Cervical screening and colposcopy Flashcards
Describe the National Cervical Screening Programme in NZ and routine screening:
All SEXUALLY ACTIVE women age 25 to 69 years old.
After first ever smear OR if first smear in more than 5 years, second smear should be performed 12 months later and if both normal smear interval increased to every 3 years.
What are the recommendations from the NCSP on screening women aged 70 years and older who were unscreened or under-screened prior to age 70?
Should have TWO consecutive normal cytology samples taken 12 months apart before ceasing cytology screening.
What are the recommendations from the NCSP for follow-up after successful treatment of high grade squamous disease?
Discharge from colposcopy to primary care for test of cure:
- Co-testing (cytology + hrHPV test) should be performed at 6 months and 12 months
- If any concerns or abnormalities, should return to colposcopy at 6 months post-treatment for co-testing.
What is the negative predictive value for hrHPV testing in detecting high grade abnormalities?
NPV 99% and is more sensitive than cytology.
Describe the 4 groups of women in which reflexive hrHPV testing is performed currently:
- Women >30 years old with AS-CUS or LSIL (without an abnormal smear in last 5 years).
- All women receiving treatment for high-grade lesions to assess whether lesion has completely resolved.
- Women with HSIL or ASC-H more than 3 years ago with subsequent repeated negative cytology
- Discordant cytology and colposcopy results for post-colposcopy management.
Why might a smear cytology be considered unsatisfactory?
Sample taking:
- Inadequate number of cells sampled
- Contact bleeding
- Contaminants e.g. lubricant
Clinical factors:
- Bleeding
- Inflammation
- Cytolysis
Lab technical processing issues.
How should an unsatisfactory smear cytology be managed?
- Repeat smear within 3 months.
- Refer to colposcopy to exclude high grade lesion after 3 consecutive unsatisfactory smear reports
- Prescribe course of vaginal oestrogen cream nightly for 2-3 weeks prior to repeating smear in postmenopausal, postnatal and breastfeeding women.
If a woman aged 25-69 with NO abnormal smear history within last 5 years has a smear report showing ASC-US or LSIL, how should she be managed?
Repeat smear in 12 months time:
- if persistent abnormality: refer for colposcopy
- if negative, repeat smear again in 12 months and if negative return to 3 yearly screening. If abnormal refer to colposcopy
If a woman aged 25-69 WITH an abnormal smear history within last 5 years has a smear report showing ASC-US or LSIL, how should she be managed?
Refer to colposcopy
If a woman aged 25-69 with with a PRIOR HIGH GRADE ABNORMALITY more than 5 years ago has a smear report showing ASC-US or LSIL, how should she be managed?
Refer to colposcopy
If a woman aged more than 30 with NO abnormal smear history within last 5 years has a smear report showing ASC-US or LSIL, how should she be managed?
She will receive reflexive hrHPV testing:
- If positive, she should be referred to colposcopy.
- If negative, she should have a repeat smear in 12 months and if negative she should return to 3 yearly screening.
What are the indications for colposcopy?
· Persistent abnormalities on repeat smear.
· HSIL, ASC-H at any smear.
· Abnormal smear in 30+ with no abnormal smears in last 5 years that tests positive for HrHPV.
· 3 consecutive unsatisfactory smear results.
· Other indications: sexual abuse investigation; cervical polyp; associated suspicious lesions of genital tract.
Describe the steps you would do to perform colposcopy:
- Examine in lithotomy position with speculum using colposcope.
General assessment:
- Adequate OR inadequate (and if inadequate, for what reason)
- Visibility of SCJ: fully, partially or not visible
- Transformation zone type 1, 2, or 3. Whole TZ should be visualised.
Note other typical appearances of CIN:
- Abnormal capillary patterns such as punctation and mosaicism
Apply acetic acid 5% and assess for acetowhite changes.
Apply Lugol’s iodine (Schiller’s test) and assess for areas of poor iodine uptake and delineate lesion.
Biopsy dysplastic areas.
Perform endocervical curettage in non-pregnant women with smears showing atypical glandular cells or adenocarcinoma in situ.
List colposcopic changes (grade 2/major changes) that make you suspicious of a high-grade lesion or invasive cancer:
- Dense acetowhite epithelium and rapid appearance of acetowhitening.
- Sharp regular border.
- Cuffed crypt (gland) openings
- Blood vessels: coarse mosaic and punctation.
- Inner border sign: inner more proximal lesion more severe/higher grade.
- Ridge sign
- Rag sign
- Iodine negative areas in association with acteowhitening.
- Erosions
- Leukoplakia
Regarding colposcopic assessment of ASC-US or LSIL:
How should an unsatisfactory colposcopy be managed?
Repeat cytology
- If low-grade, repeat colposcopy, cytology and hrHPV testing in 12 months.
How should LSIL / CIN1 confirmed on histology be managed?
· Treatment is not recommended because such lesions are considered to be an expression of a productive HPV infection
· Refer back to sample taker for repeat cytology at 12 and 24 months; if both negative can return to 3 yearly screening.
· Refer back to colposcopy if either repeat test shows ASC-US/LSIL or higher degree of abnormality.
A woman is referred to colposcopy with an ASC-H/HSIL smear but her colposcopy was satisfactory and normal or biopsy negative.
How should she be managed?
Perform review cytology (repeat smear):
- If review confirms high-grade lesion, repeat colposcopy and cytology in 3 months time.
If repeat cytology and colposcopy at 3 months:
- Normal: repeat cytology in 12 months
- LSIL: individualise management with MDM
- HSIL, CIN2/3: treatment
A woman is referred to colposcopy with an ASC-H/HSIL smear but her colposcopy was UNsatisfactory:
How should she be managed?
Perform review cytology (repeat smear):
- If review confirms ASC-H or HSIL, cone biopsy/type 3 excisional treatment recommended.
- If review confirms ASC-US or LSIL, individualise management at MDM.
Excisional treatments of the cervix are associated with what obstetric risks?
- Preterm delivery
- Low birth weight
- Premature rupture of membranes.
What is the most important risk factor for treatment failure with excisional treatment?
Involved excision margins.
List the indications for colposcopy during pregnancy:
- HSIL/ASC-H smear
- Glandular lesion on smear
- Concerning cervical appearance or persistent postcoital bleeding
List the issues with colposcopy during pregnancy:
- Cervix is hypetrophied and hyperaemic
- Increased vaginal wall laxity making visualisation difficult
- Deciduosis: similar appearance to malignancy with exaggerated squamous metaplasia and vascular changes
- Increased risk of bleeding
- Increased amount of cervical mucus produced
Goal: to rule out invasive cancer. Biopsy ONLY if invasive cancer is suspected. Otherwise, reassess 6-12/52 postpartum
During pregnancy:
When should treatment for invasive cancer be performed?
What are the issues associated with excisional treatment during pregnancy?
- Excisional treatment should be performed between 12 and 20 weeks ideally.
Issues include:
- Risk of pregnancy loss
- Risk of haemorrhage; may need haemostatic sutures
- May need cerclage
- High risk of recurrence or persistence.
Describe squamous metaplasia
- Through exposure to oestrogen, the glycogen in the cells of the vagina is converted into lactic acid.
- This acidity, along with other factors, stimulates the replacement of the columnar epithelium with squamous epithelium.
- This process is known as metaplasia
- Metaplasia results in the formation of a new SCJ
- The area between the original SCJ and the new SCJ is known as the transformation zone
