You are one of a special group of women who have a report of an inconclusive or abnormal PAP smear. About 3% of all women will develop these changes in a lifetime. You have been advised to have a colposcopy performed for more evaluation.
What is a Pap smear?
A pap smear is a routine screening test done by your provider during a pelvic exam. The surface of the cervix (mouth or neck of the womb or uterus) is scraped with a spatula and the scraped-off cells from the cervix are fixed on a glass slide. This slide is called a pap smear and is sent to a special lab where it is processed and evaluated by highly trained technicians and doctors. By improvement in technique, the pap smear has become very sensitive in picking up early changes in the cervix. Consequently, we have many more patients with inconclusive or abnormal pap smears to evaluate than we had just a few years ago.
Does a report of inconclusive or abnormal pap smear mean you have cancer?
Almost never! The pap smear will detect early abnormal changes in the cells of the cervix long before cancer develops. This is the purpose of the pap smear. The majority of patients referred to the colposcopy clinic have a final diagnosis of either “mild to moderate dysplasia” or “normal” cervix. Mild to moderate dysplasia means that there are early changes in the cells of the surface layer of the cervix, which have a potential for developing into cancer many years from now. A few patients will have a diagnosis of carcinoma-in-situ. This condition is a little more advanced than severe dysplasia, but does not mean invasive cancer. It, too, has a potential for developing into invasive cancer, if left untreated.
How do you get a diagnosis or know what’s wrong?
Specially trained providers use an instrument called a “colposcope” to examine your cervix carefully. The colposcope is similar to a microscope. It is attached to a floor stand and magnifies the cervix under a powerful beam of light. By using this instrument, the doctor can locate any suspicious areas on the surface of the cervix that are not visible to the naked eye. The provider will take small tissue samples (biopsies) from these areas. The specimens are sent to the pathology lab for processing and evaluation. Upon receipt of results of biopsy, you will be contacted by your provider who will then read the report and discuss the treatment advised.
Does taking a “small sample” of the cervix cause pain?
Yes, though discomfort is probably a better word. Such discomfort is generally minimal and lasts only a few minutes. One of the biopsies includes going into the cervical canal and can cause cramps.
Are there any complications after cervical biopsy?
Generally, complications are rare. You will have vaginal spotting of blood for a few days. Rarely, you may bleed heavier than a menstrual period within a few hours after having the biopsy. You should call your provider if you bleed excessively- more than one sanitary napkin/tampon per hour.
Will I be restricted in my activities after a cervical biopsy?
No. You can carry on your normal activities, although you should avoid intercourse for 14 days while the cervix is healing.
What is a “mild to moderate” dysplasia diagnosis on a cervical biopsy?
“Mild to moderate” dysplasia is the earliest abnormal change in the cells within the surface layer of the cervix. It has potential, if left untreated, of progressing to a more severe change after several years.
What is Colposcopy?
It is an examination of the cervix through a special instrument called a colposcope. The examination is done to gain a more detailed knowledge of the abnormality so that decisions can be made about the best form of treatment, should this be necessary. The colposcope resembles a microscope and it enables the doctor to have a magnified view of the outer cervix. The examination does not take long, possibly ten or fifteen minutes and is done while you are awake in the rooms.
How is Colposcopy Performed?
The colposcope is placed between your legs which are apart and resting in supports. The doctor will use a spectulum to hold the walls of the vagina apart making it possible to see the cervix.
What Happens Next?
What follows depends on the appearance of the area. It may be that after closer observation it is decided that nothing will be done.
A Pap smear may be taken to check for consistency with the earlier “positive” smear. Then the doctor will dab a little acetic acid on the cervix which shows up the abnormal area clearly.
It may be that a biopsy is required, and if this is so, a tiny sample of the tissue will be taken. Women do not always feel this but some women certainly experience pain at this point. There may be a small amount of bleeding afterwards and period like cramps may occur for a day or two. The specimen taken at biopsy will be sent to pathology to help decide on the treatment required or to confirm the diagnosis.
