Colposcopy and cervical treatments

The doctor or nurse uses a special microscope, called a colposcope, to look at the cells of the cervix in detail.

A liquid is painted on to the cervix to show up any abnormal cells. During colposcopy a small piece of tissue may be taken from the cervix. This is known as a biopsy. The tissue is then examined in even closer detail in the laboratory to allow further assessment of the cells. Treatment for any abnormal cells can sometimes be given at the same time as the colposcopy examination.

Note: the information below is a general guide only. The arrangements, and the way tests are performed, may vary between different hospitals. Always follow the instructions given by your doctor or local hospital.

What is the difference between colposcopy and cervical screening?

A cervical screening test is offered regularly to all women to prevent cancer of the neck of the womb (cervical cancer). The cervical screening test is looking for early changes (or abnormalities) in the cervical cells, that, if left untreated, might develop into cancer in the future. See the separate leaflet called Cervical Screening (Cervical Smear Test) for more details.

A cervical screening test can be performed more quickly and needs less training than colposcopy. This means that it is a more suitable test to look for changes in the cervix in large groups of people. Cervical screening has been proven to reduce the number of cases of cervical cancer. This is why there is a National Screening Programme throughout the UK.

Abnormal changes in the cells are found in some women. These abnormal changes are known as dyskaryosis. In the vast majority of cases, an abnormal result does not mean cervical cancer. However, the presence of dyskaryosis indicates that cancer may develop at some time in the future (often many years away).

A cervical screening test shows if abnormal cells are present but does not show enough detail about the cells. Colposcopy allows a closer and more detailed look at these abnormal cells.

About 1 cervical screening test in 8 is abnormal. If the result is not normal then the advice may be to repeat the test within the following 12 months, or a colposcopy may be recommended. About 1 in 25 women who have a cervical smear have an abnormal result that results in advice to have a colposcopy.

During colposcopy, the extent of the area where the abnormal cells are present is seen. This is done by applying special liquids to the neck of the womb (cervix), which stain the abnormal cells. Colposcopy also allows a sample of tissue (a biopsy) to be taken. This sample is then sent to the laboratory for further tests. This means that the exact type of abnormality in the cells can be identified.

Why do I need a colposcopy?

The usual reason for needing a colposcopy is because you have had an abnormal cervical screening test result. This happens quite commonly, so you should try not to be too alarmed. Remember that in most cases, an abnormal cervical screening test does not mean you have cancer of the neck of the womb (cervical cancer). It is rare for cervical cancer to be diagnosed this way.

Sometimes you can be referred for a colposcopy because you have had a number of cervical screening tests in a row that were inadequate. This can happen if there was too much blood or mucus present around your cervix at the time of your cervical screening test, or because too few cells were removed during the procedure. Because of this, not enough cells could be seen clearly under the microscope.

You might also be referred for a colposcopy if you have had a borderline or mildly abnormal smear which was then tested for human papillomavirus (HPV). This is a type of virus that can be passed on by having sex. It doesn't cause any symptoms so you can have it for many years and not know it. It is so common that most women who have ever had sex get it at some time in their lives but usually it goes away without any treatment. It is important because it is involved in the development of most cases of cervical cancer. However, most women who are infected with HPV do not develop cancer. Girls aged 11-14 years in the UK are offered immunisation against HPV. See the separate leaflet called Human Papillomavirus (HPV) Immunisation for more details.

Rarely, you might be referred for a colposcopy because the doctor or nurse carrying out your cervical screening test is worried about infection, inflammation or a non-cancerous growth (a polyp) around the neck of the womb (cervix), vagina or vulva.

How will I know if I need a colposcopy?

When you have your cervical screening test, you should be told when (and how) to expect your results. You will generally be informed directly, by letter. Your GP will also receive a copy of your results.

The laboratory advises what action is needed for each cervical screening result. Some women will have an abnormality that means a colposcopy is needed. You will often be sent this information in the post. In some areas, women who have an abnormality will be referred directly to a colposcopy clinic. In other areas, the GP has to make this referral. If this is the case, your GP should inform you of the referral. You do not need to do anything. BUT speak with your GP if you are worried or there is something you do not understand. AND contact your GP if you know you are waiting for a colposcopy appointment but have not heard anything after a few weeks.

Before colposcopy

You should receive written information about the procedure before your appointment. If there is anything you don't understand you can either ring the clinic directly or discuss this with your GP. There are some things that you should think about before your colposcopy that can help you prepare:

• Some clinics prefer not to perform colposcopy whilst a woman is having her period. This is because it can be difficult to obtain a good view of the neck of the womb (cervix) if there is a lot of blood. Also, some women may prefer not to have an intimate examination whilst bleeding. If your period starts and you think that you will still be bleeding when you have your appointment, it is probably best that you telephone the clinic for advice. In some cases your appointment may be rearranged. Do not feel embarrassed about this - it is completely out of your control and colposcopy clinics are very used to this sort of thing.

• You should avoid sex and not wear a tampon for 24 hours before your colposcopy.

