obstetrics and gynecology|Soft-ECC]] curette employing fabric to simultaneously collect tissue, or a [[cytobrush]] (like a small pipe-cleaner) to scrape the inside of the cervical canal. The ECC should never be done on a patient who is pregnant. [[Ferric subsulfate solution|Monsel's solution]] is applied with large cotton [[wikt:Special:Search/swab#Noun|swabs]] to the surface of the cervix to control bleeding. This solution looks like [[mustard (condiment)|mustard]] and turns black when exposed to blood. After the procedure this material will be expelled naturally: Patients can expect to have a thin coffee-ground like discharge for up to several days after the procedure. Alternatively, some physicians achieve [[hemostasis]] with [[silver nitrate]].{{citation needed|date=September 2020}}

==Interpretation==
[[File:Cervix quadrants and directions.svg|thumb|Locations of colposcopy findings can be described in terms of quadrants, or corresponding to a [[clock face]] when the subject is in [[supine position]].]]

One model for scoring colposcopy findings is the ''Swede Score'', which assigns a score between 0 and 2 for five different parameters, based on what is visible during the colposcopy, as given in table below:

{|class="wikitable plainrowheaders"
|+Swede Score for interpreting colposcopy findings<ref name=principles2011>{{cite book |author=<!--Staff writer(s); no by-line.--> |title=Principles and Practice of Colposcopy |publisher=JP Medical Ltd |date=2011 |isbn=9789350250945 |page=91 |url=https://books.google.com/books?id=quotjPrR2WwC&pg=PA91 |url-status=dead |access-date=2017-08-30 |archive-date=2023-07-09 |archive-url=https://web.archive.org/web/20230709100203/https://books.google.com/books?id=quotjPrR2WwC&pg=PA91 }}</ref>
! scope="col" rowspan=2 | Parameter
! scope="col" colspan=3 | Score
|-
! scope="col" | 0
! scope="col" | 1
! scope="col" | 2
|-
! scope="row" | Uptake of<br> [[acetic acid]]
| 0 or transparent || Shady, milky || Distinct, stearin-like
|-
! scope="row" | Margins and surface
| 0 or diffuse || Sharp, but irregular, jagged, "geographical" satellites || Sharp and even, difference in surface level such as "cutting"
|-
! scope="row" | Vessels
| Fine, regular || Absent || Coarse or atypical
|-
! scope="row" | Lesion size
| <{{spaces|thin}}5&nbsp;mm || 5–15&nbsp;mm or spanning 2 quadrants || >{{spaces|thin}}15&nbsp;mm or spanning 3–4 quadrants or endocervically undefined
|-
! scope="row" | [[Iodine]] staining
| Brown || Faintly or patchy yellow || Distinct yellow
|}

The total Swede Score ranges between 0 and 10. A score of 5 or above is reported to identify all potential high-grade lesions (HGL) and 8 or above to have a 90% chance of being a HGL.<ref name=principles2011/> A score below 5 does not require biopsy because of low risk of cancer, a score from 5 to 7 requires biopsy, and a score 8 or above does not require biopsy because it is likely more efficient to intervene directly (e.g., by excision).<ref name=principles2011/>

== Complications ==
Significant complications from a colposcopy are not common but may include bleeding, infection at the biopsy site or [[endometrium]], and failure to identify the lesion.  [[Monsel's solution]] and [[silver nitrate]] interfere with the interpretation of biopsy specimens, so these substances are not applied until all biopsies have been taken. Some patients experience a degree of discomfort during the curettage, and many experience discomfort during the biopsy.{{cn|date=February 2020}}

Colposcopy with biopsy does not cause [[female infertility|infertility]] or subfertility.<ref>{{Cite journal | last1 = Spracklen | first1 = C. N. | last2 = Harland | first2 = K. K. | last3 = Stegmann | first3 = B. J. | last4 = Saftlas | first4 = A. F. | title = Cervical surgery for cervical intraepithelial neoplasia and prolonged time to conception of a live birth: A case-control study | doi = 10.1111/1471-0528.12209 | journal = BJOG: An International Journal of Obstetrics & Gynaecology | volume = 120 | issue = 8 | pages = 960–965 | year = 2013 | pmid = 23489374 | pmc =3691952 }}</ref>

== Follow up ==
{{see also | Cervical cancer#prevention}}
Adequate follow-up is critical to the success of this procedure. Treatments for significant lesions include ablative treatments ([[Cryosurgery|cryotherapy]], thermocoagulation, and [[laser]] ablation) and excisional methods ([[loop electrical excision procedure|loop electrosurgical excision procedure]] or LEEP, or [[Cervical conization]]).{{citation needed|date=September 2020}}

== References ==
{{reflist|2}}

== External links ==
* [http://screening.iarc.fr/colpo.php?lang=1 Colposcopy and Treatment of Cervical Intraepithelial Neoplasia:  A Beginner's Manual (IARC Screening Group)]
* [http://screening.iarc.fr/atlascolpo.php Atlas of colposcopy – principles and practice (IARC Screening Group)]
* [http://www.asccp.org/ American Society for Colposcopy and Cervical Pathology]
* [http://www.womenandbabies.co.uk/gynaecology/colposcopy.html Women & Babies] Colposcopy and gynaecology procedures undertaken by the Women & Babies Consultants.

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{{Urogenital surgical procedures}}
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{{DEFAULTSORT:Colposcopy}}
[[Category:Diagnostic obstetrics and gynaecology]]
[[Category:Endoscopy]]
[[Category:Female genital procedures]]
[[Category:Cervical cancer]]