• Reference Number: HEY-736/2023
• Departments: Gynaecology
• Last Updated: 29 September 2023

Introduction

This leaflet has been produced to give you general information about your procedure. The information in this leaflet is intended to be a general guide to the colposcopy service. Not all of the information provided in this leaflet will apply to you. Most of your questions should be answered by this leaflet.  It is not intended to replace the discussion between you and your doctor but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team caring for you.

What is colposcopy?

Colposcopy is usually an outpatient procedure and is carried out in the Gynaecology Outpatient Department. An appointment usually takes about 20 minutes. The colposcopy examination is performed by a doctor or specialist nurse colposcopist.

A colposcopy is an examination of the neck of the womb (cervix) using a special microscope called a colposcope. The colposcope is a large magnifying glass with a high powered light source attached. The colposcopist uses the colposcope to magnify and direct the light on to your cervix to assist with the examination.

The colposcope allows the colposcopist to have a more in-depth and magnified look at your cervix than during a smear test. The colposcopist can also view the surrounding area where the cervix meets the top end of the vagina. The colposcope does not touch or go inside you.

Why do I need a colposcopy?

There are many reasons why you may have been referred to the Colposcopy Clinic.

• Your cervical screening test/cervical sample (previously known as a ‘smear test’) has identified that you may have some abnormal cells on the cervix.
• Your GP has difficulty obtaining a cervical sample (‘smear’).
• Your cervical sample has been reported as inadequate.
• Your GP is worried about the appearance of your cervix.
• Your GP has referred you to the colposcopy clinic as you have been experiencing symptoms.

Abnormal screening test

This does not mean that you have cervical cancer.

Abnormal cervical screening (cervical sample/smear) results are very common. A cervical screening test is when cells are taken from the skin of the cervix. These cells are checked microscopically to detect abnormal or pre-cancerous changes many years before they can cause any serious problems.

We know that some of these cell changes can return to normal without treatment. We also know that some cell changes, if left untreated over a period of years, may develop into a cancer. Detecting the cell changes early enables preventative treatment to be given.

Women who have regular cervical screening tests are very unlikely to develop cervical cancer. A colposcopy is done to try and detect early abnormal changes of the cervix and to monitor these changes until they return to normal. If your cervical sample shows that you have high grade changes, we will advise you to have treatment to return the changes to normal.

What causes an abnormal result?

Abnormal cervical screening results are caused by the Human Papilloma Virus (HPV). This virus is contracted mainly by sexual skin-to-skin contact. This means that sexual intercourse is not required to contract the virus. HPV is a very common virus and most women will get it at some point in their lives. It is not yet possible to tell who will go on to develop abnormalities of the cervix. HPV usually has no symptoms  so most women are unaware that they have the virus. The virus may have been present for many years before it was detected on the cervical sample. Most women will get rid of the virus naturally by the normal functioning of their immune system, without it causing any problems. Even those women who contract high risk HPV rarely go on to develop cervical cancer.

Primary HPV Testing

Your cervical sample is tested for the types of HPV that can cause cervical cancer.  If your cervical sample showed that you have a negative result for the most common types of HPV that cause cervical cancer, your risk of cervical cancer is very low and there is no need to check for abnormal cells even if you have had these in the past.

If you have a positive result for HPV, your cervical sample will be checked for abnormal cells. Abnormal or precancerous cell are also known as dyskaryosis, this is not cancer, but they could develop into cancer if left untreated.

Dyskaryosis

When your cervical screening test is HPV positive and shows abnormal changes in the cells of the cervix this is called ‘dyskaryosis’. Most abnormal results show minor cell changes. These are called borderline, mild or low-grade dyskaryosis.  These cell changes are often linked to the HPV. In many cases these minor changes will go back to normal by themselves.

A small number of women have moderate or severe changes to the cells on their cervix. This is called high-grade dyskaryosis. These changes are also pre-cancerous in nature. The majority of cases do not lead to cancer of the cervix in the future. These changes are less likely to return to normal on their own. A simple treatment (discussed further in this leaflet) may be all that is required so that the cells of the cervix can return to normal.

