Follow up Pap tests (following abnormal Paps, high risk HPV infection, and cervical dysplasia) are now performed at no less than 1 year intervals. There are only rare exceptions to this Pap screening interval and they are beyond the scope of this 3rd year level of training.

The cervix is located at the end of the vagina at the opening of the uterus.

Invasive cancer of the cervix is frequently visible. Pre-cancerous changes are usually invisible to the unassisted eye.

Pap smears are used to screen for cancer and pre-cancerous 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 significance, or ASCUS. When the atypia persisted, she was brought into the office for colposcopy evaluation.

I started by positioning her at the edge of the exam table, inserting a vaginal speculum and visualizing the cervix. I sprayed her cervix with 4 percent acetic acid. This sometimes causes mild stinging. Acetic Acid can bring out colposcopically useful patterns such as aceto white epithelium and mosaic.

These images show the effect of the 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 the colposcope, I turned 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 curette usually creates a small clot, this clot as a rich source of endocervical cells from my biopsy specimen. I retrieved the clot using long forceps.

Then I take exocervical biopsies of any suspicious areas I’ve identified during my colposcopy exam. I make sure that I have biopsied the most suspicious looking areas. Suspicious areas would include acetowhite epithelium changes, mosaic patterns, abnormal vessels or exophytic lesions.

In this patient, I took three biopsies of the exocervix and in other patients I might take more or fewer or none.

Monsel solution does a very good job of stopping oozing from biopsy sites. The solution is essentially iron with quite a bit of air whipped into it. It is sticky and tenacious 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 colposcopy evaluation.

I asked her to return in six months for another pap smear.