Throughout the examination your doctor will explain what is going on and afterwards will discuss the finding as far as he is able at this stage. If minor changes only are seen, you may be told that treatment is not necessary but you will be reminded to report again for a Pap smear after a certain period of time. If an abnormality (dysplasia) is confirmed, arrangements will be made for treatment. If a biopsy has been taken it may be three days before the results are available.
What is a “mild to moderate” dysplasia diagnosis on a cervical biopsy?
“Mild to moderate” dysplasia is the earliest abnormal change in the cells within the surface layer of the cervix. It has potential, if left untreated, of progressing to a more severe change after several years.
What, exactly, is Dysplasia?
Dysplasia, or CIN (cervical intraepithelial neoplasia), are the words used to refer to a condition that occurs when the cells on the surface of the cervix are replaced by abnormal cells. This is not a cancerous condition but, if neglected, it has the potential to become cancerous.
There are three levels from mild to severe.
- CIN 1 = Mild dysplasia
- CIN 2 = Moderate dysplasia
- CIN 3 = Severe dysplasia
CIN 1 and more minor changes are also termed low grade abnormalities, whereas CIN 2 and 3 are termed high grade abnormalities.
What About Treatment?
The treatment chosen will depend on the extent of the problem diagnosed. The aim of any treatment will be to destroy or remove abnormal cells (dysplasia).
Can “mild to moderate” dysplasia be treated in the office? And how?
The majority of patients with “mild to moderate” dysplasia can be treated with cryosurgery. This method is a way of treating the cervix. Because the abnormal cells are found in the surface layers of the cervix, the freezing technique destroys the surface layer, which is cast off. The cervix then will produce a new surface layer of normal cells. Think of the freezing as similar to a burn on the skin of your hand (without the pain). The surface layer is destroyed and cast off like a blister; then a new “skin” replaces the old.
Possible treatments are:
- Electro-diathermy which destroys the cells by using a heat producing electric current.
- Laser treatment, where a high intensity light beam is used to destroy the abnormal cells.
- Cryotherapy, where a freezing technique is used to destroy the affected area.
- Cone biopsy – a procedure where a cone shaped wedge containing abnormal cells is removed from the cervix. This procedure will assist in the confirmation of the diagnosis and remove the abnormal tissue at the same time.
- Diathermy loop excision (LEEP or LLETZ) where an electric current running through a wire loop is used to excise the abnormality.
Usually treatment takes place at a Day Surgery Unit or in the doctor’s rooms. Some treatments take place under general anaesthetic and other treatments are performed under local anaesthetic, which means you will be awake during the treatment.
You should feel well enough for your normal work the following day. Any cramping or period-like pain you may experience should be relieved by a mild pain killer. As the area treated heals over the next few weeks, there may be some pinkish vaginal discharge. Intercourse should be avoided over the next four weeks as healing is taking place.
If the more serious condition of cancer is diagnosed, other treatment will be recommended by your doctor. This may mean surgery or radiotherapy or both. Early treatment means complete cure for most women.
Follow Up:
Your doctor may ask you to come back for further colposcopic examination to make sure healing has taken place and that treatment has been effective. These are important visits which ensure your good health and feeling of confidence so do not neglect them. You may be advised to have Pap smears more frequently than the usual two years.
What is Carcinoma-in-situ?
Carcinoma–in-situ is a more advanced lesion, affecting the cells within the surface layer of the cervix. However, it is not a true cancer. But if left untreated, it has the potential for developing into cancer. If you have carcinoma-in-situ you will be referred to a gynecologist for further treatment.
What is cryosurgery?
Cryosurgery is a procedure in which abnormal body tissues (sometimes referred to as lesions) are destroyed by exposure to extremely cold temperatures.
When is it used?
