Cervical cancer screening

-Automatic translation

A colposcopy is a microscopic examination of the cervix, performed if abnormal cells are detected in the cervical smear. Abnormal cells are most often caused by HPV infection. Mild pre-stage changes often disappear spontaneously without treatment, and therefore, monitoring after 6-12 months is sufficient. However, if this does not happen, or if there are high-grade abnormal cervical cells in the smear, a colposcopy is required for further diagnosis. During colposcopy, the cervix is examined and the spread of abnormal cells is investigated. Biopsies are also taken for histological analysis. The biopsies are taken from areas that show abnormal cells.

How is a colposcopy performed?

Colposcopy does not require anesthesia or sedation. The physician performs the examination, which will take about 15-20 minutes. The woman undergoes a routine gynecological examination, the cervix is examined and samples are taken.

As a general rule, it takes about 7-10 days to get the results of a colposcopy. A decision is then made as to whether a cone biopsy is needed. Ideally, colposcopy should be performed by those who have received special training. As of 1 January 2021, Landspítali and Akureyri Hospital (SAK) will mostly take care of colposcopy in Iceland.

Referrals to colposcopy

Colposcopes are performed at the Landspítali University Hospital, the Akureyri Hospital, and at some gynecologists' clinics. The Cancer Screening Coordination Centre and gynecologists send a referral for a colposcopy.

A referral to Landspítali University Hospital is sent from Heilsugátt. The referral should include the patient's phone number and e-mail address, together with the results of the last cervical sample (cell sample, HPV test), the date of the last cervical sample, and the reason for the colposcopy. If there is a request for an examination under anesthesia, this must be stated in a referral.

A referral to Akureyri Hospital must be sent by mail to the Department of Gynecology. Eyrarlandsvegur. 600 Akureyri.

Waiting time for colposcopy

• 2 weeks
  Symptomatic women, medical indication
  Suspected invasive cancer
  AIS

• 6 weeks
  HSIL (moderate and severe)
  ASC-H
  AGC

• 12 weeks
  LSIL
  ASCUS
  Persistent hr-HPV, cell sample normal
  Persistent inadequate sample for analysis

Follow-up after colposcopy

Monitoring of CIN (SIL, Squamous intraepithelial neoplasia)

The recommended follow-up after colposcopy and biopsy should always be based on the clinical assessment and medical history of the patient. These instructions are for reference.

Women with low-grade intraepithelial lesions or less (LSIL, ASCUS, persistent hr-HPV, persistent inadequate samples)

Colposcopy result:

1. Colposcopy satisfactory, examination normal, biopsy without pre-stage changes/CIN 1 biopsy

• Follow-up in 12 and 24 months with cervical biopsy for HPV testing

• If hr-HPV is negative at 12 and 24 months, a woman will return to routine screening based on her age.

• If hr-HPV is positive either at 12 or 24 months, a cytologic evaluation is performed

  • Cytology is normal, a follow-up with a cervical sample monitoring for HPV status in 12 months

  • Cytology with cellular abnormalities

    • Referral to colposcopy

2. Colposcopy satisfactory, examination of high-grade change, biopsy ≥ CIN 2

• Cone biopsy

• Monitoring of CIN 2, see the section on monitoring of CIN 2

3. Graphical overview - Flow chart 1

Women with a high-grade intraepithelial lesion (HSIL (moderate/severe), ASC-H)

Colposcopy result:

1. Colposcopy satisfactory, examination normal, biopsy without cellular abnormalities, or CIN 1

• Follow-up in 6 and 12 months with cervical biopsy for HPV testing

• If the cell sample is normal and hr-HPV is negative, a woman will return to routine screening based on her age.

• Abnormal cells and/or hr-HPV positive

  • Referral to colposcopy

2. Colposcopy satisfactory, examination of high-grade change, CIN 2/CIN 3: biopsy.

• Cone biopsy

• Monitoring of CIN 2, see the section on monitoring of CIN 2

3. Graphical overview - Flow chart 3.

Monitoring of CIN 2

Follow-up with colposcopy, cytology, and HPV testing every 6 months.

Can be offered to women of childbearing age who have not started having children and are considering having children in the future if:

• Colposcopy is satisfactory and no CIN 3 or invasive growth has been detected.

• CIN 2 changes in less than 2 quarters of the cervix

• CIN 2 biopsy confirmed

• The woman agrees to follow up every 6 months with colposcopy and cervical biopsy

• The woman understands that the time for CIN 2 changes to disappear can be 24 months

• If CIN 2 remains at follow-up after 24 months, a cone biopsy is recommended

Monitoring of AGC and AIS

The recommended follow-up after colposcopy and biopsy should always be based on the clinical assessment and medical history of the patient. These instructions are for reference.

A colposcopy and cervical biopsy (cervical scraping for tissue analysis or cytobrush test). Samples are sent to Landspítali's pathology department for analysis.

Women over 40 years old and women with risk factors for endometrial cancer (e.g. obesity) should be assessed for vaginal ultrasound and an endometrial biopsy may be performed.

Women with AGC in cytology

Colposcopy result:

1. Colposcopy satisfactory, examination normal, biopsy normal/CIN 1

• Follow-up in 12 months with colposcopy, cytology, and HPV testing at 12 months

  • Colposcopy normal, no abnormal cells, and hr-HPV negative

  • Cytologic evaluation and HPV testing at 12 months and 24 months

  • h-HPV positive and/or abnormal cells

• Referral to colposcopy

  • hr-HPV negative and no abnormal cells

  • A woman returns to routine screening based on her age

2. Colposcopy satisfactory, biopsy ≥ CIN 2

• Cone biopsy

  • Colposcopy satisfactory, biopsy with abnormal cells in epithelial neoplasia or AGC in cytobrush test

• Cone biopsy

  • Colposcopy satisfactory, AIS biopsy

• Cone biopsy

  • Colposcopy unsatisfactory, regardless of biopsy results

• Cone biopsy

3. Graphical overview - Flow chart 2.

Women with AIS in cytology

Colposcopy should be performed to assess squamous cell changes that often accompany AIS.

Irrespective of the outcome of colposcopy, a cone biopsy should be performed.