Colposcopy: the test of the vagina and cervix

By Cristiano Antonino On Feb 15, 2023

Colposcopy is a test that allows an accurate visualisation of the skin of the vulva, the mucous membrane (i.e. the lining surface) of the vagina and the cervix

If any abnormal area is revealed during colposcopy, a small tissue sample (biopsy) can be taken at the same time, which is then sent to a laboratory for microscopic analysis.

Colposcopy is usually requested to thoroughly examine the vagina and cervix in the presence of an abnormal Pap test

To perform colposcopy, the gynaecologist uses a magnifying instrument resembling binoculars, called a colposcope.

The colposcope amplifies the vision by 2 to 60 times, allowing the doctor to detect abnormalities that would have escaped a naked-eye view.

Some types of colposcope are connected to a camera or video camera that allow permanent images of the suspicious areas highlighted during the test to be obtained.

Performing colposcopy also requires that the surfaces to be examined are gently swabbed with a cotton ball soaked in acetic acid and sometimes an iodine solution (Lugol’s solution).

These substances, applied to the mucous membranes being tested, have the ability to highlight any abnormal areas that may be present.

Generally, one or more biopsies are taken at the abnormal areas that may be detected, so that microscopic analysis of the tissue taken can make a final judgement: i.e. whether it is inflammatory cells, precancerous cells (i.e. cells that could develop into cancer) or cancerous cells.

What is the colposcopy test for?

Colposcopy is indicated in the following conditions

in the presence of an abnormal Pap test, in order to carefully examine the mucous membrane of the cervix for abnormal areas. If an abnormal area is detected during the colposcopy, a small sample of tissue from the surface of the cervix (cervical biopsy) or from the epithelium lining the canal through which the uterus opens into the vagina (endocervical canal) is usually taken at the same time as the test.
In the presence of an ulcer or any other abnormality (e.g. a genital wart) found by the patient herself or during a gynaecological check-up, in the vulva, vagina, and/or cervix.
To check over time (in medical jargon for “follow-up”) the evolution of an abnormal area highlighted at the level of the vagina or cervix or to confirm the effectiveness of a treatment carried out for the presence of a precancerous lesion.

How to prepare for Colposcopy?

Do not use douches, ovules, vaginal creams or tampons in the 48 hours preceding the Colposcopy.

It would also be preferable to avoid sexual intercourse during this time.

Both the trauma associated with sexual intercourse and the use of intravaginal substances can alter or mask the cells on the surface of the cervix to varying degrees.

Colposcopy should be performed at a time of the cycle when there is no menstruation or bleeding, as the presence of blood may interfere with a good visualisation of the characteristics of the mucous membrane being tested.

The best time to take the sample is early in the menstrual cycle, i.e. 10-20 days after the onset of menstruation.

Before carrying out the test, the gynaecologist will briefly reconstruct the patient’s medical history by questioning her about

the time of menarche (the first menstruation), the characteristics of the menstrual cycle, the date of the last menstruation. If amenorrhoea is present, it may be useful for the patient to take a pregnancy test or blood sample before the test to rule out pregnancy. It is essential for the doctor to rule out pregnancy before performing the test. Although colposcopy is a perfectly safe test during pregnancy, and even a cervical biopsy has a low risk (risk of miscarriage), there may be more bleeding at the site of the test.
Any medication intake and or known or suspected allergies to drugs and/or other substances.
Any bleeding problems.
Any present or previous vaginal, cervical or pelvic infections and any related systemic (e.g. antibiotics or antifungals) and/or topical (e.g. application of ova, creams) therapies.

Prior to the colposcopy, the patient will be asked to sign a consent form for the test in which she declares that she has been informed of the risks involved in the test and consents to its performance.

Finally, it may be useful for the patient to empty her bladder before the test in order to ensure greater comfort during the procedure.

Colposcopy: how the test is performed

Colposcopy is a test that is performed on an outpatient basis by an experienced gynaecologist.

If a biopsy is needed during the procedure, the tissue taken is sent to an experienced pathologist for microscopic analysis.

Firstly, the patient must empty her bladder, remove all clothing below the waist, and lie on the gynaecological couch with her back and feet in the metal supports.

This position is necessary so that the gynaecologist can examine the vagina and genital area.

At this point, he/she will introduce an instrument into the vagina called a speculum, the purpose of which is to pull the vaginal walls apart and thus allow the inside of the vagina and the cervix to be viewed.

The colposcope will then be placed at the entrance to the vagina so that the gynaecologist, looking through the microscope, has a magnified view of the surface of the vagina and cervix.

The surfaces to be examined will then be gently swabbed with a cotton ball soaked in acetic acid and sometimes an iodine solution (Lugol’s solution).

These substances, applied to the mucous membranes being tested, have the ability to highlight any abnormal areas that may be present.

If the test has revealed the presence of one or more abnormal areas, one or more biopsies will then be taken at these areas, so that microscopic analysis of the tissue taken can make a final judgement: i.e. whether it is inflammatory cells, precancerous cells (i.e. cells that could develop into cancer) or cancerous cells.

