Colposcopy was first described by Hans Hinselmann of Germany in 1925 as a screening tool for cervical cancer. Somehow, it did not gain much importance for a few decades but started gaining popularity in the 1960s. Currently, it has near-universal acceptance as the most effective follow-up test for women suspected of having premalignant or malignant cervical lesions. Its judicious use can result in a marked reduction in unnecessary surgical procedures. Changing physiology after menopause poses certain challenges in performing colposcopy. Hence, it is essential to be aware of these challenges and their possible solutions.
Colposcopy is indicated when the presence of a malignant or premalignant lesion in the cervix, vagina, or vulva is suspected or when an unusual cervical lesion is detected on inspection of the vagina and cervix for an unrelated reason. The above is mostly encountered as abnormal pap smear which is reported by 2001 version of the Bethesda system.
In 2020, the ASCCP updated its 2012 management guidelines for abnormal cervical cancer screening results, with input from 19 stakeholder organizations including ACOG. Salient indications for colposcopy according to these guidelines are as follows:
- Recommendations for colposcopy, treatment, or surveillance are based on the patient’s risk of cervical intraepithelial neoplasia (CIN) 3+ Colposcopy can be deferred for certain patients such as those with minor screening abnormality indicating human papillomavirus (HPV) infection with a low risk of underlying CIN 3+
- Because HPV 16/18 poses the highest risk of CIN3 and occult cancer, further evaluation (e.g. colposcopy with biopsy) is needed even if cytology results are negative
- If HPV 16/18 is positive and further testing of the same sample is not available, colposcopy is the next step.
- No absolute contraindication
- Special precaution is needed in pregnancy with placenta praevia. Pregnancy per se is not a contraindication
- Active cervicitis and vulvovaginitis should be treated before doing colposcopy
- Patient’s inability to tolerate a standard per speculum examination is the only true limiting factor.
- Inadequate or inaccurate evaluation is the most worrisome complication as it may lead to missed diagnosis of invasive cancer. This can lead to treatment delays and poorer outcomes.
The performance of colposcopy in the postmenopausal woman is conducted in the same manner as for other nonpregnant women. Current guidelines do allow for HPV testing or repeat cytology in postmenopausal women with a cytology finding of low-grade squamous intraepithelial lesion (LSIL), recognizing the lower risk of cervical pathology in older women with historically negative cervical cancer screening. In postmenopausal women, the squamocolumnar junction is more often located in the endocervix, thereby resulting in the unsatisfactory colposcopic examination.
PHYSIOLOGICAL AND PATHOLOGICAL VARIATIONS
A report by Castle et al. indicates that the Xpert HPV assay is a sensitive and reliable diagnostic tool for detecting hr HPV DNA as well as grade 2 or greater CIN in a colposcopy referral population. Dogan and Guraslan prospectively studied 1658 women (77.7% pre- and 22.3% postmenopausal) and concluded that conventional cytology has less efficiency in detecting the precancerous lesions in postmenopausal cases; therefore, the colposcopic examination may be appropriate in postmenopausal women.
The hormonal changes developing in the postmenopausal period, especially hypoestrogenism, causes atrophy of the genital organs and atypical finding in cervical cytology. The possibility of inadequate colposcopic examination increases as the transformation zone recedes inside the endocervix and cannot be evaluated due to genital atrophy. The benign degenerative changes in the immature squamous cells connected to hypoestrogenism, obvious atrophy can imitate squamous intraepithelial lesions and noninvasive cancer in postmenopausal women.
Dogan and Guraslan also found that ASCUS/LSIL ratio in postmenopausal patients was 4.07, and in the premenopausal group, it was 2.8. LSIL in premenopausal group and HSIL in postmenopausal group were significantly high. There are studies suggesting that local estrogen therapy can distinguish the real preneoplastic changes from benign cytologies imitating atrophy by decreasing vaginal atrophy. There are also studies suggesting that HRT can cause artifacts mimicking LSIL by increasing glycogenation.
Local estrogen therapy was recommended for postmenopausal women in 2006 ASCCP consensus, this proposal was withdrawn in 2012. Studies suggest that abnormal cervical cytology predicts the precancerous lesions less frequently in postmenopausal women than in premenopausal women due to epithelial changes in atrophy. Considering the failure in the application of effective cervical cancer screening programs in postmenopausal women, it will be appropriate to direct the abnormal cervical cytology detected cases to colposcopy.
- Vaginal atrophy leads to difficult speculum insertion. Lack of lubrication makes instrumentation painful. A condom worn as a sleeve over the speculum might help
- Cervical Os contracts and becomes smaller and tighter. It becomes difficult to view endocervix and squamocolumnar junction. An endocervical speculum might be helpful. However, endocervical sampling is required. Excisional procedure might be needed
- Glandular abnormality is difficult to assess as glandular tissue also moves up into the canal. Directly cone biopsy/loop electrosurgical excision procedure might be required
- Thinner cervical tissue due to reduced estrogen levels makes the vascular network prominent during colposcopy. These vessels can mimic the atypical vessels of cancer. Thinner cervical surface tissue may cause the cervix to appear “shiny” and lead to multiple biopsies which should ideally be avoided.
Hence, the indications, the procedure itself, and the management by colposcopy might be a challenge in postmenopausal women, and individualization might be needed for adequate diagnosis and treatment of cervical precancerous and early cancerous lesions in this group of women.
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Conflicts of interest
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