1. Cytology Codes & management Colposcopy- Management of cervical lesions

2. Cytology codes 0/G-?Glandular neoplasia (non cervical)
1-Inadequate Specimen 
2/N-Negative 
3/M-Low grade dyskaryosis (CIN 1) 
4-High grade dyskaryosis (severe) (CIN 3) 
5-High grade dyskaryosis ?invasive squamous carcinoma 
6-?Glandular neoplasia of endocervical type 
7-High grade dyskaryosis (moderate) (CIN 2) 
8/B-Borderline change in squamous cells 
9/E-Borderline change in endocervical cells 
X-No Cytology test undertaken 

3. Action Codes
A-To be used for all cases where the next test is to be performed at the normal (routine) recall interval for the DHA responsible for the women. 
R-To be used for all cases in which a further smear is recommended in an interval less than the routine recall interval of the DHA. 
S-To be used for all cases where referral to a gynaecologist is recommended and for those smears from patients under the care of a gynaecologist or other relevant specialist. 
H-Record the result and do not change current recall details.  

4. Cytology Infection Code Descriptions
0-Human Papilloma Virus (HPV) negative 
1-Trichomonas 
2-Candida 
3-Wartvirus 
4-Herpes 
5-Actinomyces 
6-Other (to be specified) 
9-HPV positive 
U-HPV unavailable 
Q-No HPV test undertaken

5. Examples
N0A
1R3 4S

6. Inadequate on 3 occasions
Guidelines for referral to the Colposcopy Clinic Barts Health NHS Trust
Inadequate on 3 occasions
Borderline or mild dyskaryosis and high risk HPV positive
Moderate or severe dyskaryosis
? Invasive or ? Glandular neoplasia
3 abnormal results over 10 years
Clinically suspicious cervix or symptoms

7. The procedure of colposcopy
When referring women for colposcopy all women should have explained to them:
The procedure of colposcopy
The possibility of a cervical biopsy

8. The Colposcope
This is a binocular microscope that allows magnification and illumination of the cervix.

9. The Colposcopy Examination
Acetic acid 5% is applied.
The abnormality is identified (aceto-white change).
The colposcopic examination is considered satisfactory when the entire transformation zone has been identified, and a colposcopic impression is made. A photograph may be taken for accurate follow up.
One or more biopsies are then taken of the abnormal areas.

10. Acetic acid is applied to the surface of the cervix
Acetic acid is applied to the surface of the cervix. The light from the colposcope is reflected back from the enlarged nuclei of the abnomal cells giving us the aceto-white change
How Acetic acid works
Acetic acid is applied to the surface of the cervix. The light from the colposcope is reflected back from the enlarged nuclei of the abnomal cells giving us the aceto-white change

11. Cervical punch biopsy forceps

12. Cervical Biopsies

13. Satisfactory Colposcopy

14. Unsatisfactory Colposcopy

15. Postmenopausal Cervix

16. Nabothian Cyst

17. Cervical Ectropion

18. Endocervical Polyp

19. HPV infection of the cervix
Colposcopic Features
Pale staining aceto-white lesion
Irregular, indistinct margins of lesion
Atypical vessels, fine mosaic pattern

20. HPV Transmitted by intimate contact
An estimated 80% of sexually active women will be exposed to the virus by age 50
Most infections will regress spontaneously after 6-12 months
Over time persistent infection can lead to cancer and other HPV related diseases

21. CIN1 Mild aceto-white uptake Irregular, indistinct margins of lesion
No obvious atypical vessels/mosaic pattern
In most women, will revert back to normal given time.
Approximately 5% of all smears show borderline or mild dyskaryosis.

22. Moderately dense aceto- white change with atypical
CIN2
Moderately dense aceto-
white change with atypical
vessels, mosaic patterns
and punctation.
Approximately 1% of all smears show moderate dyskaryosis.

23. CIN3 Densely staining aceto-white lesion Straight margins
Atypical vessels, coarse mosaicism, punctation
Large volume lesion
Poor iodine uptake
Approximately 0.5% of all smears show severe dyskaryosis.

24. Micro-invasive lesions of the cervix
Densely staining acetowhite lesion
Atypical vessels, suspicious of invasion
Often large volume lesions
Poor iodine uptake
May bleed easily
Less than 0.1% of smears suggest invasive carcinoma.

25. Treatment – LLETZ (Large Loop Excision of the Transformation Zone)
A diathermy pad is placed on the woman’s leg.
Local anaesthesia is injected into the four quadrants of the cervix. An appropriately sized loop is chosen and the abnormal area removed in one piece under colposcopic guidance. Ball diathermy is used to achieve haemostasis.
Facilities are available in the clinic in the event of an emergency situation.
Follow up information is reinforced before the woman leaves the clinic.

26. LLETZ

27. What are the complications?
Treatment for CIN is generally very safe. Very few complications exist but some important problems can occur.
Bleeding.
Infection.
Cervical stenosis’ and ‘cervical incompetence’
Premature rupture of membranes during pregnancy leading to early delivery
Women are advised not to insert ANYTHING into the vagina for at least 4 weeks.

28. What is the success rate?
Ninety five percent of women have a negative smear 6 months following their first treatment.

29. Follow-up
A follow-up check after treatment for precancerous changes is absolutely essential.
We perform Liquid Based Cytology and HPV testing six months after treatment.
If residual precancerous cells are left behind, further Colposcopy and biopsy is performed, and a repeat LLETZ procedure, will be arranged if necessary.

30. Changes to practice HPV testing TRIAGE
Given that cervical cancer will not develop without HPV, women with borderline changes or mild dyskaryosis who have a negative high risk HPV test are not likely to need treatment and should be able to safely return to routine screening.
TEST OF CURE
It has now been clearly established that the successful removal of abnormal cervical cells usually also leads to the disappearance of the HPV within 12 months or so.

31. www.bsccp.org.uk www.jotrust.co.uk www.patient.co.uk
Further Information