Abnormal Cervical Smears Colposcopy

A cervical screening test, or smear test, is a method of detecting abnormal (pre-cancerous) cells in the cervix in order to prevent cervical cancer. The cervix is the entrance to the womb from the vagina.

  1. Cervical screening is not a test for cancer; it is a test to check the health of the cells of the cervix. Most women's test results show that everything is normal, but for 1 in 20 women the test will show some abnormal changes in the cells of the cervix.
  2. Most of these changes will not lead to cervical cancer and the cells may go back to normal on their own. However, in some cases, the abnormal cells need to be treated to prevent them becoming cancerous.

In the UK, women are routinely invited to have regular cervical screening tests as part of the National Cancer Screening Programme. The tests are done to prevent cervical cancer (and not to diagnose cancer as some people wrongly think). During each test some cells are removed from the cervix with a plastic brush. The cells are examined under a microscope to look for early changes that, if ignored and not treated, could develop into cancer of the cervix. If abnormal cells are found, these can be treated (removed), during a procedure called colposcopy.

A cervical screening test involves taking a sample of cells from your cervix. The cells are taken from an area of the cervix called the transformation zone (TZ), also called the squamocolumnar junction (SCJ). This area marks the divide between the cells that line the uterus - called columnar cells, and the cells of the cervix - called squamous cells. At this meeting point, the cells are continually dividing and growing. This means there is more chance of the cells here developing abnormalities that could become cancerous. In young women this area is generally easy to see. The surface of the cervix is normally shiny, smooth and pale pink in colour. The columnar cells that line the uterus and the cervical canal are reddish and more grainy in appearance.

A thin plastic stick with a small brush at the end is used to remove some cells gently from the surface of the cervix. The brush has plastic bristles which are longer in the middle. These bristles are placed into the cervical os. As the brush is rotated round 360°, the shorter bristles splay out and remove cells from the TZ on the surface of the cervix. The brush is rotated around the cervix five times, in a clockwise direction. This is because the bristles have a cutting edge that only works when rotated clockwise. This procedure is not painful. The cells on the brush are then sent to the laboratory.

In older, postmenopausal women, the TZ may be more difficult to see. Often this is because it has been drawn up into the cervical canal. The cervix is also often much smaller. For these women, a different shaped brush (called an endocervical brush) is used to reach the cells in the cervical canal.

Liquid-based Cytology

Liquid-Based Cytology (LBC) is a way of preparing the cervical samples for examination in the laboratory. It has now replaced the traditional smear test in the UK. Two systems for LBC are in use. Both systems use brushes which look similar. In one, the head of the brush that contains the cells is broken off into a pot that contains special preservative liquid. The brush head is sent to the laboratory in the pot (this is the SurePath® brand method). In the other system, the brush is rinsed in the preservative to wash the cells into the pot. The brush is then discarded (this is the ThinPrep® brand). In both methods, the procedure to obtain the cells is the same. It is just how the cells on the brush are dealt with that is different between the two methods. The liquid is sent to the lab where it is spun to separate out the cells from the preservative and other material such as mucus and blood. The cells are then placed on a slide and examined under a microscope.

LBC is now the preferred technique for cervical screening as it is more likely to produce a good set of cells that can be examined under the microscope. With the older smear method, about 1 in 10 tests had to be repeated because cells were not seen clearly or too few cells were present. This was often because of mucus and blood that was also smeared on to the slide. LBC is overall a more reliable test. A repeat test is much less likely to be needed with LBC (about 2 in 100). The LBC slides are easier to examine, speeding up time in the laboratory. This leads to faster results for women.

LBC also gives the opportunity to perform other tests on the same specimen. Tests for human papillomavirus (HPV) are possible on an LBC sample. HPV has been shown to cause cancer of the cervix (cervical cancer). Scientists are currently investigating whether adding HPV testing to the LBC specimen helps doctors to decide who needs treatment and more frequent cervical screening - and, who can have tests less frequently.

Doctors and nurses will still commonly refer to cervical screening tests as smear tests when talking to patients. From a patient point of view it really makes no practical difference how the cells are collected from the cervix; the main part of the examination, using the speculum, is the same.

The NHS Cervical Screening Programme

The NHS Cervical Screening Programme invites all women for regular tests automatically. You need to be registered with a GP, as this is how the programme gets your name. It is therefore important that your GP has correct address details for you. A computer system is used. Your record on the computer is updated when you have a test so it knows when your next one is due. You should get a letter asking you to make an appointment to have a test when it is due. Computerised recall systems are good - but not foolproof. Cervical screening is a free service on the NHS.

