1. COLPOSCOPY Cervical Screening QARC Training School October 2012

2. Terminology Dyskaryosis Cervical Intraepithelial Neoplasia (CIN)

3. Normal epithelium Disease progression Invasive cervical cancer Time Years Months HPV infection; koilocytosis CIN I CIN II CIN III CIN I 57% CIN II 43% CIN III 32% Approx. likelihood of regression Borderline Mild Moderate Severe Dyskaryosis

4. Indications for Colposcopy ABNORMAL CYTOLOGY Moderate or severely dyskaryotic result Borderline/mild samples that are high risk (16 & 18) HPV positive Abnormal glandular cells FINDINGS OR SYMPTOMS Suspicious appearance to cervix Symptomatology – post coital bleeding

5. Examination Cusco Speculum ??repeat LBC sample Acetic Acid +/- Lugols Iodine Colposcope Punch Biopsy Silver nitrate

6. Treatment Excisional – LETZ, Knife Cone Destructive - Cold Coag, Laser Ablation Rarely - Hysterectomy

8. Follow-Up prior to HPV testing After Treatment for high grade CIN (or worse) – Cervical sampling 6, 12 then annually for 10 years After Treatment for low grade CIN – 6, 12, 24 then normal recall After hysterectomy (if no Cervix) – no longer part of re-call! Gynaecologist sets intervals

9. What is HPV test of cure? Women who have a normal, borderline or mild cervical screening result six months after treatment for CIN and who also test negative for high-risk HPV have a very low risk of residual disease. Samples taken six months post treatment that are cytology negative are HPV tested. Women whose samples show no high-risk HPV will proceed to three year routine recall – avoiding the need for up to 10 years of annual cervical screening. Women who have an abnormal cervical screening result or whose samples show high-risk HPV six months after treatment will be referred back to colposcopy.

10. Question 1

11. Question 2

12. Question 3

13. Question 4

14. Question 5

15. Question 6

16. Question 7

17. Question 8

18. Question 9

19. Letz and pregnancy Knife cone worse than Letz Laser ablation carries no risk Complications Premature labour (<37/40) 1.7 RR Premature rupture of membranes 2.7 RR Low birthweight 1.8 RR Cervical stenosis – emergency LSCS

20. Colposcopy in Pregnancy Aim is to exclude invasive disease No evidence of more rapid progression in pregnancy Avoid treatment but can biopsy Warts more florid Sampling and colposcopy are easily interpreted despite pregnancy changes If has invasive disease when pregnant Treat Ca cx if under 24/40 i.e. terminate pregnancy. After 24/40 deliver by LSCS as soon as baby is viable (32/40)

21. Colposcopy after the menopause Transformation zone is usually not visible With low grade cytology try to repeat ‘sample’ after a course of topical oestrogen

22. Cervical Dysplasia Oncogenic virus is the cause of over 99% of cases Co-factors Smoking Parity Immunocompromise (Transplants & HIV)

23. HPV triage as an adjunct to LBC & Colposcopy LBC allows HPV testing No value in the assessment of women with high grade dyskaryosis – assumption is that they are all HPV +ve In women with borderline and mild dyskaryosis may allow decision about who needs colposcopy Follow up after treatment for CIN