• You should not use any vaginal creams or pessaries for 24 hours before your colposcopy. This includes lubricants, thrush treatments, douches and spermicides.

• Some people find the colposcopy examination a little uncomfortable. For this reason, you may choose to take some paracetamol about an hour before your appointment.

• You may want to wear a loose, full skirt on the day of your colposcopy so that you do not have to remove all of your lower clothing.

• It is often a good idea to bring someone with you who can take you home after your colposcopy. This is especially important if the clinic has told you that you may have treatment, as well as the colposcopy, at your first appointment. They do not have to come into the examination room with you. (However, if you do want a friend or relative with you during your examination this is also possible.)

What should I expect when I have my colposcopy?

The whole procedure normally takes about 15-20 minutes. It may be longer if you have treatment at the same time (see below). It is best to allow an hour for the whole visit:

• The doctor or nurse will usually start by asking you some questions. These may include information about your periods, the date of your last period, what contraception you use and your general health.

• You will then be asked to remove your clothing from the waist down. (You can usually keep a loose skirt on.)

• You will be asked to lie in a reclining chair, or on a couch, in the same position as during a cervical screening test. This is with your knees bent and your legs apart. In some clinics you may be able to place your legs apart in padded supports called stirrups.

• An instrument called a speculum (the same instrument that is used during a cervical screening test) will be inserted into your vagina. It is gently opened to show the neck of the womb (cervix), at the top of the vagina.

• The doctor or nurse will then look through the colposcope to obtain a good view of your cervix. The colposcope itself does not go inside your vagina. It is essentially like a big pair of binoculars on a stand that can be moved around. There is also a light to help see inside your vagina. Sometimes, the colposcope can be attached to video equipment so that the examination can be viewed more clearly on a TV screen. This means that you have the opportunity to watch too - but only if you would like to!

• A long swab (like a fat cotton bud) is used to dab liquids on to the cervix. These liquids stain any abnormal cells that may be present. Two different liquids are normally used - weak vinegar (acetic acid) and iodine.

• A small sample of tissue (a biopsy) from your cervix may also be taken. This will be sent to the laboratory for further examination. The biopsy is only about the size of a pinhead; however, taking it can be painful. If this is expected, local anaesthetic is usually used to numb the neck of your womb first.

• Sometimes it is suggested that you have treatment at your first colposcopy visit (see below). However, often, you may be asked to return for treatment once the biopsy results are back.

• It is worth bringing a sanitary towel or panty liner with you, to use after your colposcopy. It is unlikely you would have much bleeding. However, you might have some discharge or staining from the iodine used in the examination. There is more likely to be discharge or bleeding if you have had a biopsy or treatment. You should not use a tampon. However, don't worry if you forget sanitary protection - the clinic will give you a pad (but it might be thicker and more bulky than the usual products you prefer).

After colposcopy

After your colposcopy you can usually return to work or carry on with your normal day. You are likely to have a small amount of bleeding, especially if you have had a sample of tissue taken (a biopsy). This can last for three to five days and you should wear a sanitary pad. Do not use tampons. You should not have sex or use vaginal creams or pessaries until the bleeding has stopped. Generally you should wait for five days.

You may notice a dark fluid-like material on the pad. It is sometimes green or looks like coffee granules. This is normal and is the liquid that has been dabbed on to the neck of your womb (cervix) during the examination.

What are the risks or complications of colposcopy?

Colposcopy is generally safe. Some women find that it is a little uncomfortable. Rarely, complications can occur. These can include heavy bleeding and infection. If you experience any heavy bleeding, smelly vaginal discharge or severe lower tummy (abdominal) pain, you should see a doctor as soon as possible.

The biopsy results

When a small sample of tissue (a biopsy) has been taken, it is sent to the laboratory for further examination under a microscope. The cell abnormality that can be seen is called cervical intraepithelial neoplasia (CIN). There is a scale from 1 to 3 according to the number of cells in the biopsy sample affected by CIN. In CIN1, only a few (1 in 3) cells are abnormal. In CIN2, up to two thirds of the cells are abnormal. In CIN3, all of the cells are abnormal. Rarely, a biopsy can show changes in your cells that have already developed into cancer. About 7 in 10 cases of CIN1 return to normal without treatment, but 1 in 10 progresses to CIN3. Only 1 in 100 cases of CIN1 become cancer (and this is over a long time).

CIN2 and CIN3 still mean it is very unlikely you have or will develop cervical cancer. However, these changes are much less likely than CIN1 to get better on their own, without treatment. So, if CIN2 or CIN3 were to be found on your biopsy, you are likely to need treatment to remove or destroy these abnormal cells on the neck of your womb (cervix).

Remember that the whole point of cervical screening (and subsequent examination/treatment of abnormal cells at colposcopy) is to prevent cervical cancer. This is by detection and treatment of early changes in the cells, which, if left untreated or unchecked for some years, could develop into cancer.

How will I know if I need any treatment?

