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PubMed1996

Avoiding conization for inadequate colposcopy. Suggestions for conservative therapy.

OBJECTIVE: To determine if conservative treatment can safely be offered to patients with cervical intraepithelial neoplasia (CIN) and inadequate colposcopic examination. STUDY DESIGN: We reviewed the charts of 733 evaluable cone biopsies of the cervix performed for CIN at the University of Texas Medical Branch at Galveston from January 1981 to September 1990. RESULTS: Of 371 conizations that indicated inadequate colposcopy, there were 62 cases that fulfilled all the following conditions: cytologic smear suggesting CIN 2 or less, negative endocervical curettage (ECC) and cervical colposcopic biopsy showing CIN 2 or less. Pathologic examination of the cone biopsy specimen in these 62 cases revealed no dysplasia in 29.0%, CIN 1 in 16.%, CIN 2 in 37.0%, 3 in 17.7%, and no microinvasive or invasive lesions. Pathologic examination of the cone specimens of 309 patients with any high-risk factor--smear suggesting CIN 3 or invasive disease, colposcopic biopsy showing CIN 3 or positive ECC--revealed no dysplasia in 11.9%, CIN 1 in 11.3%, CIN 2 in 16.8%, CIN 3 in 49.8%, microinvasive carcinoma in 5.5% and frankly invasive carcinoma in 4.5%. CONCLUSION: Conservative therapy may be offered to patients with inadequate colposcopy, CIN 1-2 on both biopsy and cytology, and negative ECC without over-looking either invasive or microinvasive carcinoma. With these criteria, 16.7% of patients with an inadequate colposcopy in our study could have avoided cone biopsy.

Cervix Uteri↗
PubMed1996

Risk factors for noncompliance in a colposcopy clinic.

OBJECTIVE: To evaluate demographic characteristics as risk factors for noncompliance with colposcopy clinic follow-up. STUDY DESIGN: A retrospective, case-control study was performed on patients evaluated in the Women & Infants' Hospital colposcopy clinic between January 1, 1992, and December 31, 1993. Data extracted from chart review included demographic characteristics, insurance status, smoking status, cytologic and histologic grade treatment received, number of appointments kept and missed, number of attempts to contact the patient and degree of compliance with colposcopy follow-up. A scoring system was created to assess a patient's level of compliance by evaluating the number of appointments kept and missed. RESULTS: After review of the first 80 patients, a noncompliance rate of 23% was determined based on our scoring system. A total of 86 noncompliant patients were then compared to 93 compliant patients. Women who were noncompliant with follow-up were more likely to be on Medicaid or to have no insurance when compared to compliant patients (odds ratio [OR] = 2.4, confidence interval [CI] .85, 6.7), but this difference did not reach statistical significance (P = .07). Noncompliant patients were less likely to have high grade lesions than compliant patients (OR = .34; CI .13, .85; P = .01). CONCLUSION: Patients with lower grade lesions may be more likely to be noncompliant with recommended follow-up than patients with high grade lesions. This association may be due to a reduced emphasis on follow-up and patient education in women with low grade lesions. Increased educational efforts should be made to attempt to reduce high rates of noncompliance in this group of women.

Adolescent↗
PubMed1996

Colposcopy in general practice.

Primary care physicians are in an excellent position to identify women most at risk for cancer precursors. They can use a variety of modalities, including colposcopy thus reducing patient anxiety and waiting time. This article describes a training program for such a service, which includes at least 100 colposcopy examinations under supervision. It is applicable outside a hospital clinic setting. Subsequent practice must have a referral base sufficient to maintain competence as well as economic viability. All GP colposcopists in the Perth area attend regular quality assurance meetings. An audit has shown that properly trained GPs can achieve a level of competence equivalent to that expected of their specialist colleagues (89% concordance between colposcopic impression and histology). The format of the audit was based on that of the Royal Australian College of Obstetricians and Gynaecologists (RACOG). Treatment must be performed by experts. General practice is the appropriate location for community screening studies using colposcopy.

Clinical Competence↗
PubMed1998

Triage of women with ASCUS and LSIL on Pap smear reports: management by repeat Pap smear, HPV DNA testing, or colposcopy?

