History, examination and investigation

History taking at a colposcopy consultation should be relevant, concise and accurately recorded.

Minimum clinical history

The colposcopist should obtain and record the following information:

• primary reason for referral (usually from referring healthcare professional), e.g. abnormal screening test, post-coital bleeding, abnormal cervical appearance or other
• screening history, previous colposcopies and treatments
• parity
• menstrual history or any abnormal bleeding
• past gynaecological history including history of sexually transmitted infections (STIs)
• past medical and surgical history with particular reference to immune-deficiency due to disease or treatment
• current medication and allergies
• smoking/tobacco use, current status
• HPV vaccination status
• relevant family history including diethylstilboestrol (DES) exposure.

The colposcopist should perform a systematic examination of the lower genital tract, including the cervix, vagina, vulva, perineum and perianal area.

Macroscopic

After visual inspection of the vulva, perineum and perianal skin, the cervix should be identified using a bivalve speculum, and observed with the naked eye and then with the colposcope. The vagina can be inspected through the entire length on slow removal of a partially open speculum.

Colposcopic

Cervix

The cervix should be examined under low-power magnification prior to application of acetic acid to:

• exclude clinical invasive disease
• note presence of inflammation, infection or atrophy.

Dilute acetic acid (3–5%) is applied to the cervix allowing for typing of the TZ and to determine the extent and degree of any abnormality.

Practice point

REC7.2: Preparation for colposcopy: post menopausal women, people experiencing vaginal dryness, or trans men A short course of topical oestrogen therapy could be considered in post-menopausal women, people experiencing vaginal dryness, or trans men, for example daily for a period of at least 2 weeks, ceasing 1-2 days prior to the appointment. The reason for this should be explained (to reduce discomfort from the speculum and to improve the diagnostic accuracy of colposcopy and any associated LBC and/or biopsy).

Practice point

REC7.3: Colposcopy and acetic acid Acetic acid should be applied for 2 minutes to allow sufficient time for aceto-white changes to become apparent. This is especially important when the lesion is low grade as it may take more time to become visible.

Application of aqueous Iodine (Lugol’s or Schiller’s solutions) before or after biopsy may assist in defining the external limits of the TZ and any vaginal extension or separate lesions. Iodine can be applied to outline the TZ at the examination preceding therapy, and this is particularly useful when there is vaginal extension of the TZ.

Remainder of lower genital tract (vagina, vulva, perineum & perianal area)

The vulva, perineum and perianal skin should be inspected and any abnormality noted. The upper vagina should be assessed at all colposcopies to avoid missing extension of cervical dysplasia or isolated lesions of vaginal intra-epithelial neoplasia (VAIN).[1]

Practice point

REC7.4: Colposcopy and VAIN When the LBC report predicts a squamous abnormality and there is no colposcopically visible cervical lesion, careful colposcopic examination of the vagina should be performed to exclude VAIN, using acetic acid and Lugol’s Iodine.

Anus and anal canal

Women who are diagnosed with cervical dysplasia or are immune- deficient are at increased risk of anal intra-epithelial neoplasia (AIN) and anal cancer. Anoscopy, its findings and subsequent management is outside the scope of this document. It is usually practised by specially trained colposcopists, sexual health physicians or colorectal surgeons.[2]

Cytology

It is not necessary to take a cervical sample for LBC at the time of colposcopy, except in exceptional circumstances outlined below.[3][4]

Practice point

REC7.5: Repeat LBC usually not necessary at time of colposcopy It is not necessary to take a cervical sample for LBC at the time of colposcopy except in the following circumstances: delay in attending for colposcopy > 3 months after referral LBC referral LBC is unsatisfactory referral LBC is negative but lacks an endocervical component prior LBC is not available because the HPV test was performed on a self-collected sample the woman has developed symptoms suggestive of cervical cancer since undergoing her screening test.

Biopsy

The colposcopically directed biopsy should be taken from the most abnormal area of the cervix. There is evidence that, in larger lesions, the higher-grade abnormality will be more centrally placed, that taking more than one biopsy will detect more high-grade disease and that taking random four-quadrant biopsies has the highest sensitivity for detecting cervical intraepithelial neoplasia (CIN) grade 2 or higher (CIN2+).[5][6][7][8][9] However, the random four-quadrant biopsy technique will cause more discomfort, is not usual practice and is not acceptable to the majority of women.

In general, biopsy of abnormal areas should be encouraged, but many experienced colposcopists do not always biopsy a lesion that appears to be low-grade, especially in young women, when the referral cytology predicts pLSIL/LSIL. For less experienced colposcopists, biopsy of a suspected low-grade lesion is appropriate to confirm the diagnosis and exclude high-grade abnormalities. Colposcopists should be aware that histologically proven high-grade abnormalities due to non-16/18 HPV types may not have the classic colposcopic appearances of CIN2/3 (Swede scores <7). Adjunctive technologies may assist in identifying the most abnormal areas but these are not widely used in Australia at this time (see Supplement. Colposcopy technologies and documentation).