It is important to remember that it is extremely rare for these abnormal changes on your cervical screening sample to be cancer.

Your GP has difficulty obtaining a cervical sample (‘smear’)

Sometimes it can be difficult to visualise and locate the cervix. This can be due to a variety of reasons, all of which are entirely normal. In the colposcopy clinic we have special couches, a good light source and instruments that can be used to obtain the cervical screening sample without too much difficulty.

Your cervical screening sample has been reported as inadequate

Inadequate test results are very common and can be attributable to many causes. This does not necessarily mean that there is anything wrong with your cervix. An inadequate sample may be due to the following reasons:

• There are not enough cells on the sample for the laboratory to examine properly.
• Your doctor or practice nurse might not have been able to view fully the entire cervix to obtain a good sample.
• Inflammation of the cervix.
• Infections of the cervix.
• Hormonal changes due to pregnancy or your sample was taken too soon after delivery.

Even though there may be nothing wrong with your cervix, it is important that you are seen in the colposcopy clinic and that your cervix is examined more closely.

Your doctor is concerned about the appearance of your cervix

If your doctor is concerned about the appearance of your cervix they will refer you to the colposcopy clinic for a more detailed examination of the cervix. This does not mean that you have cancer. This examination will determine whether or not there is an abnormality of the cervix.

Your doctor has referred you to the colposcopy clinic as you have been experiencing symptoms

You may have been having symptoms such as bleeding after sex and/or bleeding in between your periods. You may also have symptoms of an increased discharge from the vagina. These symptoms might be related to the health of your cervix. During the colposcopy procedure the colposcopist may diagnose or treat problems. The following procedures may be performed:

Removal of polyps from the cervix

Polyps are smooth, red, finger like growths in the cervix. The cause of polyps of the cervix is not entirely understood. They may result from infection, long term inflammation or congestion of the blood vessels in the cervical canal. Polyps can also be an abnormal response to an increase in oestrogen levels. Almost all polyps are non-cancerous (benign). The polyp is grasped with special forceps and twisted off. It usually comes away fairly easily. Any polyp removed is sent to the laboratory to ensure that it does not contain abnormal cells.

Biopsies of the cervix (small samples of tissue from the cervix)

It is usual for the colposcopist to take a small sample of tissue from your cervix. The samples are sent to the laboratory to examine and make an accurate diagnosis of your condition.

Treatment of ectropion (sometimes called erosion)

An ectropion itself is a normal finding. It is a medical term for when the inner lining of the cervix comes to the outside of the cervix. It is often associated with hormonal changes such as pregnancy and the contraceptive pill. Many women have symptoms of bleeding after sex and/or vaginal discharge without evidence of infection. The ectropion can be treated by freezing (cryocautery) or cauterisation (diathermy).

Biopsy of the cervix under local anaesthetic

If a larger biopsy of the cervix is required to obtain results. You will be given a local anaesthetic so you will be awake while the procedure is done. The injection will sting initially but you will not feel pain while the biopsy is carried out.

Taking of a cervical sample (smear)

We might need to take a further sample of cells from your cervix using two brushes. The second brush can reach cells that are higher up in the cervix.

What if I am having a period when my appointment is due?

It is not normally possible to do a colposcopy examination if you are having a period. If you have infrequent or irregular periods then please keep your original appointment. If you feel uncomfortable about having the examination whilst you are having your period, then please call us to rearrange the appointment.

What if I am pregnant?

If you are pregnant then please keep any appointment that has been arranged for you. A colposcopy examination will not harm your baby and if you need any treatment then this can usually wait until you have delivered your baby.

What happens when I come to the colposcopy clinic?

Does it mean that I have cancer?

Women who have regular cervical screening tests are very unlikely to develop cervical cancer. A colposcopy examination is done to try and detect early abnormal changes of the cervix and monitor these changes until they return to normal.

What happens before the colposcopy examination?