  • First invitation for screening in England is at age 25. It is age 20 in Scotland, Wales and Northern Ireland.
  • Routine recall (repeat screening test):
    • Age 25 years: first invitation to cervical screening in England.
    • Age 25-49 years: cervical screening tests are every 3 years. In Scotland, Wales and Northern Ireland cervical screening is 3-yearly from age 20.
    • Age 50-64 years: cervical screening tests are every 5 years.
    • Age 65 years: routine cervical screening ceases.

Women over 65 years of age should be screened if: They have not had a cervical screening test since the age of 50. Or if a recent cervical screening test has been abnormal. (Cervical screening does not stop simply due to age until a woman with a previously abnormal cervical screening test has had 3 negative results).

Results of Cervical Screening Test

Cervical screening tests examine a sample of cells from the cervix. They cannot examine all of the cells. Cell results are called cytology and Cervical cytology results are reported as:

  • Normal.
  • Inadequate.
  • Abnormal. Of which there are several grades or degrees of abnormality:
    • Borderline.
    • Mild dyskaryosis.
    • Moderate dyskaryosis.
    • Severe dyskaryosis.
    • Invasive or glandular neoplasia.

Normal result

About 9 in 10 routine cervical screening tests are normal. You will be sent a letter inviting you for another one in 3-5 years, depending on your age. A normal result means you have a very low chance of developing cervical cancer. It is not a guarantee that cervical cancer will not occur. No screening test is 100% accurate. Some tests will be falsely reassuring (so called false negative results) - where the test is reported as normal but an abnormality is present. This is why it is important to have tests regularly. Cervical cancer takes years to develop from the earliest abnormalities, so there should be plenty of opportunity to detect abnormalities before problems do develop. (It is also possible to have false positive results. This means that a result is incorrectly labelled as abnormal. This can cause a lot of worry, but usually the colposcopy examination will reveal that things are normal.)

Inadequate test

This sometimes occurs, but is far less common now that the LBC technique is used. About 2 tests in every 100 are inadequate and need to be repeated. Inadequate simply means no result can be given as not enough cervical cells were present for examination under the microscope. It might be that the laboratory can only see cells from the vagina or columnar cells from the endometrium, or that there were just too few cervical cells. In the unusual event that a woman has three inadequate tests in a row, the National Cervical Screening Programme advises that she be referred on for colposcopy examination (see under Colposcopy)

Abnormal result

About 1 in 20 tests is reported as abnormal. There is a range of changes that may occur. In nearly all cases, these changes do not mean cancer. Dyskaryosis is a medical term used to describe abnormal cell changes, seen with cervical screening. Dyskaryosis is not cancer. About 9 out of 10 cases of dyskaryosis revert back to normal on their own, without treatment. Nearly all abnormal tests show no more than small changes in the cervical cells. Dependent on the degree of abnormality, women with abnormal results may:

  • Have a repeat cervical screening test at a shorter time interval.
  • Be referred to a gynaecologist or to a colposcopy clinic - for further examination of the cervix +/- treatment. The urgency of this referral depends on the actual result of the cervical screening test.

Borderline Change

Borderline change is the mildest abnormality seen on cervical screening. About 3-4 in 100 cervical cytology results are borderline. Whilst the cells are not quite normal, they are not abnormal enough to be categorised as dyskaryosis.

Mild Dyskaryosis

Mild dyskaryosis is a common abnormal result from cervical screening. It is found that about 2 tests in every 100 show mild abnormalities of the cervical cells. Most of these changes go back to normal without any treatment.

Moderate or Severe Dyskaryosis

For even fewer women, cervical screening will show moderate or severe dyskaryosis. About 6-7 in every 1,000 smear tests show either of these abnormalities. If your smear shows moderate or severe dyskaryosis it is still very unlikely that you will have cervical cancer. The main difference is that these changes are less likely to return to normal by themselves, so you will probably need some treatment. Treatment will happen at colposcopy.

Invasive or Glandular Neoplasia

Less than 1 cervical screening test in 1,000 has one of these, more serious abnormalities. Neoplasia means new growth of cells. Invasive neoplasia on a smear suggests cervical cancer might be present. This is not proven until a sample of cervical tissue (a biopsy) has been taken at colposcopy.

Glandular neoplasia is another significant abnormality that can be seen on cervical screening. It suggests that there is an abnormality in the lining of the womb (the endometrium), rather than on the cervix. This is because glandular cells (found lining the womb) are different to the ones normally found on the cervix. Glandular neoplasia again does not necessarily mean cancer, but cancer needs to be excluded. You will probably need to have colposcopy and may need to have a small camera passed into the womb (called hysteroscopy).

It is important to remember that it is rare for an actual cervical cancer to be found on cervical screening. Remember that screening is designed to find early changes that could become cancer in the future, if left untreated.