BACKGROUND: The purpose of this study was to determine the efficacy of a repeat Papanicolaou (Pap) smear and the Hybrid Capture tube-based (HCT) HPV DNA test for detecting cervical intraepithelial neoplasia (CIN) grade 2 or 3 in women with recent atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) Pap smear reports. METHODS: Women with a recent Pap smear report of ASCUS (n = 169) or LSIL (n = 110) had a repeat Pap smear, sampling of the cervix for HCT HPV DNA assay and a colposcopy examination. Data were evaluated using three different triage thresholds for colposcopy examination: a repeat Pap smear of persistent ASCUS or more severe dysplasia, a finding of persistent LSIL or more severe dysplasia, and a carcinogenic HPV test result. RESULTS: The sensitivity, specificity, and positive and negative predictive values for detecting CIN 2/3 were 70%, 45%, 7%, and 96% for a repeat Pap smear using an ASCUS-positive threshold and 20%, 86%, 8%, and 94% for a repeat Pap smear using an LSIL-positive threshold, respectively, when women with an initial ASCUS Pap smear were considered. HPV testing for carcinogenic viruses alone or in combination with a repeat Pap smear (using ASCUS as a positive threshold) yielded results of 50%, 67%, 9%, and 96%, respectively, and 70%, 37%, 7%, and 95%, respectively, for detecting CIN 2/3. In women with an initial LSIL Pap smear, respective values for detecting CIN 2/3 by a repeat Pap smear with an ASCUS threshold were 92%, 26%, 14%, and 96%, and for an LSIL threshold 23%, 64%, 8%, and 86%, respectively. Hybrid Capture HPV testing alone or in combination with a repeat Pap smear yielded 69%, 43%, 14%, and 91%, respectively, and 100%, 21%, 14%, and 100%, respectively. CONCLUSIONS: A Pap smear triage threshold restricted to LSIL or more severe dysplasia for women with prior ASCUS or LSIL Pap smear results was clearly ineffective for detecting high-grade cervical precancerous lesions. In contrast, when the repeat Pap smear triage threshold was expanded to include persistent ASCUS as abnormal, 83% of the women with CIN 2/3 were detected. Detection of carcinogenic HPV DNA using the HCT test was almost as sensitive for detecting CIN 2/3 as a solitary repeat Pap smear using an ASCUS or more severe positive threshold. Combining the HPV test with a repeat Pap smear did not significantly improve the sensitivity of cytology for detecting high-grade CIN. This study suggests that women with ASCUS and particularly LSIL Pap smears should be referred for a colposcopy examination until better triage methods become available.

Adult↗
PubMed1998

An introduction to colposcopy. Concepts, controversies and guidelines for practice.

Colposcopy is a clinical procedure used to investigate the health of the cervix and lower genital tract. This article is limited to an overview of the colposcopic examination. Colposcopy consists of four sequential steps visualization, assessment, sampling, and documentation and correlation. Since most women are dependent on their primary care providers for information and guidance, a post-colposcopic appointment will aid in the discussion of treatment options and help alleviate any fears or unanswered questions. Regardless of the treatment, stress the need for frequent follow-up exams for Pap smears or repeat colposcopy.

Colposcopy↗
PubMed2002

Association of knowledge, anxiety, and fear with adherence to follow up for colposcopy.

OBJECTIVES: To evaluate the association of pre-visit anxiety with pre- and post-visit knowledge, satisfaction, and adherence to colposcopy follow-up visits. METHODS: A group of 122 women presenting for colposcopy between July 1999 and May 2000 were studied. Immediately prior to their appointment, 98% of eligible patients participated in a self-administered questionnaire. Patients were sent a follow-up questionnaire within two weeks of the appointment. Statistical analyses included Chi-Square and Fisher's exact tests for categorical variables. RESULTS: The mean follow up was 112 days (SE 9.47). Although the mean fear score was 7.3 (SE 3, range 1-10) and mean anxiety score was 7.8 (SE 2.8, range 1-10), there was no significant association with pre-visit fear and adherence to follow up. Pre-evaluation knowledge was positively associated with fear, anxiety, post-visit knowledge, and adherence to follow up. CONCLUSIONS: Pre-visit intervention may improve adherence and reduce anxiety associated with colposcopy.

Journal Article↗
PubMed2002

Colposcopy quality control for clinical trials: the positive effects from brief, intensive educational intervention.

