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Colposcopy is a technique used to examine the cervix (the neck of the uterus) using magnifying lenses and special dyes. The procedure takes about 10 minutes and does not require general anesthesia. The success of colposcopy depends on its ability to detect pathological findings. Numerous studies have emphasized the importance of colposcopy experience in this regard. During the examination, the cervix is sequentially stained with green light, acetic acid, and Lugol’s iodine.
In a properly conducted colposcopy, the vagina should also be examined with Lugol's iodine, and the vulva (the outer genital area) should be carefully inspected. Biopsies are taken from any suspicious areas. The colposcopy biopsy procedure is not painful and is usually performed easily with local anesthesia.
A diagnosis cannot be made with a Pap smear test. The Pap smear test is a screening test. For a definitive diagnosis and to avoid missing potential cancer, a colposcopy biopsy must definitely be performed. This is especially important for women who smoke or have high- or moderate-risk HPV infections, as colposcopy is necessary to prevent cervical cancer. (1) Smoking significantly increases the risk of cervical cancer, so this group of patients should be closely monitored, and efforts should be made to support smoking cessation.
The final treatment or follow-up should be decided based on the pathology results reported after a colposcopy biopsy.
In cases where the pathology result shows CIN 1, follow-up is usually sufficient. Lifestyle changes, such as quitting smoking, maintaining good sexual hygiene, and using vaginal gels or medications to boost immunity, should be encouraged. Attention to sexual hygiene is necessary to prevent the transmission of new HPV infections. Additionally, the HPV vaccine should be planned and administered, regardless of the patient’s age, to prevent cervical cancer. It is important to note that CIN 1 lesions regress in about 60% of cases.
Detecting CIN 1 through colposcopy biopsy is crucial in preventing cervical cancer. (2) The type of HPV virus infecting the patient should be considered when determining the frequency of follow-up. HPV types 16 and 18 are highly carcinogenic, so follow-up intervals should be shorter for patients with these infections. It is well-known that CIN 1 lesions caused by HPV type 16 have a lower regression rate. (3) HPV vaccination is recommended for patients who are negative for HPV types 16 and 18 to facilitate safer follow-up and prevent cervical cancer.
Before 2020, ACOG recommended follow-up for CIN 2 patients. However, in 2020, it published guidelines stating that instead of follow-up, a conization procedure should be performed. The transition from CIN 2 to CIN 3 is rapid, and there is minimal cellular difference between the two. Therefore, for patients with CIN 2 or CIN 3 detected on colposcopy biopsy, conization (removal of the cervix in a cone shape) should be planned and performed promptly. (4) In patients under 25, short-term follow-up may be an option for CIN 2.
Follow-up discussions should take into account the patient’s desire for pregnancy or children. Additionally, individuals under 27 generally have a better immune response, and there is a small possibility that the HPV virus will clear from the body. However, this is not true for patients infected with HPV types 16 and 18. (5) Therefore, conization should be performed for patients with HGSIL.
Conization is performed under general anesthesia and can be done using either hot or cold conization methods. In hot conization, the cervix is removed in a cone shape using a special device called LEEP. In LEEP conization, care must be taken to ensure that the boundaries are clear of any abnormal tissue. For this purpose, the cervix is stained with Lugol’s iodine, and it should be removed until no negative areas are visible. The transformation zone (the area where HPV-induced precancers and cancers begin) must be fully excised. Cold conization is performed with a scalpel.
If the area is extensive or there is uncertainty about clean surgical margins, cold conization should be applied. Performing a hysterectomy (removal of the uterus) immediately for patients with an HGSIL result from colposcopy biopsy is incorrect. It is important to remember that if in situ or invasive cancer is detected, a deeper operation, such as a type 3 hysterectomy, should be performed. If cancer cells were missed during the biopsy, a second operation will be needed, which can delay treatment and have adverse effects. (6)
For CIN 2 and CIN 3 patients who undergo conization, a new pathology result will be reported. If in situ cancer is found, a simple hysterectomy (removal of the uterus) should be performed. (7) If invasive cancer is detected, a type 3 hysterectomy, which includes removal of the uterine ligaments, ovaries, and lymph nodes, should be performed. The cervix is a highly vascular area with dense lymph nodes, and surgery is essential for cervical cancer treatment.
After conization, patients with recurrent CIN 2 or CIN 3 (HGSIL) should be closely monitored with colposcopy biopsy. Relying solely on Pap smear tests is not a proper approach and can lead to delayed cancer diagnosis. In clinical practice, colposcopy biopsy should be done in office conditions, and patients should be reminded of their follow-up every six months.
In pregnant women with CIN 1, colposcopy biopsy should be performed one month after delivery. Pap smear tests may be taken during pregnancy for patients with CIN 1 (LGSIL). A gynecological exam and Pap smear test do not pose a risk for miscarriage. The rate of detecting ASCUS (atypical cells) in both pregnant and non-pregnant women is similar. If ASCUS is detected in the Pap smear, close follow-up is required. (8)
For pregnant women with CIN 2 and CIN 3 (HGSIL),follow-up for nine months is essential. Since the progression from HGSIL to invasive cancer typically occurs within 1-2 years, pregnancy termination is not necessary for these patients. However, a conization procedure should be planned and performed shortly after the completion of pregnancy. The procedure should be done without delay, regardless of breastfeeding or other factors.
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