Colposcopy

Colposcopy is a more detailed examination of the cervix. In this test a speculum is gently put into the vagina so the cervix can be seen. This part is exactly the same as for a cervical screening test. The doctor (or specialist nurse) uses a magnifier (colposcope) to look at the cervix in more detail. The actual colposcope does not go inside your vagina. A liquid is used to paint the cervix which shows up the abnormal cells. It takes longer than a normal cervical screening test (about 15 minutes). It is usually done in a specialist colposcopy clinic at hospital. During colposcopy it is usual to take a small piece of tissue from the cervix (biopsy) to make a more detailed assessment of the cells.

You may be referred for a colposcopy if you have one of the higher grades of abnormality on your smear test (usually moderate/severe dyskaryosis, invasive or glandular neoplasia). You may also be referred for colposcopy if you have had three inadequate or borderline results in a row or if you have had three abnormal results (of any grade) within a 10-year period. The laboratory that reports the cervical screening results will determine what action needs to be taken (based on the current result and your past results). Either the laboratory will refer you directly to colposcopy, or they may ask your GP to make this referral. This happens quite commonly, so you should try not to be too alarmed. Remember that in most cases, an abnormal cervical screening test does not mean you have cervical cancer. It is rare for cervical cancer to be diagnosed this way.

Before your colposcopy

You should receive written information about the procedure in advance of your appointment. If there is anything you don't understand you can either ring the clinic directly, or discuss this with your GP. There are some things that you should think about before your colposcopy that can help you prepare:

  • Some clinics prefer not to perform colposcopy whilst a woman is having her period. This is because it can be difficult to get a good view of the cervix if there is a lot of blood. Also, some women may prefer not to have an intimate examination whilst bleeding. If your period starts and you anticipate you will still be bleeding when you have your appointment, it is probably best that you telephone the clinic for advice. In some cases your appointment may be rearranged. Do not feel embarrassed about this - it is completely out of your control, and colposcopy clinics are very used to this sort of thing.
  • You should avoid sex and not wear a tampon for 24 hours before your colposcopy.
  • You should not use any vaginal creams or pessaries for 24 hours before your colposcopy This includes lubricants, thrush treatments, douches and spermicides.
  • Some people find the colposcopy examination a little uncomfortable. For this reason, you may choose to take some paracetamol about an hour before your appointment.
  • You may want to wear a loose, full skirt on the day of your colposcopy so that you do not have to remove all of your lower clothing.
  • It is often a good idea to bring someone with you who can take you home after your colposcopy. This is most important if the clinic has told you that you may have treatment at your first appointment. They do not have to come into the examination room with you (but if you do want a friend or relative with you during your examination this is also possible).

Colposcopy Procedure

The whole procedure normally takes about 15-20 minutes. It may be longer if you have treatment at the same time (see below). It is best to allow an hour for the whole visit:

  1. The doctor or nurse will usually start by asking you some questions. These may include information about your periods, the date of your last period, what contraception you use and your general health. You will then be prepared for colposcopy examination on a couch.
  2. The doctor or nurse will then look through the colposcope to get a good view of your cervix. The colposcope itself does not go inside your vagina. It is essentially like a big pair of binoculars on a stand that can be moved around. There is also a light to help see inside your vagina. Sometimes, the colposcope can be attached to video equipment so that the examination can be viewed more clearly on a TV screen. This means that you have the opportunity to watch too (but only if you would like to!).
  3. A long swab (like a fat cotton bud) is used to apply liquids to the cervix. These liquid stain any abnormal cells that may be present. Two different liquids are normally used - acetic acid (like vinegar) and iodine.
  4. A biopsy (a small sample of tissue) from your cervix may also be taken. This will be sent to the laboratory for further examination. The biopsy is only about the size of a pinhead, but taking it can be slightly uncomfortable. If this is anticipated, local anaesthetic is usually used to numb the cervix first.
  5. Sometimes it is suggested that you have treatment at your first colposcopy visit (see below). However, often, you may be asked to return for treatment once the biopsy results are back.
  6. It is worth bringing a sanitary towel or panty liner with you, to use after your colposcopy. It is unlikely you would have much bleeding, but you might have some discharge or staining from the iodine used in the examination. There is more likely to be discharge or bleeding if you have had a biopsy or treatment.

After your Colposcopy

After your colposcopy you can usually return to work or carry on with your normal day. You are likely to have a small amount of bleeding, especially if you have had a biopsy. This can last for three to five days and you should wear a sanitary pad. Do not use tampons. You should not have sex or use vaginal creams or pessaries until the bleeding has stopped. Generally you should wait for five days. You may notice a dark fluid-like material on the pad. It is sometimes green or looks like coffee granules. This is normal and is the liquid that is painted on to your cervix during the examination.

Risks or Complications of Colposcopy

Colposcopy is generally a safe procedure. Some women find that it is a little uncomfortable. Rarely, complications can occur. These can include heavy bleeding and infection. If you experience any heavy bleeding, smelly vaginal discharge or severe lower abdominal pain, you should see a doctor as soon as possible.

