Colposcopy management of abnormal smears and what to tell

Gwen Thompson Nurse Colposcopist Belfast City Hospital

Colposcopy
Introduction Who to refer When to see them Colposcopic management of the patient Conclusions

Colposcopy
Secondary screening Labour intensive Expensive Intrusive and embarrassing to the patient High rate of anxiety

Colposcopy
Rapid increase in referrals Anxiety from cytologist re medico-legal
implications of false negative smear Approximately 3% of smear population Pressure on clinics Long wait for appt. - Long wait for exam - Overworked staff.

Colposcopy
Who to refer current guidelines

Colposcopy who to refer

Any clinical suspicion of cervical carcinoma Invasive cells on cytology
Ideally the patient should be seen at the next available clinic

Colposcopy who to refer

One smear with Severe Dyskaryosis One smear with Moderate Dyskaryosis One smear with Glandular Abnormality
The correlation between Moderate dyskarosis and CIN II is at least 75%, instance of false positive cytology is <5%

Colposcopy who to refer

X 2 smears with mild dyskaryosis 6 months
apart X 1 smear with mild dyskaryosis then 1 smear with borderline change 6 months apart 50% of patients with 1 mildly dyskaryotic smear will return to normal

Colposcopy who to refer

X 3 consecutive borderline smears X 3 consecutive inadequate smears
Non dyskaryotic causes for abnormal smears should be treated eg cervicitis,vaginal atrophy, infection between smears to reduce false positive cytology

Colposcopy who to refer

After 1 abnormal smear of any grade whilst
under cytological follow up following colposcopy/treatment Cytologists recommrndation 3 smears with mild/borderline changes over a 10 year period ( without colposcopy)

Colposcopy
When to see the patient

Colposcopy when to see

Immediately Clinical suspicion of cancer Invasive cells on cytology

Colposcopy when to see

Within 4 weeks Moderate/Severe dyskaryosis Glandular change Abnormal cytology following treatment

Colposcopy when to see

Within 8 weeks Mild dyskaryosis Borderline change Unsuitable smears Any other patient!

Colposcopy when to see

Northern Ireland Audit on Colposcopy 983 case notes independently audited 54% of all patients seen within 8 weeks 34% of patients with mod/severe dyskaryosis seen within 4 weeks 34% of patients with mod/severe dyskaryosis waited > 8 weeks

Colposcopy
Binocular vision Invented in 1960s Allows magnification Video link Digital recording Only as good as the user !

Colposcopy for mild dyskaryosis

IMMEDIATE Risk of high grade CIN Reduce defaulters Reduce anxiety Not all CIN detected cytologically DELAYED May return to normal Avoids over treatment High grade CIN lesions are small Risk of cancer low

Colposcopy - treatment
Generally treat high grade CIN Low grade CIN may be followed up
TREATMENT OPTIONS 1. See and treat (LLetz/Cold coagulation) 2. Biopsy and treat 3. Direct treatment no colposcopy

LLETZ ( large loop excision of the transformation zone)

Commonest mode of treatment 80% should be performed under local
anaesthetic Allows complete histological diagnosis Well tolerated 5% haemorrhage post treatment (primary or secondary)

Colposcopy What to tell the patient

Anxiety score greater than elective surgery Most women believe they have cancer Patients can feel anger, sadness and anxiety High default rate (colposcopy) associated with
continued anxiety

Colposcopy What to tell the patient

Significant reduction in anxiety with: Patient information regarding colposcopy Correct information about CIN Video/TV whilst waiting in the clinic Reduce waiting time for appointments

Conclusions
Colposcopy service should be patient friendly
and informative Colposcopy service should be of a high quality Prompt clinic appointments within the guidelines Colposcopy clinics should audit practice Future workload will increase

READING LIST
NHSCSP 2004 The Northern Ireland Guide for General
Practitioners and Smear Takers

CONTACT NUMBER
Gwen Thompson Nurse Colposcopist Belfast City Hospital Lisburn Road Belfast BT7 9AB Email: Gwen.Thompson@bch.n-i.nhs.uk Tel No: 02890329241 Bleep 0548