Gynecologic Procedures: Colposcopy, Treatment of Cervical Intraepithelial Neoplasia, and Endometrial Assessment
BARBARA S. APGAR, MD; AMANDA J. KAUFMAN, MD; CATHERINE BETTCHER, MD; and EBONY PARKER-FEATHERSTONE, MD, University of Michigan Medical Center, Ann Arbor, Michigan
Am Fam Physician. 2013 Jun 15;87(12):836-843.
http://www.aafp.org/afp/2013/0615/p836.pdf
Women with abnormal pap smears need further testing. Colposcopy is typically done to determine where to biopsy the cervix, but this is not a reliable indicator. Some lesions (those that are small and those that are not HPV type 16) cannot be found with this procedure, and there is a high false negative rate. Taking multiple biopsies from the "white" area will increase the sensitivity of the procedure.
Depending on the result of the pap and colposcopy, and endocervical curettage may be needed. Recent thought has debated the necessity of the test, especially if the patient is going to require excision. It appears to be of limited benefit.
The treatment for CIN is ablation, excision (LEEP), or cold knife conation. The procedures have similar outcomes, but ablation destroys the tissue. Excision and conation allow histological evaluation. Cold knife conation is preferred when margin status must be preserved. There is a small risk of perinatal death with excision, but the benefits may outweigh this. Post LEEP margin status is not perfect, but those with positive margins should have repeat sampling 4-6 months later (rather than immediately). HPV DNA testing should be done at 1 and 2 years after excision. Positive testing will require additional sampling.
Transvaginal ultrasound is a good test to look for endometrial problems. An endocervical thickness less than 3-4 mm in postmenopausal or 5 mm in premenopausal women can rule out endocervical cancer. Saline infusion ultrasound may give additional information regarding anatomical structure and differentiate consistent from focal changes in the endothelium. Hysteroscopy is a very sensitive and specific diagnostic procedure with little adverse risk
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