The Biopsy Results

When a biopsy is taken, the sample of tissue is sent to the laboratory for further examination under a microscope. The cell abnormality that can be seen is called cervical intra-epithelial neoplasia (CIN). There is a scale from 1 to 3 according to the number of cells in the biopsy sample affected by CIN. In CIN1, only a few (1 in 3) cells are abnormal. In CIN3, all of the cells are abnormal. Rarely, a biopsy can show changes in your cells that have already developed into cancer. About 6 in 10 cases of CIN1 return to normal without treatment, but 1 in 10 progresses to CIN3. Only 1 in 100 cases of CIN1 becomes cancer (and this is over a long time). CIN2 and 3 still mean it is very unlikely you have or will develop cervical cancer. However, these changes are much less likely than CIN1 to get better on their own, without treatment. So, if CIN2 or 3 were found on your biopsy, you are likely to need treatment of these abnormal cells on your cervix. Remember that the whole point of cervical screening (and subsequent examination/treatment of abnormal cells at colposcopy) is to prevent cervical cancer. This is by detection and treatment of early changes in the cells, which, if left untreated or unchecked for some years, could develop into cancer.

Treatment Options

There are a number of different treatments available for CIN. The aim of the treatment is to destroy or remove all of the abnormal cells on your cervix without affecting too much normal tissue. Most treatments can be done as an outpatient, at colposcopy. The treatment may cause a little discomfort, perhaps similar to a period pain. The treatment that you have will depend on the extent of your abnormality as well as what treatment the clinic has available and the preference of the doctor or nurse. Treatment options include:

  • Loop diathermy: a thin wire loop cuts through and removes the abnormal area of cells. This is also known as a large loop excision of the transformation zone (LLETZ). It is the most common form of treatment used in the UK.
  • Cryotherapy: freezing the affected area of the cervix, which destroys the abnormal cells.
  • Laser treatment: this destroys or cuts away abnormal cells.
  • Cold coagulation: a heat source is used to burn away and remove the abnormal cells.

A local anaesthetic is usually given before any treatment, to numb the cervix. The treatment is normally very straightforward and quick. There is a small risk of bleeding at the time of treatment. Occasionally, the doctor or nurse may suggest that you have a cone biopsy (see Cone Biopsy) or, very rarely, a hysterectomy (removal of your uterus and cervix) as a treatment for CIN. If this is the case, you will need to be admitted to hospital.

After Treatment Care

You may have some mild discomfort, like a period pain, after your treatment. Painkillers such as paracetamol may help to ease the pain.You are likely to have some bloody vaginal discharge. This can last up to six weeks. It is like the blood loss during a period. If you are worried that it is too heavy,or if it becomes smelly, then see your usual doctor. You should use sanitary pads and not tampons. You should avoid sex and not do any heavy exercise until the discharge has stopped.

Follow-up Plans

This depends on the results of your colposcopy and whether you needed any treatment. Some women may need a follow-up colposcopy examination. Other women may just need a follow-up cervical screening test, usually after about four months. The doctor or nurse who performs your colposcopy will advise what follow-up you will need. Most colposcopy clinics will see you again four to six months after your first examination or treatment. If all is well at your follow-up appointment, you will be given advice about when you should have your next cervical screening test. This test can be carried out by your usual clinic or GP surgery. You will usually be advised to have a cervical screening test every year for a number of years (often 10 years if you had CIN2 or 3). If you have any further abnormal cervical screening test results you may need to have another colposcopy examination. Treatment of CIN is usually almost 100% effective. In the vast majority of women, it is unlikely that CIN will come back.

HPV Testing (The Future of Cervical Screening)

The Sentinel Implementation Project is being run by scientists interested in the usefulness of HPV testing on LBC samples taken for routine cervical screening. It is being carried out at 6 centres in England. HPV tests are being done on two groups of women:

  1. Women who have a borderline or mild dyskaryosis result on cervical screening. This is being called HPV triage. The idea is to reduce the number of repeat tests a woman needs to have, and to reduce the anxiety of being called for colposcopy unnecessarily. Both of these cause women a lot of worry. Only about 1 in 5 of these women ends up needing treatment for abnormal cells. The idea is to test these women for HPV. If a woman does not have a high-risk strain of HPV (that is, a strain proven to be associated with the development of cervical cancer), she is very unlikely to need treatment. These women could continue with routine screening. Women found to have high-risk strains of HPV would have immediate colposcopy.
  2. Women who have had treatment for CIN at colposcopy. Here the HPV testing would be a test for cure. After treatment, a repeat cervical screen would be performed, and tested for abnormal cells (as routine) and HPV. If both tests were negative (ie, no abnormal cells and no HPV), women could return to the normal screening programme (instead of needing yearly smears for 10 years).