Manangement of gynaecological cancer - diagnosis and surgical treatment. Abnormal cervical smears - colposcopic assessment and treatment. Management of pre-cancerous change in the vagina and vulva along with vulval pain and painful intercourse.
Opinions can be given for all aspects of general gynaecology including menstrual problems, pelvic pain, infertility, prolapse and bladder problems, infections, contraception, menopause and hormone replacement therapy. For complex problems, appropriate recommendations for higher specialist opinions can be provided.
Full pregnancy care is available and all modes of delivery are provided. Women can be delivered at The Portland Hospital or St Georges Hospital, both of which have well equipped neo-natal units.
WHAT IS COLPOSCOPY?
Colposcopy is a method of examining the cervix (neck of womb) under magnification and strong illumination with a device called a colposcope which looks rather like a pair of binoculars mounted on a stand. From the woman's point of view, the actual procedure of undergoing colposcopy is similar to having a cervical smear taken but takes longer as it involves the application of various solutions to the cervix in order to identify any abnormalities. The colposcope can also be used to examine the vagina and vulva.
WHY IS COLPOSCOPY PERFORMED?
Women between the ages of 25 and 65 are invited to attend for cervical smears where a sample of cells is scraped from the cervix to be examined under a microscope by a cytologist. The procedure is part of a screening process designed to detect changes in the cervix at a PRE- cancerous stage and offer diagnosis and treatment.
The commonest reason for performing colposcopy is because a woman's cervical smear has shown the presence of abnormal cells. These abnormal cells are regarded as being pre-cancerous - that is, if they were left untreated, then- eventually they could become cancerous. The finding of abnormal cells on a smear often causes alarm in women but they need to be reassured that the chances of actually having cancer are extremely small. These pre-cancerous changes are graded as mild, moderate or severe though some smears are reported as being 'borderline' when the change is only very slight. Even if they have pre-cancer it may never progress further and, if it does, this may take a number of years. Fortunately there is a quick and easy treatment for the condition which, for most women can be performed in the out-patient clinic and eliminates the condition in over 90% of cases. Other reasons for women being referred for colposcopy include repeated smear results returning as inadequate, post-coital bleeding (bleeding after sexual intercourse), inter-menstrual bleeding (bleeding in between menstrual periods) or an unusual/concerning appearance of the cervix.
WHAT DOES THE COLPOSCOPIC EXAMINATION INVOLVE?
As far as the woman is concerned, the actual colposcopy is similar to having a smear taken (and in many clinics, a repeat smear is taken routinely). The person performing the colposcopy (colposcopist) will insert a speculum (in the same way as when a smear is taken) in order to visualise the cervix. In the majority of cases, when the colposcopy is being performed for an abnormal smear, a dilute solution of acetic acid (vinegar) is applied to the cervix using cotton wool. Occasionally this may sting but otherwise should be no more uncomfortable than undergoing a routine smear. This allows the colposcopist to visualise any changes in the 'skin' (epithelium) covering the cervix. There are a variety of appearances depending upon the nature of the condition. Some changes are variations of normal but some may be more consistent with pre-cancerous change and the colposcopist may wish to take a small sample of tissue (biopsy) - about the size of a grape pip, which is sent to the pathologist for a definitive diagnosis. This generally causes some bleeding which is controlled by applying a chemical (silver nitrate) contained in the end of an applicator rather like a long matchstick and this may occasionally sting. Once the bleeding is under control, this completes the diagnostic examination. Sometimes the colposcopist needs to examine the vagina and or vulva in the same manner by applying acetic acid and taking biopsies though this may need the additional injection of some local anaesthetic.
CAN COLPOSCOPY BE PERFORMED DURING PREGNANCY?
There are no reasons why colposcopy cannot be performed during pregnancy and it is safe to take biopsies (though it may bleed more than normal). However unless the pregnancy is in its very early stages (less than 10 weeks) treatment is generally not performed due to the risk of heavy bleeding. If the condition is confirmed as being truly PRE-cancerous then the colposcopy can be repeated later in the pregnancy and/or 6-12 weeks after the baby is born.
WHAT HAPPENS IF THE COLPOSCOPY AND BIOPSY CONFIRM THE PRESENCE OF PRE-CANCEROUS CHANGE?
The pathologist may confirm the presence of precancerous change in the biopsy. These changes are called CIN (Cervical Intra-epithelial Neoplasia) and, like the smear results, these are graded as mild (CIN 1), moderate (CIN 2) or severe (CIN 3).
