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Colposcopy |
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Colposcopy Protocol
Responsible for policy - Paul Carter
Last reviewed - 22/3/2005
Last date page electronically updated - 11/09/2005
Next review - 1/4/2006
COLPOSCOPY CLINIC PROTOCOL
It should be noted that this protocol is a guide to treatment and not policy set in stone.
Management of borderline and mildly dyskaryotic smears
(I) Complete colposcopy & absence of visible abnormality
(II) Complete colposcopy & visible abnormality
Management of moderately and severely dyskaryotic smears
(I) Complete colposcopy & absence of visible abnormality
(II) Complete colposcopy & visible abnormality
Management of glandular abnoramlities
Persistent borderline/Inflammatory smears
(I) Under Local Anaesthesia in Colposcopy Clinic
(I) Complete excision of CIN I
(II) Complete excision of CIN II & III
(III) Criteria for follow-up in colposcopy clinic
Dyskaryosis following previous treatment
Management of the abnormal smear during pregnancy
GENERAL PROTOCOLS FOR THE COLPOSCOPY SERVICE
Demographic details of all patients to be entered into database at the time of consultation.
Record of consultation to be entered into database.
Include record of suitability for treatment under local anaesthetic.
Diagram of colposcopic impression to be included.
At least three copies of the computer generated correspondence to be given to secretary.
Copy1 to be sent to referring doctor (with copy to GP if not the referring doctor).
Copy 2 to enter patients records.
Copy 3 to stay with secretary to await results.
All results to be entered into 'Results' section of database and communicated in writing to GP and patients.
Rapid access 'High Grade Clinics' where select and treat policy will operate.
Parallel clinics for low grade lesions and selected follow-up cases.
No further appointments for defaulters unless re-referral from GP(exceptions for possible invasive disease and at the discretion of the individual clinician).
Patients who do not attend to be informed of the above in writing with a copy to GP.
Patients arriving more that 10 minutes late will be rebooked.
Monthly clinico-pathology meeting to review.
1. Monthly statistics.
2. All treatments with positive endo-cervical margins.
3. All treatments with positive ecto-cervical margins if high grade.
4. Major discrepancy between cytology and/or colposcopy and biopsy.
5. All negative biopsies and treatments.
6. Glandular abnormalities
7. Cases of re-treatment
8. Patients posing a clinical dilemma for further management.
Patient records/clinical summary to be available on all patients discussed in clinico-pathology meeting.
MANAGEMENT OF BORDERLINE/MILDLY DYSKARYOTIC SMEARS
(I) Complete colposcopy & absence of visible abnormality
(a) - Repeat smear & review 9/12 if result is no worse than mild dyskaryosis.
(b) - Inspect vagina for possible origin of dyskaryotic cells.
(c) - If repeat smear normal & follow-up colposcopy & smear normal at 9/12 then refer to GP for repeat smear after 6,12 and 24 months and then return to normal screening.
(d) - If colposcopy normal at 9/12 but mild dyskaryosis persists - give patient options;
i) continue colposcopy review every 9/12 until 2 consecutive normal smears or dyskaryosis deteriorates and treatment is needed.
ii) treatment (esp if family complete/post-menopause/suspected poor compliance).
(II) Complete colposcopy & visible abnormality
(a) -Take biopsy/biopsies and if CIN I confirmed - review 9/12.
(b) - If lesion persists give patient options;
i) continue 9/12 colposcopy review until lesion resolves and two consecutive smears are normal.
ii) lesion remains unchanged & patient requests treatment.
(c) - lesion deteriorates cytologically/histologically and treatment is required.
(d) - If initial biopsy confirms CIN II/III - offer treatment.
(III) Incomplete colposcopy & visible abnormality
(a) - As for (II) but brush smears necessary in addition to spatula/broom.
(b) -Low threshold for treatment if cytological/histological/colposcopic abnormality persists with incomplete colposcopic assessments.