You are welcome to bring a friend or relative with you to support you though the consultation and examination. A female nurse will be present throughout your visit.

The colposcopist will explain to you what your cervical sample result shows and why you need a colposcopy. The colposcopist may suggest treating any abnormality seen on examination at your first appointment.

Before the procedure you will be asked some simple background questions relating to your periods, the type of contraception you use, your general health, allergies and any medications that you take. You will also be asked if you have any children or if you have had any operations in the past. You may be asked more questions, dependent on your answers. You will be asked if you are happy to go ahead with the procedure.

Will I need treatment?

In most cases a decision to do a treatment on your first colposcopy visit depends on your smear result and the findings of the colposcopy examination. If at the examination your cervix clearly shows the changes associated with abnormal cells then you will be offered treatment.

In cases where the examination shows less evidence of an abnormality, a biopsy will be taken from your cervix to confirm the type of abnormal cell changes present. A decision to do treatment at a later date may be made.

What happens during the examination?

You will be shown to a changing area and asked to remove your lower garments. A sheet is provided in order to maintain your dignity as much as is possible. You will be assisted onto an examination couch and your legs will be supported on rests. Once you are comfortable on the couch, the colposcopist will gently insert an instrument into your vagina. This instrument is called a speculum. It is the same instrument that is used when you have a smear. This holds open the vaginal walls and allows a good view of the cervix.

The colposcopist may repeat the cervical sample before performing the colposcopy examination. The colposcopist will dab different liquids onto the cervix with a cotton wool ball. This should not hurt, but you may feel a slight stinging sensation. These liquids can highlight various types of cells on the cervix. The liquids identify the areas of abnormality to the colposcopist. Sometimes an obvious abnormality is discovered. The colposcopist will then decide whether or not it is appropriate to treat your cervix at your first visit. Occasionally, it is not appropriate to treat you and in this case, the colposcopist will take a small tissue sample (punch biopsy) from the cervix.

Cervical punch biopsies

To help the colposcopist make an accurate diagnosis of your condition, it is usual to take a small ‘punch’ biopsy from your cervix. A cervical punch biopsy is the removal of a small piece of skin from the neck of the womb. This biopsy is sent to the pathology laboratory for testing to confirm any changes in the cells that may have been seen at the time of the colposcopy examination.

When women have a biopsy taken from the cervix they say that it is uncomfortable but not painful. This pain may feel like a period type pain. To relieve the pain, we recommend that you take paracetamol or ibuprofen during the next 24 hours after the biopsy.

Having a biopsy taken from the cervix will also cause you to have a discoloured discharge because of the liquids used to perform the examination. You may also have some light bleeding from the biopsy site. The discharge may take up to a week to gradually clear up. While the biopsy site is healing (which could be up to two weeks) there is a risk of infection. To help prevent the risk of infection we advise you to avoid sexual intercourse, swimming, tampons and vaginal creams. You may shower and take a bath as usual but avoid bubble bath and talcum powder.

If you think that you may have an infection you must consult your GP as you may need antibiotics.

What will the biopsy result tell the colposcopist?

The biopsy results will show whether or not there is an abnormality of the cells of the cervix. The medical term used to describe cell changes confirmed by a biopsy is called Cervical Intraepithelial Neoplasia, more commonly known as CIN. The degree of change is described on a scale of 1 to 3, according to how many of the cells are affected.

CIN 1 means that only a third of the cells in the affected area are abnormal. These may be left to return to normal or may be treated, depending on the opinion of your colposcopist and your own personal choice.

CIN 2 means that up to two-thirds of the cells in the affected area are abnormal. Treatment will usually be needed to return the cells to normal. You may also be offered ‘conservative management’ of CIN 2. This will be discussed with your colposcopist.

CIN 3 means that all the cells in the affected area are abnormal. Treatment will be needed to return the cells to normal.

Only very rarely will a biopsy show that the cell changes have turned into cancer.

It takes approximately four to six weeks to obtain your results. We will write to you and your doctor to confirm your results and your plan of care.

