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The cervix is located at the end of the vagina and is the opening of the uterus. Invasive cancer of the cervix is frequently visible. Precancerous changes are usually invisible to the unassisted eye.
Pap smears are used to screen for cancerous and precancerous changes. When abnormalities are found, colposcopy with directed biopsies can provide a definitive diagnosis.
This patient’s Pap smear showed atypical squamous cells of undetermined signficance, or ASCUS. When the atypia persisted, she was brought into the office for colposcopic evaluation.
I started by positioning her at the end of the exam table, inserting a vaginal speculum, and visualizing the cervix. I sprayed her cervix with 4% acetic acid. This sometimes causes mild stinging. The acetic acid can bring out colposcopically useful patterns such as acetowhite epithelium, and mosaic. These images show the effect of acetic acid on this patient’s cervix. In another patient, the change from an invisible lesion to a visible lesion is dramatic.
The colposcope has adjustable magnification, binocular vision, and a powerful light source. Either normal light, or red-free light can be used.
After carefully evaluating the exocervix with a colposcope, I turn my attention to the endocervical canal. This is important to make sure that I’ve seen the proximal extent of any visible lesion. An endocervical speculum can help me in viewing the endocervix.
Next, I use an endocervical curette to sample the endocervical canal. The endocervical curettage usually creates a small clot. This clot is a rich source of endocervical cells from my biopsy specimen. I retrieve the clot using long forceps.
Then I take exocervical biopsies of any suspicious areas I’ve identified during my colposcopic exam. I make sure that I’ve biopsied the most suspicious areas. Suspicious areas would include acetowhite epithelium, mosaic changes, abnormal vessels, or exophytic lesions. In this patient I took three biopsies of the exocervix. In other patients, I might take more, or fewer, or none.
Monsel’s Solution does a very good job of stopping oozing from the biopsy sites. The solution is essentially iron with quite a bit of air whipped into it. It is sticky and tenaceous, and over time, turns gritty black.
This patient continued some minor oozing, so I applied a second coat of Monsel’s Solution. I told the patient she could expect a little bit of bleeding and a gritty black discharge for the next several days. I then applied direct pressure for about a minute to achieve complete hemostasis.
The pathology report showed only chronic cervicitis, as I suspected from my colposcopic evaluation. I asked her to return in another 6 months for another Pap smear.