(IV) Incomplete colposcopy & no visible abnormality
(a) - Six monthly colposcopy with spatula & brush smears until 2 normal consecutive smears or dyskaryosis persists/deteriorates and treatment is recommended.
(b) - Recommend treatment if dyskaryosis persists/deteriorates.
MANAGEMENT OF MODERATELY/SEVERELY DYSKARYOTIC SMEARS
(I) Complete colposcopy & absence of visible abnormality
(a) - Repeat smear & review 6/12 if no worse than mild dyskaryosis & ask cytologist to review referral slide. If repeat smear worse than mild change, offer treatment.
(b) - If colposcopy normal at 6/12, repeat smear & consider 4 quadrant biopsy and review every 6/12 if no worse than mild dyskaryosis or CIN I.
(c) - If colposcopy normal at 1 year but mild dyskaryosis persists - give patient options;
i) Observation - continue colposcopy review every 6/12 until 2 consecutive normal smears or dyskaryosis deteriorates and treatment is needed.
ii) treatment (esp if family complete/post-menopause/poor compliance).
(d) - If colposcopy & smear normal at 1 year repeat after further 6/12 and then refer back to GP, if normal, for repeat smear after 6/12 and then annually if normal.
(e) - Remember to inspect the vagina as a possible source of dyskaryotic cells.
(II) Complete colposcopy & visible abnormality
(a) - If lesion consistent with cytological diagnosis offer treatment.
(b) - If lesion not consistent with cytology, repeat smear & take biopsy/biopsies and if no worse than mild dyskaryosis/CIN I, review 6/12. If worse offer treatment.
(c) - If lesion persists at 6/12 check, give patient options;
i) continue 6/12 review until lesion resolves and next two smears are normal.
ii) lesion remains unchanged & patient requests treatment.
iii) lesion deteriorates cytologically/histologically and treatment is required.
(d) - If biopsy confirms CIN II/III - offer treatment.
(III) Incomplete colposcopy & visible abnormality
(a) - Offer treatment.
(IV) Incomplete colposcopy & no visible abnormality
(a) - Offer treatment.
If colposcopy consistent with smear, arrange admission for EUA & staging & cone biopsy.
If colposcopy is complete & suggests CIN only, proceed to LLETZ.
If colposcopy suggests CIN only but is incomplete then admit for EUA, staging & cone biopsy as above.
Mark histology as urgent and request review at monthly meeting.
MANAGEMENT OF GLANDULAR ABNORMALITIES
Assume these are high grade lesions with possible confusing colposcopic appearances.
Irrespective of colposcopic appearance- arrange for LLETZ with deeper cone, and some form of endometrial sampling due to the possible multifocal nature of these lesions.
Request review at monthly meeting.
Arrange further treatment if deep margins are involved.
Review 6 monthly in colposcopy clinic for 5 years.
ENDOCERVICAL CELLS ONLY: Repeat smear and consider reversing spatula or rotating with tip placed laterally.
SQUAMOUS CELLS ONLY: Repeat smear using brush and spatula.
POST TREATMENT: Repeat using spatula & brush and apply counter-traction with a tenaculum if cervical stenosis prevents adequate sampling of endo-cervix. Consider L.A. injection to cervix in order to enable endo-cervical sampling.
PERSISTENT POST TREATMENT: Admit for dilatation of cervix and endo-cervical curettage. Consider local oestrogen cream to evert SCJ in post-menopausal women.
PERSISTENT BORDERLINE/INFLAMMATORY SMEARS
(a) Repeat colposcopy on 6 monthly basis but if a normal smear is not achieved consider 4 quadrant biopsy/LLETZ.
(b) If colposcopy is incomplete - have low threshold for LLETZ.
(II) Abnormal colposcopy
Take biopsy/biopsies and manage accordingly (regular review/LLETZ) until 2 consecutive normal smears are obtained.
