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Subject: Colposcopy and Directed Cervical Biopsy
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A colposcope is typically defined as a stereoscopic binocular field microscope with a long focal length and powerful light source. Modern colposcopes permit magnification between 2× and 40×, although most routine colposcopic work can be done at 10× to 15× magnification. Some scopes have a single fixed magnification level. Others have a series of par-focal lenses or a smooth zoom capability that allows for easy adjustment of the magnification via knob or rotor.
Interchangeable eyepieces with various levels of magnification are available. Some eyepieces can be individually adjusted to compensate for variance in an individual user’s vision. A diopter scale on the side can identify these. Eyepieces can be adjusted in a manner similar to microscopes to adjust to each colposcopist’s interpupillary distance.
The usual working distance (focal length) of a colposcope is 30 cm. Most scopes also have a fine focus handle that is attached to a machine screw under the mounting bracket for the colposcope head. Applying pressure to this handle to subtly control the alignment of the scope and twisting it produces very gradual forward or backward movements of the head for exquisite fine focus control.
A flexible articulating arm or overhead boom colposcope can be mounted on a stable base (with or without wheels), the wall, or an examination table. A column- or stick-mounted scope can easily be moved.
A colposcope usually has a powerful light source, with a rheostat to adjust the level of illumination. The colposcope should be equipped with a green or blue filter (red-free filter). These filters remove red light, thereby enhancing vascular detail by making the blood vessels appear dark.
Atypical squomous cells cannot rule out high grade disease (ASC-H), low-grade squamous epithelial lesion (LSIL), high-grade squamous epithelial lesion (HSIL), or atypical glandular cells (AGUS)
Repeated Pap smears with atypical squamous cells
Repeated Pap smears consistent with LSIL in a patient younger than 21 years of age
Pap smear with repeated unexplained inflammation
Abnormal-appearing cervix or abnormal-feeling cervix (by palpation)
Patients with a history of intrauterine diethylstilbestrol (DES) exposure
Active cervical or vaginal infection, because it can lower test sensitivity and increase bleeding (relative contraindication)
Severe bleeding disorders
Late pregnancy or active labor
PITFALL: Repeating the Pap smear is often unnecessary, and even a correctly performed Pap smear may irritate the cervix and cause bleeding.
PITFALL: Calling the solution acetic acid may increase the patient’s perception of burning; describing the solution as vinegar is preferable.
PITFALL: A tenaculum is almost never necessary to move the cervix and may cause cervix-obscuring bleeding.
PITFALL: Unsatisfactory colposcopy with cytologic evidence of dysplasia usually requires cervical cone biopsy for further evaluation.
PITFALL: Make sure the patient is not allergic to iodine (shellfish) or benzocaine before using these solutions.
PITFALL: Do not do an ECC on pregnant patients.
PEARL: The bush should appear bloody when the procedure is done correctly. If only mucus is present on the brush, an inadequate sample was used.
PEARL: The cervix can be manipulated with a cotton-tipped applicator or hook if necessary to provide an adequate angle for biopsy.
PEARL: It is not necessary to include normal margins with biopsy samples.
PITFALL: Beginning colposcopists often place samples from different biopsy sites in different bottles, subsequently correlating them with colposcopic impressions. Separate specimens can increase costs and generally are not necessary, because the entire TZ is treated based on the worst biopsy result found.
PITFALL: Do not apply Monsel solution until all biopsies are completed.
PITFALL: Swab out the excess Monsel solution and blood debris, which appears as a coffee-ground-like black substance that eventually will pass and may cause alarm (and late-night phone calls).
PITFALL: Post-procedure fainting and light-headedness are not uncommon. Have the patient rest supine for at least several minutes and then sit up slowly.
Vasovagal responses postprocedure
Bleeding or spotting
Infection (very rare)
A 20% solution of benzocaine (i.e., Hurricane solution) can be obtained at Beutlich Pharmaceuticals LP, 1541 Shields Drive, Waukegan IL, 60085. Phone: 847-473-1100 or 1-800-238-8542. Web site: http://www.beutlich.com/products.htm.
Cooper Surgical, Shelton, CT. Phone: 1-800-645-3760 or 203-929-6321. Web site: http://www.coopersurgical.com.
Olympus America, Inc., Melville, NY. Phone: 1-800-548-555 or 631-844-5000. Web site: http://www.olympusamerica.com.
Utah Medical Products, Inc., Mid-vale, UT. Phone: 1-800-533-4984 or 801-566-1200. Web site: http://www.utahmed.com.
Wallach Surgical Devices, Inc., Orange, CT. Phone: 203-799-2000 or 1-800-243-2463. Web site: http://www.wallachsurgical.com.
Acetic acid (3% to 5%) and normal saline can be obtained from a supermarket (i.e., white vinegar) or from a medical supply source.