- Prepare your patient. Obtain informed consent and answer her questions. Assure her you will attempt to minimize pain (often a consuming worry). Make sure to know the pregnancy status of your patient. Ibuprofen 800 mg may be offered prior to procedure or the night before and morning of the procedure, although its efficacy is questionable.
- A bimanual exam should have been done with the annual exam. If a bimanual examination is needed, perform it here.
- Quickly examine the vulva for obvious condylomata or other lesions. If cervical biopsy is well-tolerated and things are going well, examine the vagina/vulva after the biopsies as the speculum is withdrawn. The excess vinegar from the cervical exam will often stain the vulva. The vulva can also be examined at the time your patient returns for follow-up and/or definitive treatment.
- Warm the speculum with water or water soluble lubricants. Insert the speculum. Consider the use of vaginal side wall retractors, a Penrose, or glove thumb with obese or multiparous women with vaginal redundancy (pregnancy too, if you develop colposcopy skills with pregnant patients).
- Examine the cervix. Is the cervix inflamed or infected-looking (see image to the right)? An active cervicitis confounds colposcopic detail. Do cultures if necessary. Repeat Pap only if this is critical information. Even a correctly performed Pap smear may irritate the cervix and often causes bleeding. Gently blot (not wipe) away any excess mucous using normal saline. Look for leukoplakia and abnormal vessels.
- Apply 5% acetic acid with a cotton ball held in a ring forceps or a rectal swab. This gently applies lots of vinegar quickly and without trauma. Repeat application every five minutes, as the vinegar effect is only temporary. Warn patients, "this may burn a little." Calling the solution "acetic acid" may help increase the patient's perception of burning. Calling it "vinegar" usually will not.
- Perform colposcopy. Start with low power (typically 5x). Scan the entire cervix with white light. Use a vinegar-soaked Q-tip to help manipulate the cervix and transformation zone into view if necessary. It is almost never necessary to use a tenaculum to move the cervix. A Kogan endocervical speculum (above) can greatly aid the examination of the distal endocervical canal if necessary. Use higher magnification to carefully document abnormal vascular patterns. The green filter can help find vascular areas.
- Is the colposcopy satisfactory? The entire transformation zone, including the entire squamocolumnar junction (shown above), must be visualized. In order to be deemed satisfactory, the borders of all lesions also must be entirely seen (not disappearing into the canal for instance) for visualization to be adequate. The uncooperative patient or severely flexed uterus with inadequate visualization are potential causes of inadequate colposcopy. Inadequate colposcopy with cytologic evidence of dysplasia frequently requires cervical cone biopsy for work-up.
- Mentally map abnormal areas. Remember that colposcopic observation's main goal is to highlight areas for biopsy. It is not, per se, a diagnostic tool. However, acetowhite areas that have sharp geographic boarders and a dimension of thickness or roughness are likely to be histologically more severe. Furthermore, all other things being equal, the presence of vessel atypia in any lesion implies more severe dysplasia. Use the following parameters to grade severity of lesions:
Lugol's solution (Schiller's test) may be used by the beginning colposcopist or at any time when further clarification of potential biopsy sites is necessary. It need not be used in all cases. The sharp outlining afforded by Lugol's iodine (Schiller's test) can be dramatic and very helpful. Iodine staining does not interfere with histology. Lugol's solution is often very helpful on the vagina and proximal vulva (non-keratinized skin). It can be used to thoroughly and simultaneously examine the entire vagina for glycogen-deficient areas, which correlate with HPV and/or dysplasia in non-glandular mucosa. It is often reserved for difficult cases when a non-cervical source of cervical Pap smear atypism is suspected (as in "normal cervical colposcopy" with dysplasia on Pap smear or normal ECC histology).
If desired, apply topical benzocaine (Hurricaine) solution to the entire face of the cervix using a cotton ball, although its efficacy is questionable.
If indicated, perform an endocervical curettage. Use a Kevorkian curette (preferably without a basket) and scrape the canal, 360 degrees, twice. The sample appears as a coagulum of mucus, blood, and small tissue fragments. Use ring forceps or a cytobrush to gently retrieve the sample. Submit on paper and label "ECC." Do not do an ECC on pregnant patients. Alternatively, a cervix Pap smear brush (the "pipe-cleaner type brush") may be placed into the os and rotated. The resulting tissue and blood coagulum may be submitted as a histological specimen in formalin. A short drinking straw may be placed over the brush to act as a sheath to protect the brush from contamination by the ectocervix while the device is being introduced or withdrawn. Place the brush inside the straw and place the straw against the os. Then advance the brush, obtain the sample, and withdraw the brush back into the straw for removal. This results in sensitivity about the same as the Kevorkian curette with a higher specificity.
- Mild acetowhite epithelium < Intensely acetowhite
- No blood vessel pattern < Punctation < Mosaic
- Diffuse vague borders < Sharply demarcated borders
- Follows normal contours of the cervix < "humped up"
- Normal iodine reaction (dark) < Iodine-negative epithelium (yellow)
- Leukoplakia - usually a very good (condylomata) or a very bad sign
- Atypical vessels - a hallmark of cancer
Perform cervical biopsy. Begin by mentally mapping a biopsy strategy. Biopsy posterior areas first to avoid blood dripping over future biopsy sites. The cervix can be manipulated with a Q-tip or hook if necessary to provide an adequate angle for biopsy. A depth of 3 mm is typically all that is necessary. Always include the area with vessel atypism in at least one biopsy site. It is not necessary to include normal- appearing tissue with biopsy samples (i.e., biopsy the margins of lesions). Beginning colposcopists can enhance their skills initially by separating samples from different biopsy sites in different bottles and subsequently correlating them with colposcopic impression. If bleeding is profuse from a particular site and more biopsies are needed, apply a Q-tip to the area and proceed with the next biopsy. Do not apply Monsel's solution until all biopsies are completed. Monsel's will ruin good histology.
Apply pressure and Monsel's solution to bleeding sites. The Monsel's should be as thick as toothpaste to be most effective. Swab out the excess Monsel's and blood debris, which appears as a nasty black substance that eventually will pass, possibly causing alarm (and potential late night phone calls).
Gently remove the speculum and view the vaginal wall collapse around the receding blades of the speculum. Are any abnormal areas apparent?
Have the patient rest supine for at least several minutes and then sit up slowly and rest again. Fainting and light-headedness are not uncommon.
Carefully draw and label a picture of lesions and biopsy sites. Correlate the pictures with the submitted samples, if placed in different containers.
Provide careful post-procedure instructions. Advise no douching, intercourse, or tampons until spotting subsides or until return visit. Patients are instructed to return for foul vaginal odor or discharge, pelvic pain, or fever. Tylenol, ibuprofen, or Aleve may be used for cramps (if any). Otherwise, follow-up is usually in 1 to 3 weeks to discuss histology results.
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