CIN 1 changes may revert to normal spontaneously in 1/3 to ½ of cases and, therefore, women have the choice of either undergoing treatment or, alternatively, having the situation kept under colposcopic review by attending for colposcopy on a 6 monthly basis until the situation resolves or deteriorates with time. CIN 2 and 3 changes do not generally revert to normal and the standard advice is to undergo treatment.
WHAT DOES THE TREATMENT INVOLVE?
Treatment can either be by destroying (ablating) the abnormal cells or by excising the abnormal area. All treatments will result in a cone shaped defect in the cervix whether by ablation or excision. Most treatments are excisional and involve the use of a wire loop to cut away a cone of tissue from the cervix. This procedure, known as Large Loop Excision of the Transformation Zone (LLETZ) is performed in the clinic setting under local anaesthetic in ¾ of women. Local anaesthetic is injected into the cervix in the same way that a dentist injects the gum and causes a similar amount of discomfort. Once the cone of tissue has been excised, the area is cauterised to stop any bleeding. The procedure takes about 10 minutes and women can continue their daily routine afterwards if they wish. Some women, for a variety of reasons need the procedure performed under a general anaesthetic and will need to be admitted to the hospital - generally as a day case. The excised tissue is sent to the pathologist for full analysis.
Ablative treatment can be performed with laser, diathermy, coagulation or freezing but it is mandatory that a biopsy has been taken before this treatment is performed in order to confirm that the condition is, indeed, pre-cancerous and not cancerous. With ablative treatment no further tissue is sent to the pathologist.
WHAT CAN I EXPECT AFTER THE TREATMENT?
Following all forms of treatment, women can expect some vaginal discharge whilst the cervix heals and during this time it is recommended that nothing is inserted into the vagina. That means no sanitary items and abstinence from sexual intercourse. The discharge is reddish/brown in colour and should not be heavier than a normal menstrual period and should not smell offensive. The discharge may last up to 4 weeks depending on the size of the area which needs to heal and, in general women, should regard the situation as rather like having a long menstrual period and behave accordingly. Therefore, showers are preferable to baths and swimming is best avoided. There is minimal discomfort after the treatment though mild cramp-like pain is possible and standard pain-killers from the local pharmacy should control this.
Occasionally after about 10-14 days, there may be more brisk bright red bleeding which is due to separation of the clots (scabs) on the healing cervix. If this bleeding is much heavier than a normal menstrual period or requires sanitary towels to be changed every hour or two, advice should be sought from the unit which performed the procedure. Very occasionally, if the bleeding is excessive, admission to hospital is required, either for a 'pack' (like a large tampon) to be inserted into the vagina or, alternatively, to undergo further cautery to the cervix.
ARE THERE ANY LONG-TERM CONSEQUENCES TO THIS TREATMENT?
There are two possible long-term consequences to treatment though both are rare - well under 1/2%.
Cervical stenosis: This involves a narrowing of the entrance to the cervix (cervical os) which may make future smears difficult and/or uncomfortable to take. Furthermore, it may cause menstrual periods to be painful due to the narrowing. Occasionally the cervix fails to dilate during labour because of the scarring and delivery needs to be by Caesarean Section.
Cervical incompetence: Conversely, the cervix can be weakened by the effect of removing/destroying a cone of tissue and this can occasionally result in late miscarriages at about 16-24 weeks of pregnancy due to the cervix simply not being strong enough to hold the pregnancy.
Many women, understandably, ask if the treatment will affect future pregnancies and they can be safely assured that it is extremely unlikely based upon studies performed so far.
HOW WILL I BE FOLLOWED UP AFTER TREATMENT?
Different units have different policies ranging from women attending their G.P. for a repeat smear 6 months later to women attending the hospital for a repeat colposcopy and smear following treatment. The important point is that a smear should be taken within 12 months of treatment and there are national guidelines as to the frequency of smears thereafter. For those women treated for low grade changes, smears are taken at 6,12 and 24 months before returning to the national screening programme of smears every 3 years until the age of 50 and then every 5 years until 65. Women treated for high grade changes are recommended to have smears at 6 and 12 months and annually thereafter for a further 9 years before returning to 3-yearly smears.
WHAT HAPPENS IF THE SMEAR IS ABNORMAL IN THE FUTURE?
Over 90% of women are cured by a single treatment. Even if the smear is showing a mild abnormality after treatment - further treatment may not be necessary but careful follow-up every 6 months is wise. If the smear shows a more severe abnormality then further treatment is likely especially if the results from the first treatment suggested that the abnormality may not have been completely removed.
British Society of Colposcopy and Cervical Pathology (www.bsccp.org.uk)
National Health Service Cervical Screening Programme (NHSCSP) www.cancerscreening.nhs.uk