Management of low grade CIN 1

CIN 1 is also defined as a low grade abnormality of the cervix. The cells are considered to have developed into a minor pre-cancerous condition. CIN 1 is usually kept under close observation with cervical sampling (smears) until the cervical samples return to normal. This is completely safe; however you must attend for your cervical sample tests as appointed. CIN 1 will return to normal in time without any active treatment.

If you have been diagnosed with CIN 1 you will be discharged from the colposcopy service. Your next cervical sample will be in one year’s time at your doctor’s practice. Your follow up will depend on that screening result. If the low grade abnormality persists for a period of two years or more, you may be offered treatment to remove the abnormal cells.

Conservative management of CIN 2

If your biopsy shows CIN 2, your colposcopist may want to discuss ‘Conservative management of CIN 2’ verses ‘Treatment of CIN 2’.

If you decide to have conservative management of CIN 2, you must agree to regular 6-month colposcopy follow ups. At these follow ups you will have further cervical sample taking, colposcopy and potential punch biopsies from your cervix.

It is important to recognise that CIN 2 may take up to 24 months to resolve. If the CIN 2 is not resolved in the 24-month period, you will be offered treatment to the cervix to remove the changes. This treatment will be the LLETZ (large Loop Excision of the Transformation of the Cervix. This is detailed below.

Treatment to the cervix

The aim of treatment to the cervix is to stop the CIN from developing into cancer by destroying or removing the abnormal cells from the affected area. There is a 95% chance of a cure with a first time treatment with only a small number of women requiring further treatment.

LLETZ (Large Loop Excision of the Transformation Zone)

In the case of more moderate to severe changes or biopsies that have shown CIN 2 and CIN 3, the cervix will require treatment to remove the abnormality. This treatment is called a LLETZ procedure (Large Loop Excision of the Transformation Zone). There is a 95% chance of cure with a first treatment, with only a small number of women requiring further treatment.

A LLETZ procedure is usually done in the colposcopy clinic and usually takes about 5 – 10 minutes. You will be given a local anaesthetic so you will be awake, but you should not feel any pain. The local anaesthetic will sting a little, but the area will very quickly go numb. The local anaesthetic may also increase your heart rate. The side effects of the local anaesthetic will only last briefly and should not cause you any harm.

A fine wire loop is used to remove the area of abnormal cells on the cervix. The wire loop is heated by an electric machine. To ensure that the procedure is safe, a sticky pad is placed on your thigh. You may also hear a noise a bit like a hoover when the procedure is performed.

You should not feel any pain during the procedure. If you feel pain please inform the nurse who is with you.

Following the treatment, you may feel period-type pain or a slight burning sensation. The pain should go away with pain relief medication such as paracetamol and ibuprofen. To prepare for the treatment, you might find it helpful to take simple pain relief such as paracetamol or ibuprofen about an hour before your appointment.

In rare cases, the colposcopist may not be able to see the entire cervix clearly. This might be because they need to get a better view (depending on the position of the cervix) or because there is a wide area to be removed. In these cases, you would be given a general anaesthetic to allow us to do the procedure more safely and effectively.

You can request to have the procedure done under general anaesthetic if you feel that you could not tolerate being awake while having it done. You must be aware that a general anaesthetic carries its own risk. Your colposcopist will explain this to you.

What are the benefits of the LLETZ procedure?

Colposcopy treatments are generally preventative. In a small percentage of women, the area of abnormality would become cancerous over the years if it were not removed. A LLETZ procedure not only removes abnormal cells, but also gives the laboratory a sample to check.

What are the risks of the LLETZ procedure?

• There is a very small risk of bleeding during and after the procedure.
• There is a very small risk of infection after the procedure.
• Whenever cautery is used during a colposcopy procedure, there is a very small risk of a diathermy burn to the vagina, vulva or groin.
• Very rarely a LLETZ may cause the opening of the cervix to become tightly closed (stenosed). This can cause painful periods. It is unlikely to cause fertility problems.
• There is a risk that a LLETZ procedure may weaken the cervix and there is some evidence that, following this treatment, women may deliver their babies early. There is a risk that having a pre-term birth is higher for women who may require deeper or more than one treatment.