OBJECTIVE: To determine whether a brief, intensive colposcopy course improves the cognitive skills of colposcopists participating in clinical trials. MATERIALS AND METHODS: Twenty-two colposcopists involved in a multicenter clinical trial attended an intensive colposcopy course designed to improve diagnostic skills. Participants completed a pretest and posttest of 10 case-based studies and the ASCCP Colposcopy Recognition Award (CRA) examination. Pre- and posttest exam and CRA results were compared for each individual and the group. RESULTS: The group mean pre- and posttest total scores were 67% and 73%, respectively. There was a significant improvement in posttest colposcopic impression mean scores compared with the pretest (56% and 44%, respectively). The greatest improvement in colposcopic impression mean scores was for low-grade, high-grade, and cancer cases; 25%, 23%, and 20%, respectively. CRA scores did correlate positively with pretest scores. CONCLUSION: A brief, intensive colposcopic educational program improved the cognitive skills of the colposcopists.

Journal Article↗
PubMed2001

Clinical evaluation of borderline nuclear changes in cervical smears at colposcopy and biopsy.

The aim of this study was to determine the incidence of cervical intraepithelial neoplasia at colposcopy and biopsy in woman with smears showing borderline nuclear changes to assess the predictive rate of colposcopy in identifying CIN and to verify the importance of follow-up. A retrospective study of 134 cases referred for colposcopic assessment with borderline nuclear changes in smears was carried out. Of the 134 patients studied, 44.8% had cervical intraepithelial neoplasia and 30% had benign changes of the cervix; 25.5% of cases were normal, 14% of the study population had HPV infection confirmed by biopsy. Of all cases of CIN, 38% were diagnosed to have low grade abnormalities, 6.8% had high-grade abnormalities. The predictive rate of colposcopy in identifying low-grade abnormalities was approximately 60% and 80.7% had a normal smear after 6 months, follow-up. As cervical intraepithelial neoplasia was found in a significant number of patients, borderline changes in cervical smears need subsequent evaluation. Even though more than two-thirds of women had negative smears at 6-month follow-up, the study recommends annual follow-up smears for several years as the long-term risk is not definitely known.

Journal Article↗
PubMed2001

'See and treat' at colposcopy--achieving the standard.

The National Health Service Cervical Screening Programme has issued quality standards for the colposcopy service nationally. One standard is that for women who undergo treatment at their first colposcopy clinic visit, 90% should have proven cervical intra-epithelial neoplasia (CIN) on histology. We have assessed data from a teaching hospital colposcopy clinic over a 9-year period to assess the criteria that should be satisfied in order to achieve this target. We propose that only those women with severe dyskaryosis on the referral smear and a colposcopic appearance of CIN 2 or 3, or those in whom the colposcopic appearance suggests CIN 3 with any grade of dyskaryosis undergo treatment at their first visit.

Journal Article↗
PubMed2003

Is colposcopy warranted in women with external anogenital warts?

OBJECTIVES.: To determine the prevalence of cervical dysplasia, diagnosed cytologically (squamous intraepithelial lesion [SIL]) or histologically (cervical intraepithelial neoplasia [CIN]), in women with external anogenital warts, and to determine the discriminating risk factors between those with and without cervical dysplasia. MATERIALS AND METHODS.: Chart review of women referred to colposcopy for external anogenital warts from 1990 to 1999. Human papillomavirus risk factors predictive for cervical dysplasia were assessed by logistic and Cox regression models. RESULTS.: There were 496 patients in this study. The prevalence of SIL by cytology was 20%: 18% low-grade squamous intraepithelial lesion and 2% high-grade squamous intraepithelial lesion. The combination of Pap smear and colposcopically directed biopsy identified dysplasia (SIL or CIN) in 30%, 4% of which were high-risk lesions (high-grade squamous intraepithelial lesion or CIN 2,3). Colposcopy performed much better than the Pap test alone in detecting CIN 2,3 lesions; 16 of 18 cases of CIN 2,3 diagnosed on biopsy had Pap smear results of low-grade squamous intraepithelial lesion or less, 7 of which were normal. Two thirds of those diagnosed with CIN 2,3 were aged 25 years and older. No differences in human papillomavirus infection risk factors were found between women with and without cervical dysplasia. CONCLUSIONS.: The high prevalence of CIN 2,3 in women with external anogenital warts warrants evaluation with colposcopy, particularly in women aged 25 years and older.

Journal Article↗
PubMed2004

The Pap test at follow-up colposcopy examinations: usefulness in the enhanced detection of cervical neoplasia.