The results of your colposcopy and the small sample (biopsy) taken will show if you need any treatment. Sometimes, the doctor or nurse may suggest that you have treatment at your first visit for colposcopy. However, they may suggest that they wait for the results of your biopsy before you have any treatment. This just depends on the clinic that you attend. It can take a few weeks for the biopsy results.

Not everyone who has a colposcopy needs treatment. If the doctor or nurse feels that you only have a mild abnormality, they may suggest that you have a repeat colposcopy in 12 months. The changes in the neck of your womb (cervix) may return to normal by themselves and they may just need monitoring.

What are the treatment options available?

There are a number of different treatments available for CIN. The aim of the treatment is to destroy or remove all the abnormal cells on the neck of your womb (cervix) without affecting too much normal tissue. Most treatments can be done as an outpatient, at colposcopy. The treatment may cause a little discomfort, perhaps similar to a period pain.

The treatment that you have will depend on the extent of your abnormality as well as what treatment the clinic has available and the preference of the doctor or nurse. Treatment options include:

• Loop diathermy: a thin wire loop cuts through and removes the abnormal area of cells. This is also known as a large loop excision of the transformation zone (LLETZ). It is the most common form of treatment used in the UK.

• Cryotherapy: freezing the affected area of the cervix, which destroys the abnormal cells.

• Laser treatment: this destroys or cuts away abnormal cells.

• Cold coagulation: a heat source is used to burn away and remove the abnormal cells.

A local anaesthetic is usually given before any treatment, to numb the neck of the womb. The treatment is normally very straightforward and quick. There is a small risk of bleeding at the time of treatment.

Occasionally, the doctor or nurse may suggest that you have one of the following procedures as a treatment for CIN:

• A cone biopsy (described later).

• Very rarely, removal of your womb and cervix (a hysterectomy).

If this is the case, you will need to be admitted to hospital.

What should I expect after my treatment?

You may have some mild discomfort, like a period pain, after your treatment. Painkillers such as paracetamol may help to ease the pain.

You are likely to have some bloody vaginal discharge. This can last up to six weeks. It is like the bleeding you have during a period. If you are worried that it is too heavy, or if it becomes smelly, see your doctor. You should use sanitary pads and not tampons. You should avoid sex and not do any heavy exercise or swim until your discharge has gone back to normal.

Will I need any follow-up?

This depends on the results of your colposcopy and whether you needed any treatment. Some women may need a follow-up colposcopy examination. Other women may just need a follow-up cervical screening test, usually after six months. This test is often called a 'test of cure'. This test can be carried out by your usual clinic or GP surgery. The doctor or nurse who performs your colposcopy will advise what follow-up you will need.

If your 'test of cure' shows no abnormal cells and is negative for HPV, you will just need another cervical screening test, including HPV test, in three years.

If your 'test of cure' shows abnormal cells or is positive for HPV you will need to have another colposcopy examination.

What is the prognosis if I need treatment?

Treatment of CIN is usually almost 100% effective. The outlook (prognosis) in the vast majority of treated women, is that it is unlikely that CIN will come back.

Cone biopsy

What is a cone biopsy?

Sometimes, all of the abnormal cells cannot be seen during colposcopy because the cells go further up into the neck of the womb (cervix). If this happens, the doctor or nurse will usually suggest that you have a minor operation called a cone biopsy. In this procedure, a cone-shaped piece of tissue is removed from your cervix so that it can be examined under the microscope in the laboratory.

You will be given a separate appointment to come back for your cone biopsy. You are usually admitted to hospital overnight. A general anaesthetic which puts you to sleep is usually given.

What happens after a cone biopsy?

After your cone biopsy, you may have some gauze packed into your vagina to help control any bleeding. Some women also have a tube to drain urine (a catheter) inserted into their bladder at the time of the operation. This is because the gauze can sometimes press on the bladder and stop it from emptying properly. The gauze and the catheter will be removed before you leave hospital.

Most women notice a bloody discharge for up to four weeks after a cone biopsy. You should wear sanitary pads and not tampons. You should see your usual doctor if:

• You are worried that the bleeding is too heavy.

• The discharge becomes smelly.

• You develop tummy (abdominal) pain.

After your cone biopsy you should rest for a few days. You should not have sex or do any heavy exercise for four to six weeks.

If all the abnormal cells are removed during your cone biopsy and there is no sign of any cancer, you do not usually need any more treatment. However, you will need to have regular cervical screening tests to make sure that no more abnormal cells develop.

Colposcopy and pregnancy

If you are pregnant, you should discuss this with the doctor or nurse before you have a colposcopy. Colposcopy can, however, be done safely in pregnancy. Treatments (if needed) are usually delayed until after having the baby - unless the abnormality is very severe and it is thought to be dangerous to wait until after the baby is born. Colposcopy in pregnancy does not affect the delivery of your child; nor does it affect your future fertility.

If you become pregnant and you have had a treatment to your cervix, such as a cone biopsy or a loop excision, in the past, you should mention this to your midwife at your first booking appointment. This is because some treatments to the cervix can make you more likely to have problems such as a preterm (early) delivery. If those looking after you are aware, they can monitor you and try to prevent any such problems.