(I) Under Local Anaesthesia in Colposcopy Clinic
a) high grade abnormality with corresponding cytological appearance
b) biopsy proven high grade CIN
c) biopsy proven low grade lesion if requested by patient
d) persistent low grade change
e) glandular abnormality
(II) Under general Anaesthesia as Day Case or In-patient
a) poor toleration of colposcopic examination
b) restricted access
c) large lesion
d) patient request for G.A.
e) pregnancy
f) other pathology requiring a procedure under G.A.
(III) Pre-treatment Counselling
a) written information sent in advance of the clinic visit
b) full explanation of procedure & post treatment expectations
c) if IUCD in situ explanation of removal and replacement
d) appropriate advice if IUCD to be removed and not replaced
e) advice on pelvic rest
f) possible complications (check on peanut allergy)
g) communication of results in writing
h) plan for follow-up
i) verbal consent sufficient for L.A. procedure but written consent for G.A.
Many colposcopic assessments will be incomplete, thus emphasising the importance of satisfactory cytological surveillance and in particular, adequate sampling of the endo-cervix with a brush and using counter-traction with a tenaculum if necessary .
(I) Complete excision if CIN I
Follow-up cytology (spatula + brush) with GP at 6/12:
If normal, repeat smear at 12 & 24 months and then return to normal screening.
(II) Complete excision of CIN II & III
Follow-up cytology (spatula + brush) with GP at 6/12
If normal further smears at 12 months and then annually for a further 9 years
(III) Criteria for follow-up in colposcopy clinic
Positive margins (NB.post-menopausal women with positive endo-cervical margins require further treatment)
Glangular change (NB. 6 monthly F/U required for 5 years in colposcopy)
Involvement of crypts
Micro-invasive disease
ABNORMALITIES DURING FOLLOW-UP AFTER TREATMENT OF CIN
Lower threshold for concern if colposcopy is incomplete and lesion was incompletely excised at endocervical margin. Must adequately sample the endo-cervix
Low grade dyskaryosis post treatment;
colposcopy & smear every 6/12 until colposcopy and smears are normal on two occasions
or problem persists/deteriorates and treatment is offered.
High grade dyskaryosis following treatment, offer further treatment
Any colposcopic abnormality should be biopsied
DYSKARYOSIS FOLLOWING PREVIOUS TREATMENT
Colposcopic assessment is required with biopsy of any visible lesion. If no lesion seen then repeat cytology if colposcopy is complete If colposcopy is incomplete then have low threshold for repeat cone biopsy if dyskaryosis is moderate or severe, or obtain adequate endocervical cytology if dyskaryosis is mild. If colposcopy remains incomplete and mild dyskaryosis persists then offer further treatment.
No vault cytology needed if previous smears (for 10 years) were normal and there is no CIN in the specimen.
If <10 years recall, and no CIN in specimen – vault smear only at 6/12. No further F/U if normal.
If specimen contains CIN which is completely excised – vault smears at 6/12 and 18/12.
If CIN is incompletely excised – follow up as if cervix was still in situ.
MANAGEMENT OF THE ABNORMAL SMEAR DURING PREGNANCY
1. Referral criteria should not differ in pregnant patients.
2. Patients to be seen within 4 weeks of referral
3. Patients with abnormal cytology and PV bleeding to be seen within 2 weeks.
4. Full colposcopic assessment with repeat cytology using spatula only (brush may cause rupture of membranes)
5. The main priority is to exclude invasive disease. This requires punch biopsies from the most abnormal looking areas.
6. LLETZ is not indicated during pregnancy due to the high chance of miscarriage
7. If invasive disease is excluded, repeat colposcopic assessments should be made at 12 weekly intervals up to 36 weeks gestation. The cytology should be repeated and further biopsies taken if necessary.
8. Following delivery, repeat colposcopy and cytology or treatment (LLETZ) should be performed after 3 months.
9. Diagnosis of invasive disease during pregnancy requires immediate referral to the Consultant Gynaecological Oncologist.
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