Sex & fertility

Further intervention —

• colposcopy
• endocervical curettage (ECC)
• endometrial biopsy
• genital wart removal

At Women to Women, we want to stress to our patients and readers who have received an abnormal Pap test result that the purpose of follow-up monitoring is to safeguard their reproductive health. It can be such a source of such frustration for women when they are unsure as to why they’re being asked to return for repeat Pap tests or colposcopy.

We want you to consider repeat Pap smears and further screening methods as tools for monitoring how well your immune system is protecting your reproductive health, and to view follow-up procedures as a means of preventing any deterioration of your cellular health into something more concerning. When you have the information you need to reverse damaging change at a cellular level, you are better able to rally your natural ability to heal.

Colposcopy and endocervical curettage (ECC)

Colposcopy of the cervix, which usually includes ECC, is the most common procedure that women undergo after an abnormal Pap. I often tell my patients that Pap smears are what we use to find the women who need colposcopy. Where the Pap is a screening tool, focusing a practitioner’s attention, the colposcopy is diagnostic and more specific.

Colposcopy typically involves a second component, where the ecto-(outer)-cervix and/or endo-(inner)-cervix are biopsied. In this procedure the clinician uses a magnification lens (the colposcope) to view the cervix for cellular changes and locate sites appropriate for biopsy. The biopsy procedure entails the removal of a tiny piece of tissue that is then sent for more detailed analysis by the lab. Sometimes more than one biopsy sample is taken, or none at all.

The colposcopy generally includes an ECC, in which the endocervical canal is scraped more vigorously than in a Pap test. The samples are placed in jars of fixative and sent to the lab. A diagram of the cervix is kept in the woman’s chart to document where the samples were taken from. Some clinics also use digital photographs to keep an accurate record.

Quite often a biopsy will show no further concerns and the woman can return to Pap test screening — usually at shorter intervals at first. Sometimes the biopsy tells us that HPV is causing cellular changes right now that warrant further monitoring or intervention. The changes on biopsy could be more severe than estimated on initial Pap test. The pathology from the colposcopy is considered diagnostic, so the colposcopy findings trump what was found on the Pap test.

If a woman has been found to have a high-risk strain of HPV, we may also need to take a look at the outlying ruggae (folds) of her vagina, as well as the vulva, to evaluate the need for more intensive HPV treatment on the vaginal walls and vulva.

Endometrial biopsy

Endometrial biopsy can be described as somewhat of a deeper Pap smear, except in this procedure the clinician collects cells from the inner lining of the uterus instead of just the tip of the cervix.

There are many scenarios that indicate the need for an endometrial biopsy, such as abnormal glandular cells (AGUS) on a Pap smear. Endometrial biopsy is also commonly recommended for women over 35 with any unusual bleeding, spotting, changes in their menstrual cycle patterns, or a thickened endometrium seen on pelvic ultrasound.

In this procedure a sterile straw is passed through the cervix to the inside of the uterus to collect a sample of cells from the inner lining of the uterus (womb). Then the straw is removed, and the collection of cells placed in jar of fixative and sent to the lab. Further management of biopsy findings beyond normal cells is complex and depends on the individual situation.

The results of a colposcopy/ECC or an endometrial biopsy dictate what may be needed next and at what interval. While we can also use HPV typing results to help guide our recommendations for follow-up, this information is less definitive than what cellular pathology can tell us. Follow-up HPV testing can help us track a woman’s immune response. Even when an HPV test turns from positive to negative, however, this does not signify that HPV is no longer present — it is more the case that her immune system has shut down the flare-up. What this does reveal is that the immune system is doing its job, and that is always good news.

Genital wart treatment

When it comes to genital warts, a woman’s treatment options vary both according to location and extent of the warts. In many cases, external warts can be treated by the patient, under the guidance of her care provider, using a regime of topical cream application. More extensive external warts are often treated directly by the provider with a range of topical or surgical treatments. Repeat treatments are sometimes needed as well.

Depending on her GYN provider’s experience, a woman with internal warts may be referred on to see a specialist for consultation and treatment. Again, treatment is based on the location and extent of the warts, but vaginal, cervical, or urethral warts are often treated with either cryotherapy or a number of topical choices. Anal warts may also be treated with these options, or they may require laser vaporization or other surgical removal. The patient may need repeat treatment in some cases.

As in all fields, technology is rapidly advancing to afford us a wider range of choices. Topical treatment of genital warts with imiquamod (Aldara) is now becoming the treatment of choice in many clinics. Aldara works as an immune system modulator, increasing the immune response and thereby decreasing virulence of the HPV. Trichloroacetic acid (TCA) and bichloroacetic acid (BCA) are also still widely used, and other developments showing promise in genital wart treatment include laser vaporization and ultrasound. According to many experts, the effect of TCA, cryofreezing, and laser therapy is largely a “cosmetic” one — that is, the warts are visibly gone but there is no guarantee the HPV at the site will be eliminated. Granted, anything that improves patient comfort and convenience represents an advancement. But it’s the immune system that holds the key.

We understand that circumstances vary widely from woman to woman, including her personal preferences, her practitioner’s range of experience, and other resources she may or may not have available to her. In providing this information, we hope to guide you as you work with your practitioner in planning the ideal treatment for your unique situation.

For additional information on abnormal Pap smears and HPV, please read our full article. You may also be interested in a list of Pap test acronyms commonly used to describe abnormal Pap test results.

 

Last Modified Date: 04/19/2011
Principal Author: Marcy Holmes, NP, Certified Menopause Clinician