The risk of doing nothing

Treatment is recommended for all women who have or are suspected of having pre-cancerous changes (CIN 2 and CIN 3). If left untreated, these abnormalities have the potential to progress into a cancer over a period of time.

What will happen if I have a coil (IUCD)?

If you have a coil, the doctor/nurse may need to take it out at the time of treatment. You should use an additional method of contraception i.e. condoms as well as the coil for 7 days before the appointment.

In some cases, the coils strings may be cut during the procedure. This means that the coil strings may be shorter. You may not be able to feel for them when you are checking for your coil. When your coil is due to be changed you may need to attend the hospital, for a short procedure, to have it removed.

What happens after the treatment?

After treatment we would like you to sit with us for 20 minutes and make sure that you are well enough to go home. We advise you to rest for the remainder of the day. After 24 hours most women feel well and usually you do not need to take any extra time off work.

You may experience some bleeding/watery discharge after treatment. This may not start straight away and may last as long as four weeks. The discharge may be anything from a slight fresh and watery blood stained spotting to a flow as heavy as a period. It should not be excessive or have an unpleasant smell. If you have these symptoms you must contact your GP as you may need antibiotic treatment.

We ask you to avoid the use of tampons and use sanitary towels for the discharge. This helps reduce the risk of infection and helps the cervix to heal as quickly as possible.

Sexual intercourse should be avoided for 4 weeks following the treatment. This again helps the cervix to heal and reduce the risk of infection.

You should have a bath or shower but do not attempt to douche inside the vagina. Please avoid the use of bubble bath, vaginal cream, talcum powder, heavily perfumed soap and vaginal deodorant. Use of these products may increase the risk of infection.

You should avoid the use of swimming pools, spas and jacuzzies until the discharge stops.

You should avoid strenuous exercise, horse riding and heavy lifting for three weeks.

Although there are no known health grounds for avoiding travel overseas following treatment, medical attention for complications arising from the treatment may not be covered by insurance. If for some reason this is problematic at the time of your treatment appointment i.e. you are going on holiday, then please contact us to rearrange your appointment.

What happens after treatment?

Notification of results

We will write a letter to your GP and you with your results. The letter will also contain your follow up plan of care. This is usually within four weeks after the treatment procedure.

Sometimes your results are discussed in our multi-disciplinary team (MDT) meetings. This is attended by colposcopists, nurses, cytologists and histopathologists. This is to review your slides and biopsies and decide the best treatment or follow up plan for you.

Follow up appointment(s)

After having had treatment to the cervix for pre-cancerous cells, you must continue with your follow up appointment(s). Your next cervical sample (smear) is called the ‘Test of Cure’. This will be taken six months after your treatment at your GP practice.

Your cervical sample will be tested for HPV. HPV is the virus that is known to cause the abnormal cells on the cervix. If the high-risk HPV is not found on your cervical sample, you will not need to be screened again for 3 years.

If your cervical sample tests positive for the HPV virus, it will also be tested for abnormal cells/dyskaryosis. Even if the cervical sample is negative for abnormal cells/dyskaryosis, you will be invited back for a further colposcopy examination. This allows a further assessment of your cervix.

There is a small chance that the abnormal cells may return in the future but providing that you attend for screening when you are invited to do so, any abnormal cells can be identified and dealt with promptly.

You may also contact your doctor for further advice. Information may also be obtained from the BSCCP (The British Society for Colposcopy & Cervical Cytology) Website: www.bsccp.or.uk

Information on gynaecology services:
https://www.hey.nhs.uk/gynaecology

Should you require further advice about the issues contained in this leaflet, please do not hesitate to contact the following areas:

Nurse colposcopist – (01482) 382644

Colposcopy secretary – (01482) 624035 / 624031

Gynaecology Outpatients
Women and Children’s Hospital – (01482) 607829 / 607893

Ward 30 (Cedar Ward) – (01482) 602739

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.