Bleeding at the sampling site is usually extremely small.

In a few cases, however, blood loss may be more conspicuous and require the application of anti-haemorrhagic agents or iron-based haemostatic solutions (Monsel’s solution) or silver nitrate.

If tissue harvesting must be performed within the endocervical canal, a procedure known as endocervical curettage (ECC) and/or endocervicoscopy will be performed instead.

Since this area cannot be visualised using the colposcope, in this case the gynaecologist will gently introduce a small, sharp-edged instrument called a curette into the endocervical canal with which he or she will scrape a small portion of tissue.

Endocervical curettage takes less than a minute and may result in slight cramping while it is being performed.

It cannot be performed during pregnancy.

Colposcopy and biopsy generally take about 15 minutes

Can this test be painful? The patient may feel a sensation of discomfort when introducing the speculum, especially if the vagina is irritated, poorly lubricated or tight.

A tingling sensation or slight cramping may occur when the cervical biopsy is performed.

These unpleasant sensations can however be minimised, if not abolished altogether, if the patient relaxes, breathing deeply while the test is being performed.

Holding one’s breath, fidgeting, or contracting the muscles of the inner thigh is completely counterproductive as it not only prolongs the time needed to perform the test, but also makes it more painful.

It is possible that after the biopsy the patient may have some minor bleeding and a vague feeling of discomfort for up to a week.

It may therefore be useful to wear a sanitary towel or sterile gauze to protect clothing.

It is also a good idea to avoid sexual intercourse, hot baths and tampons for at least a week after the biopsy to allow the cervix to heal.

Slight burning for a day or two after the test may eventually be normal.

However, you should contact your gynaecologist immediately if abnormal reactions occur after the test, such as

heavy vaginal bleeding (more than a normal menstruation)
fever
abdominal pain
abundant and foul-smelling vaginal discharge.

What risks are involved in having a colposcopy test?

Very rarely, colposcopy can cause an infection or prolonged bleeding. Bleeding can be prevented by applying haemostatic substances or anti-haemorrhagic agents to the cervix.

Possible results of Colposcopy

The gynaecologist will issue the initial colposcopy report to the patient immediately, i.e. at the end of the test.

In the case of a biopsy, however, the final result will only be ready a few days later (1 to 3 weeks depending on the time required by individual laboratories).

Colposcopy and cervical biopsy

Normal: Application of acetic acid and iodine did not reveal any abnormal areas. The mucosa of the vagina and cervix appear normal. Microscopic examination of biopsy tissue taken during the test at an area that appeared abnormal showed normal tissue.
Abnormal: Abnormal areas were revealed by application of acetic acid and/or iodine Ulcers or other lesions, such as genital warts, or outcomes of inflammatory processes (usually infectious based) were noted in the vagina or cervix.

Microscopic examination of the biopsy tissue taken during the test revealed the presence of abnormal cells, which indicate the presence of cancer or which could give rise to cancer (precancerous lesions).

What can interfere with the result of Colposcopy?

The presence of blood can interfere with proper visualisation of the cervical and vaginal mucosa and thus with the test result.

A vaginal infection can alter the appearance of the mucous membranes being tested, altering the results of the Colposcopy.

Colposcopy performed less than 48 hours after the use of douches, lubricants or vaginal drugs can produce inaccurate results as these products can variously mask cells on the surface of the cervix.

Colposcopy may give a false-negative result if the tissue sampling is quantitatively (the cells taken are numerically small) or qualitatively (the cells taken are not from the area in which the lesion is present) inadequate.

Colposcopy: general considerations

Colposcopy is not an investigation to be performed routinely, i.e. as a screening test for cervical cancer.

A Pap test is performed for this purpose.

Although a normal colposcopy and a negative biopsy do not exclude with absolute certainty the presence of cancer, under these conditions, the probability of cancer is rather remote.

If the results of a colposcopy and biopsy disagree with those of a recent Pap test (e.g. Pap test positive – Colposcopy and biopsy normal – Pap test positive again), it may be necessary to repeat the biopsy or, sometimes, to perform a somewhat more extensive type of biopsy, performed as a day-hospital procedure (hospitalisation for no more than 12 hours) under local, regional or general anaesthesia, such as LASER-colposcopy or LEEP.

In some cases, this type of biopsy can also have curative purposes, as the diseased tissue can be totally removed.

A colposcopy with a positive biopsy for the presence of cancerous cells is usually sufficient to make a diagnosis of cervical cancer.

They do not, however, provide adequate information about the extent of the tumour and the depth of tissue invasion.

Colposcopy should always be performed by an experienced gynaecologist with considerable experience in the field.

Colposcopy can be performed without risk during pregnancy.

In contrast, a cervical biopsy should only be performed during pregnancy if there is a well-founded suspicion of cancer.

While cervical biopsy does not appear to increase the risk of miscarriage, it does carry an increased risk of bleeding at the sampling site and should therefore be avoided during pregnancy.

The removal of tissue from the endocervical canal (endocervical curettage) is always contraindicated during pregnancy.

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