*7.1.1. Colposcopy procedure*

years PAP smear alone every three years smear screening alone every 3years with termination of screening at the age of 65 years if still negative. High-risk patients such as off springs of mothers exposed to diethylstilbestrol, immunosuppressed patients, and patients with CIN2 or higher who had been treated are however advised against following the routine screening

Patients who had had hysterectomy and had never had any CIN2 or greater can have discon‐

This method is an innovation to improve the sensitivity of the conventional pap smear where samples are suspended in liquid media, centrifuged to concentrate the exfoliated cells which are subjected thereafter to cytology. The Food and Drug Adminstratio in the USA approved Thinprep and BD Surepath in the years 1996/1999 for the purpose of analyzing cytology

The superiority of this screening method is based on improved cell collection and the random distribution of cells collected which is more representative. This method reduced the propor‐ tion of unsatisfactory smears in a study by(Ronco et al, 2007, Arbyn et al 2008) but did not show improved sensitivity instead has a low predictive value to detect CIN 2 and above relative to the traditional Pap smear. A cost analysis also revealed increased cost relative to

In areas with limited resources a resort to inspection of the cervix have assisted in the screening process without application of acetic acid (unaided). When the cervix is painted with 3-5% Acetic acid it causes reversible coagulation of nuclei proteins and prevention of the penetration of light hence abnormal tissues appearing as "aceto-white areas". This has been used with good outcome in areas like India and other less developed countries where there are absence of technical manpower such as pathologist to analyze cytology specimens. This method is simple easy to perform, cheap and acceptable by most patients and can be done by nurses, paramedics amongst others and removes the need for histological confirmation. The method enables a one stop treatment of suspected cases of premalignant lesions however there is the danger of overtreatment of postmenopausal patients when this method is applied because of non visualization of the transformation zone. This screening method has similar sensitivity to PAP but lower specificity of 64-79%. Visualization of the cervix can be aided by the use of a X4 magnification glass (Aviscope) and is said to have better sensitivity compared to VIA

Following the invention of an optical device by Dr Hans Hinselmenn in 1925, the visualization of the cervix using the colposcope is now an integral part of gynaecological oncology prac‐

guidelines for low risk patients.

132 Contemporary Gynecologic Practice

**6.1. Liquid based cytology**

Pap smear (De Jager et al 2013).

**7.1. Colposcopy**

**7. Visual inspection using acetic acid**

samples.

tinuation of screening using the Pap smear or HPV testing.

With patient in lithotomy position the cervix is exposed using a bivalve speculum allowing macroscopic examination of the cervix. The exposed cervix is subsequently painted with 3-5% acetic acid. This causes a reversible denaturing of the cellular protein the abnormal cells producing the "acetowhite reaction" of cervical intraepithelial neoplasm. The complete visualization of the squamocolumnar junction is important in this procedure because it tells the extent of anomaly of the lesion. Where there is failure of complete visualization of the SCJ the colposcopy is said to be unsatisfactory. Abnormality patterns in colposcopy include: punctuations, mosaicism and abnormal vessels

When colposcopy is used as a screening method for asymptomatic patients it is known to have a poor sensitivity of 34-43%, a specificity of 68% and a positive predictive value of 4-14% hence should not be used a primary screening method for this group of asymptomatic patients (Nidhi G et al 2009).The method of screening is relatively easy to perform with the added advantage of doing it as an office procedure but had the disadvantage of cost of equipment and the time in training a Colposcopist.

#### **7.2. Cervicography**

The absence of skilled colposcopist will hamper the use of colposcopy hence in most devel‐ oping countries the use of the cervicograph have been shown to effectively identify up to 90% of lesions identified by colposcopy. The procedure involves taking two photographs using a specialized camera that develops the slides into 35mm size. Developed images can be subject to comparison from a computerized bank of pictures or reviewed by other colposcopist contacted by possible telemedicine.