Consensus-based recommendation*

REC7.6: Biopsy of high grade lesions The cervix should be biopsied when the LBC prediction is pHSIL or HSIL and the colposcopic appearance shows major change (see IFCPC definition above) and the abnormal TZ is visible (Type 1 or Type 2 TZ).

Practice point

REC7.7: Biopsy visible lesion if suspicious for invasion when T3 TZ colposcopy In some situations, when there is a visible high-grade lesion on the ectocervix but there is a T3 TZ (lesion extends into canal out of visual range), it may be reasonable to take a cervical biopsy of the visible lesion if there is any suspicion of superficially invasive or invasive carcinoma.

Practice point

REC7.8: Biopsy of low-grade lesions is encouraged but not always necessary Women with a LBC prediction of pLSIL or LSIL and a colposcopic impression of low-grade disease or less may not always require a biopsy. However, biopsy is accepted practice for confirmation of the colposcopic impression and exclusion of high-grade disease, and should be encouraged, especially for less experienced colposcopists.

Endocervical curettage

Endocervical curettage (ECC) as an outpatient investigation is practised frequently in the USA and rarely in Australia. There is a lack of evidence to support its routine use in clinical practice.[10] There is a lack of prospective studies evaluating the utility of ECC performed at the time of diagnostic colposcopy. However, the findings of a recent retrospective study[11] suggest that ECC may be useful in predicting cervical cancer. The study included 455 women who had ECC at the time of colposcopy for an incompletely visible endocervical lesion, atypical glandular cells on smear or discrepancy between colposcopic impression and cytological abnormality. 

The ECC was performed by two expert colposcopists who used a Kevorkian curette to sample four endocervical quadrants. They analysed the reliability of ECC in detecting high-grade CIN (CIN2/3) and cervical cancer, and concluded that ECC had a high sensitivity in the diagnosis of endocervical pre-cancerous lesions and cancer. ECC resulted in a diagnosis of cancer in 96% of cases, either directly from the analysis of ECC tissue or from that of the cone biopsy made necessary by the ECC findings of a pre-cancerous lesion. They also concluded that, in some situations, a negative ECC could safely allow a period of surveillance and reduce the number of unnecessary treatments. The authors recognised that, because they were very experienced colposcopists, it may not be possible to extrapolate their results to all colposcopists. 

It is possible, despite a lack of evidence, that ECC could be used in Australian practice, particularly when there is a discrepancy between referral LBC prediction (low-grade squamous intraepithelial lesion (LSIL), possible high-grade squamous intraepithelial lesion (pHSIL), or high-grade squamous intraepithelial lesion (HSIL)) and colposcopy in the presence of a Type 3 TZ. ECC may provide reassurance that there is no significant endocervical lesion and that an immediate diagnostic excision could be deferred and be replaced by short-term surveillance.

Imaging

Women who are referred for evaluation of abnormal glandular cytology, especially those with atypical glandular cells or endocervical cells of undetermined significance, may not always have a detectable lower genital tract abnormality.[12] In this situation, imaging of the upper genital tract could be performed. Imaging may detect gross disease of the fallopian tube, ovary and of the endometrium in postmenopausal women, as these sites may be giving rise to the abnormal glandular cells. Further investigation, such as endometrial sampling, to exclude an endometrial origin for atypical glandular cells, may be required. 

However, in the renewed NCSP, LBC is only carried out following a positive oncogenic HPV test result. Therefore, the detection (via the screening episode) of abnormal glandular cells from extra-cervical sites will be reduced, given that endometrial, tubal and ovarian pathology is not HPV-related. However, such abnormal glandular cells could be present coincidentally, unrelated to the positive oncogenic HPV test result (see Chapter 11. Management of glandular abnormalities).

Practice point

REC7.9: Upper genital tract investigation Upper genital tract imaging (usually transvaginal ultrasound) should be considered in cases where no lower genital tract abnormality is detected at colposcopy after referral with abnormal glandular cytology (including atypical glandular cells or endocervical cells of undetermined significance). In some women, further investigation, such as endometrial sampling to exclude an endometrial origin for atypical glandular cells, may be required.

High-quality patient management requires meticulous documentation of the woman’s medical record. The results of consultations, examinations and treatments must be recorded – preferably electronically, as this will facilitate the submission of colposcopy data to the National Cancer Screening Register (see Colposcopy data required for the National Cancer Screening Register). Colposcopy data can be entered into the National Cancer Screening Register using the Healthcare Provider Portal (this requires a Healthcare Provider Individual Identifier (HPI-I) and a Provider Digital Access (PRODA) account). The National Cancer Screening Register website provides information about how to access and use the Healthcare Provider Portal. 

Information can also be provided to the NCSR by HL7 direct links with specific clinical software systems or by using the paper form. It is useful to keep an annotated diagram of the cervix and vagina or keep a digitally captured image.