Cryosurgery is used to treat skin lesions such as freckles (for cosmetic reasons), hemorrhoids, warts, and some skin cancers.
It is also used to treat skin changes from genital wart virus and precancerous changes on the surface of a woman’s cervix. These precancerous abnormalities are usually found from a Pap smear. (The lesions are also called “dysplasia”, CIN, or cervical intraepithelial neoplasia.) Sometimes freezing is not an option if the abnormalities are too large.
How do I prepare for cryosurgery?
Most likely you will not have to do anything to prepare for cryosurgery. It is a simple procedure and it is done in a short time in your health care provider’s office.
What happens during the procedure?
Your health care provider will use a probe-like tool to treat the affected areas. A very cold gas, usually nitrous oxide, is pumped through the probe. The gas makes the tip of the probe very cold.
Your provider will touch the tip of the probe to the affected area. When the cervix is treated you probably won’t feel the cold sensation. Most women tolerate this procedure well, and leave the office with no discomfort.
How long your provider keeps the probe touching the skin or cervix depends on the size and type of the lesion and what type of gas is being used. For some abnormal tissue, such as genital warts, the procedure works best if the tissue is frozen quickly, allowed to thaw for a few minutes, and then frozen again.
Is cryosurgery painful?
Generally not. It can cause mild cramping. Occasionally, it is accompanied by a temporary feeling of lightheadedness and flushing.
How long does it take?
About ten to fifteen minutes in the examining room.
Does it ever have to be repeated?
Yes. A second treatment is necessary in 10 to 20% of cases, if the changes persist.
What are the after effects of cryosurgery?
You will have a very watery vaginal discharge for 2 to 6 weeks. This may be mixed with some blood. You may need to use many sanitary napkins during these first few weeks. However, cryosurgery will not affect your menstrual cycle or cause infertility. Complete healing of the cervix takes about 3 months.
Are there any restrictions to activities?
You can carry-on your normal activities; however, you should avoid intercourse or douching for at least 2 weeks during the time of heavy watery discharge. The cervix is undergoing a healing process. Irritation to this area should be avoided, as bleeding can occur.
What happens after the procedure?
For skin lesions such as warts, a small blister will form. The blister will later become a scab or a crust. Your health care provider will tell you how to care for the wound.
There are usually no complications from this procedure. However, occasionally women who are having cervical cryosurgery have hot flushes or faint. If you have cryosurgery of the cervix, you will be asked to stay in the health care providers office for at least 10 minutes after the procedure. Although it is rare, sometimes women faint more than 10 minutes after the procedure, so it is a good idea to have someone take you home. Many women have mild abdominal cramping after cervical cryosurgery. Many women also have a watery discharge from the vagina after the procedure.
Some abnormal tissues may need to be treated more than once. Your health care provider will tell you how often you need to be checked for recurrence or retreatment. You will need a follow-up visit to check healing and to see if any abnormal tissue still remains.
If you have cervical cryosurgery for an abnormal Pap smear, your health care provider will tell when you should have your next Pap smear.
Follow your health care provider’s instructions for checking back for problems, questions, and your next visit.
What are the benefits of cryosurgery?
Cryosurgery is very effective and is less expensive than other treatments. It can be done in your health care provider’s office and anesthesia is not necessary.
What are the risks associated with cryosurgery?
If you are being treated for a cervical lesion, during or after cryosurgery you may experience: – fainting – hot flushes – lower abdominal cramping.
If you are being treated for a skin lesion, you may have: – discoloration of the treated area – damaged hair and sweat glands in the treated area – minor scarring.
When should I call the doctor?
Call your doctor’s office if:
- The treated area is bleeding or not healing.
- The lesions reappear.
- The treated area develops symptoms of infection.
- You have abdominal cramps after cervical cryosurgery that last longer than
24 hours. - You have a foul-smelling vaginal discharge after cervical cryosurgery for
longer than your doctor told you to expect.
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