OBJECTIVE: The frequency at which results of the Pap test performed at follow-up colposcopy examinations were more abnormal than the concurrent tissue specimens and the frequency at which the Pap result gain in high-grade squamous intraepithelial lesion (HSIL) resulted in the increased detection of cervical intraepithelial neoplasia 2,3 were investigated. MATERIALS AND METHODS: Pap test and concurrent tissue samples obtained at all follow-up colposcopy examinations in the year 2000 were coded for comparability of results and were ranked in ascending order from normal to malignant. The frequency at which the Pap test results were more abnormal than the concurrent tissue results was calculated. Results of subsequent cervical investigations were retrieved for all with a Pap test gain in diagnosis of HSIL. RESULTS: In 35% of 2,902 examinations (n = 1,027), the Pap test results were more abnormal than the tissue specimens. The gain in diagnosis was HSIL in 2% (63 of 2,902) and low-grade squamous intraepithelial lesion or better in 33% (964 of 2,902). Among those with a gain in HSIL, cervical intraepithelial neoplasia 2,3 or cancer was tissue-confirmed in 28 samples, for a health benefit of the Pap test of 1.0% (28 of 2,902). CONCLUSIONS: The usefulness of the Pap test performed at follow-up colposcopy examinations for the enhanced detection of CIN 2,3 in this cohort is minimal, and the practice safely could be discontinued.

Journal Article↗
PubMed1999

Atypical squamous cells of undetermined significance: A cytohistological study in a colposcopy clinic.

Cytohistologic correlation was performed by 3 observers on 100 atypical squamous cells of undetermined significance (ASCUS) cases from a colposcopy clinic. Our objectives were to: 1) subclassify ASCUS cases and determine their clinical significance; 2) assess the independent predictive value of different cytologic parameters for biopsy-proven dysplasia (BPD); and 3) calculate interobserver variability. The prevalence of BPD was 73% in the ASCUS favor dysplasia (AFD) group, and 27% in the ASCUS favor reactive (AFR) group (P 0.001). The sensitivity of cervical cytology (AFD) for detecting BPD was 88.5%. Using multiple logistic regression, only nuclear membrane irregularity was found to be independently predictive of BPD (P 0.0001). The interobserver agreement (kappa) was 0.41. Colposcopic smears were inferior to referring smears in detecting dysplasia, with 67% of patients having a referring diagnosis of dysplasia. In a colposcopy clinic population there is a high prevalence (73%) of BPD in the AFD group. Attention should be paid to nuclear membrane irregularity in the risk stratification of ASCUS cases. Diagn. Cytopathol. 1999;21:211-216.

Biopsy↗
PubMed1985

Treatment of cervical intraepithelial neoplasia III by hysterectomy without intervening conization in patients with adequate colposcopy.

One hundred forty-four patients found to have cervical intraepithelial neoplasia (CIN) III on colposcopically directed biopsy who had completed childbearing were treated with a vaginal hysterectomy (112 patients) or abdominal hysterectomy (32 patients). The mean age of these patients was 28.6 years and the mean gravidity, 3.4. All patients had adequate colposcopy of the cervix and vagina. The transformation zone and lesion(s) were completely visualized. The uterus was submitted for histologic examination in all cases. The cervix was sectioned in a radial fashion (minimum 12 sections), and the proximal endocervix and lower uterine segment were sectioned transversely. CIN III was present in the cervix of 117 patients, CIN II in 9 patients, CIN I in 8 patients, and no evidence of residual neoplasia in 9 patients. Microinvasive cancer (1.3 mm stromal invasion without lymph-vascular space invasion) was present in one patient. After surgery, patients were seen every 3 months for 2 years and every 6 months thereafter. All 144 patients were followed up for at least 12 months, 124 patients for 24 months, 103 patients for 36 months, and 60 patients for 60 to 120 months. To date, all patients are alive and well and there have been no cases of recurrent vaginal neoplasia or cancer. These data suggest that: adequate colposcopy is an accurate method to rule out invasive cervical cancer and abdominal or vaginal hysterectomy is an effective therapeutic procedure in women with CIN III who have completed reproductive function.

Adult↗
PubMed1995

Operator variability in disease detection and grading by colposcopy in patients with mild dysplastic smears.

