1. Method of triage


2. Indications for referral


3. Superficial ablative therapy


4. Conization


5. Further follow-up

Method of triage
At the initial follow-up visit the results of the colposcopy are discussed and an appropriate treatment plan is formulated. Here follows a method of triage:

Indications for referral
Indications for referral include the following:

• A positive endocervical curettage (ECC)

 
• Lack of correlation among cytology, colposcopic findings, and histology

 
• Lesion not found on colposcopy

 
• Severe dysplasia, carcinoma in situ (CIS), or microinvasive carcinoma on cytologic or histologic examination

 
• Unsatisfatory colposcopy or evaluation
• Entire transformation zone (TZ) not seen
• Severe inflammation or atrophy
• Cervix or entire lesion not visualized
• Negative evaluation after significant abnormality on cervical or vaginal cytologic examination


• Suspected adenocarcinoma

 
• Complex lesion

 
• Recurrence of confusing lesion after cone biopsy, laser therapy, cryotherapy, or electrocautery

Superficial ablative therapy
Destructive methods of treatment may be used in the following circumstances:

1. The presence of mild or moderate dysplasia
2. A small lesion
3. A smooth lesion
4. A purely ectocervical location
5. When the entire squamocolumnar junction is visible

Local treatment such as cryotherapy should be avoided if:

1. A discrepancy exists among cytology, colposcopy, and colposcopic-directed biopsies
2. Multifocal involvement is evident
3. Severe dysplasia, CIS, or more advanced lesions such as invasive carcinoma are suspected
4. The ECC reveals a pathologic condition

Nitrous oxide or carbon dioxide can be used via cryoprobe and has an 80% to 85% success rate. Local therapy leads to cell rupture, cell protein denaturation, and cell destruction. Other superficial ablative treatment modalities include electrocoagulation and laser therapy.

Method of conization
Conization is indicated when:

1. Multifocal involvement is found
2. Severe dysplasia or CIS is present
3. Endocervical disease is suspected
4. Discrepancy exists among cytology, colposcopy, and findings on biopsy

If a negative colposcopy follows a minor cytologic abnormality (atypical squamous cells of undetermined significance, low-grade squamous intraepithelial lesion), conservative follow-up with repeat Papanicolaou (Pap) smears and if necessary colposcopy may be adequate. If however the abnormal cytology was significant, however, a diagnostic conization may be needed.

Conization can be viewed as both diagnostic and therapeutic in certain cases. If complete excision is achieved (e.g., by means of a loop electrical excision procedure) and the disease is found to be purely intraepithelial, nothing further need be done, except for careful follow-up via cytology and colposcopy. In incomplete excisions, positive margins are found. If the ectocervical margin is involved, follow-up colposcopy is reliable. When the apex of the cone is involved, cytologic follow-up should be supplemented by periodic ECCs.

The preservation of the uterus for future fertility purposes must be carefully weighed against the risks of potential disease recurrence or progression.

Further follow-up
The further follow-up of women after colposcopy depends on the findings, the risk factors, the treatment prescribed, and the interval of testing recommended by the clinician. If ablative or excisional therapy is performed, the patient must be reevaluated post treatment to determine therapeutic cure and to assess the need for possible further or future interventions.

Many colposcopists assess posttreatment patients by both cytology and colposcopic examination. Repeat Pap smears are generally scheduled every 3 to 4 months during the first year following diagnosis and treatment. It may be prudent to perform at least one colposcopic exam during the first postoperative year. Women who have had positive endocervical treatment margins following excisional therapy may need repeat ECCs. Whereas residual disease is any neoplasia detected by cytology, colposcopy, or biopsy during the first year after treatment, recurrent disease is defined as any neoplasia found after that interval.

Click here for a further description of the present cytologic classification system.