BACKGROUND: To determine interoperator variability in the colposcopic evaluation of patients with mild dysplastic smears, retrospective comparison of colposcopy and biopsy results in 856 patients examined by 11 colposcopists in the Outpatient Colposcopy Clinic of "L. Mangiagalli" Institute, Milano, was performed. METHODS: The patients underwent a complete colposcopic assessment and target biopsy on suspect areas if a screening smear showed mild dysplasia. Colposcopic findings and disease detection rate for each operator were compared. RESULTS: There was no significant (P > 0.05) difference in the recording of abnormal colposcopic findings. Significant differences were found, however, in abnormal transformation zone grading (P < 0.001), biopsy rate (P < 0.05), and squamocolumnar junction visualization (P < 0.005). There was no significant difference in overall disease detection (P > 0.5) but there was a statistically significant, inverse relation (r = -0.6, P < 0.01) between the high grade (cervical intraepithelial neoplasia grades 2 and 3) and low grade (human papillomavirus/cervical intraepithelial neoplasia grade 1) detection rate for each operator. CONCLUSIONS: High grade disease detection in patients with mild dysplastic smears is influenced the subjectivity of the colposcopic examination. This should be considered when planning optimal management for patients with mild dysplasia.

Adolescent↗
PubMed2005

Triage with human papillomavirus testing of women with cytologic abnormalities prompting referral for colposcopy assessment.

BACKGROUND: The current study was conducted to evaluate the cost-effectiveness of triaging for colposcopy using human papillomavirus (HPV) testing. METHODS: HPV tests were performed in a consecutive series of women who were referred for colposcopy for persistent atypical squamous cells of undetermined significance (ASCUS)-favor reactive (n = 35 women), ASCUS-favor squamous epithelial lesion (n = 164 women), atypical glandular cells of undetermined significance (n = 74 women), low-grade squamous epithelial lesion (n = 161 women), or high-grade squamous epithelial lesion (n = 78 women). The cost effectiveness of triaging women with ASCUS results using HPV testing was determined compared with the current protocol. RESULTS: The sensitivity of HPV testing for cervical intraepithelial neoplasia > Grade 2 was very high. Cost analysis showed a moderate increase in cost with the addition of HPV triage. CONCLUSIONS: Because HPV testing is highly sensitive, it may be useful as an alternative to the current policy of 6-month repeat cytology for women with ASCUS.

Cervix Uteri↗
PubMed1993

A comparison between loop diathermy conization and cold-knife conization for management of cervical dysplasia associated with unsatisfactory colposcopy.

Eighty-six women with cervical dysplasia and unsatisfactory colposcopy were managed with excisional conization--43 with outpatient loop diathermy conization under local anesthesia and 43 matched controls with cold-knife conization as inpatients under general anesthesia. Both groups were similar in terms of age, parity, and severity of dyskaryosis on initial cytology, treatment success rates, and completeness of excision. However, loop diathermy conization was significantly quicker (2.8 +/- 2.9 min vs 14 +/- 18.6 min) and associated with less intraoperative blood loss (3.3 +/- 2.8 ml vs 79.1 +/- 74.6 ml) (P < 0.01) than cold-knife conization. Furthermore, the proportion of women with at least one complication was significantly less following loop (4.7%) than cold-knife conization (20.9%) (P < 0.05). We conclude that outpatient loop diathermy conization performed under local anesthesia is quicker and causes less intraoperative blood loss and immediate postoperative complications than cold-knife conization for management of cervical dysplasia associated with unsatisfactory colposcopy.

Adult↗
PubMed1977

The study of anorectal disease by colposcopy.

The incidence of significant, but otherwise nonapparent, perianal and anal disease in mildly symptomatic patients in this series was 6 per cent. Colposcopy helped define these lesions. Because perianal and anal neoplasms develop slowly and become manifest late, diagnosis is difficult. Colposcopy allows easier and earlier detection in patients with vague early complaints.

Anus Diseases↗
PubMed1992

Colposcopy to establish physical findings in rape victims.

OBJECTIVE: Conventional rape examination protocols have been poor in yielding genital findings (10% to 30% typically). We report our experience with a revised protocol employing colposcopy to perform genital examinations of victims and to document findings. STUDY DESIGN: Physical examinations were performed on rape victims seen by San Luis Obispo County's Suspected Abuse Response Team between 1985 and 1990, and the results were reviewed for this study. RESULTS: Of 131 patients seen within 48 hours and who experienced penile penetration, 114 (87%) had positive findings. Colposcopic magnification allowed examiners to characterize these findings as acute mounting injuries, typically seen at 3, 6, and 9 o'clock on the posterior fourchette and consisting chiefly of lacerations, ecchymosis, and swelling. CONCLUSIONS: An examination protocol that includes colposcopy may be the most reliable means to document and characterize genital findings in rape victims and to evaluate whether findings may be linked to a reported sexual assault.

Colposcopy↗