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LETTER TO EDITOR
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 263-264  

Colposcopy postmenopause: A challenge in cervical cancer elimination goal!


Sri Ram Cancer Centre, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, Rajasthan, India

Date of Submission26-Jul-2022
Date of Decision29-Jul-2022
Date of Acceptance04-Aug-2022
Date of Web Publication14-Jan-2023

Correspondence Address:
Ranu Patni
14 Gem Enclave, Pradhan Marg, Malviya Nagar, Jaipur - 302 017, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmh.jmh_138_22

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How to cite this article:
Patni R. Colposcopy postmenopause: A challenge in cervical cancer elimination goal!. J Mid-life Health 2022;13:263-4

How to cite this URL:
Patni R. Colposcopy postmenopause: A challenge in cervical cancer elimination goal!. J Mid-life Health [serial online] 2022 [cited 2023 Jan 26];13:263-4. Available from: https://www.jmidlifehealth.org/text.asp?2022/13/3/263/367752




   Introduction Top


Colposcopy was first described by Hans Hinselmann of Germany in 1925 as a screening tool for cervical cancer.[1] Somehow, it did not gain much importance for a few decades but started gaining popularity in the 1960s. Currently, it has near-universal acceptance as the most effective follow-up test for women suspected of having premalignant or malignant cervical lesions. Its judicious use can result in a marked reduction in unnecessary surgical procedures. Changing physiology after menopause poses certain challenges in performing colposcopy. Hence, it is essential to be aware of these challenges and their possible solutions.

Colposcopy is indicated when the presence of a malignant or premalignant lesion in the cervix, vagina, or vulva is suspected or when an unusual cervical lesion is detected on inspection of the vagina and cervix for an unrelated reason.[2] The above is mostly encountered as abnormal pap smear which is reported by 2001 version of the Bethesda system.[3]

In 2020, the ASCCP updated its 2012 management guidelines for abnormal cervical cancer screening results, with input from 19 stakeholder organizations including ACOG.[4] Salient indications for colposcopy according to these guidelines are as follows:

  • Recommendations for colposcopy, treatment, or surveillance are based on the patient’s risk of cervical intraepithelial neoplasia (CIN) 3+ Colposcopy can be deferred for certain patients such as those with minor screening abnormality indicating human papillomavirus (HPV) infection with a low risk of underlying CIN 3+
  • Because HPV 16/18 poses the highest risk of CIN3 and occult cancer, further evaluation (e.g. colposcopy with biopsy) is needed even if cytology results are negative
  • If HPV 16/18 is positive and further testing of the same sample is not available, colposcopy is the next step.


Contraindications:

  • No absolute contraindication
  • Special precaution is needed in pregnancy with placenta praevia. Pregnancy per se is not a contraindication
  • Active cervicitis and vulvovaginitis should be treated before doing colposcopy
  • Patient’s inability to tolerate a standard per speculum examination is the only true limiting factor.


Complications:

  • Infection
  • Bleeding
  • Inadequate or inaccurate evaluation is the most worrisome complication as it may lead to missed diagnosis of invasive cancer. This can lead to treatment delays and poorer outcomes.


The performance of colposcopy in the postmenopausal woman is conducted in the same manner as for other nonpregnant women. Current guidelines do allow for HPV testing or repeat cytology in postmenopausal women with a cytology finding of low-grade squamous intraepithelial lesion (LSIL), recognizing the lower risk of cervical pathology in older women with historically negative cervical cancer screening.[5] In postmenopausal women, the squamocolumnar junction is more often located in the endocervix, thereby resulting in the unsatisfactory colposcopic examination.[6]


   Physiological and Pathological Variations Top


A report by Castle et al. indicates that the Xpert HPV assay is a sensitive and reliable diagnostic tool for detecting hr HPV DNA as well as grade 2 or greater CIN in a colposcopy referral population.[7] Dogan and Guraslan prospectively studied 1658 women (77.7% pre- and 22.3% postmenopausal) and concluded that conventional cytology has less efficiency in detecting the precancerous lesions in postmenopausal cases; therefore, the colposcopic examination may be appropriate in postmenopausal women.[8]

The hormonal changes developing in the postmenopausal period, especially hypoestrogenism, causes atrophy of the genital organs and atypical finding in cervical cytology. The possibility of inadequate colposcopic examination increases as the transformation zone recedes inside the endocervix and cannot be evaluated due to genital atrophy.[9] The benign degenerative changes in the immature squamous cells connected to hypoestrogenism, obvious atrophy can imitate squamous intraepithelial lesions and noninvasive cancer in postmenopausal women.[10]

Dogan and Guraslan also found that ASCUS/LSIL ratio in postmenopausal patients was 4.07, and in the premenopausal group, it was 2.8. LSIL in premenopausal group and HSIL in postmenopausal group were significantly high.[8] There are studies suggesting that local estrogen therapy can distinguish the real preneoplastic changes from benign cytologies imitating atrophy by decreasing vaginal atrophy.[11] There are also studies suggesting that HRT can cause artifacts mimicking LSIL by increasing glycogenation.[12]

Local estrogen therapy was recommended for postmenopausal women in 2006 ASCCP consensus, this proposal was withdrawn in 2012.[13] Studies suggest that abnormal cervical cytology predicts the precancerous lesions less frequently in postmenopausal women than in premenopausal women due to epithelial changes in atrophy.[14] Considering the failure in the application of effective cervical cancer screening programs in postmenopausal women, it will be appropriate to direct the abnormal cervical cytology detected cases to colposcopy.[8]

Challenges:

  • Vaginal atrophy leads to difficult speculum insertion. Lack of lubrication makes instrumentation painful. A condom worn as a sleeve over the speculum might help
  • Cervical Os contracts and becomes smaller and tighter. It becomes difficult to view endocervix and squamocolumnar junction. An endocervical speculum might be helpful. However, endocervical sampling is required. Excisional procedure might be needed
  • Glandular abnormality is difficult to assess as glandular tissue also moves up into the canal. Directly cone biopsy/loop electrosurgical excision procedure might be required
  • Thinner cervical tissue due to reduced estrogen levels makes the vascular network prominent during colposcopy. These vessels can mimic the atypical vessels of cancer. Thinner cervical surface tissue may cause the cervix to appear “shiny” and lead to multiple biopsies which should ideally be avoided.


Hence, the indications, the procedure itself, and the management by colposcopy might be a challenge in postmenopausal women, and individualization might be needed for adequate diagnosis and treatment of cervical precancerous and early cancerous lesions in this group of women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Noller K, Wagner A.Jr., Colposcopy, Sciarra JL, ed. Gynecology and Obstetrics. Philadelphia, Pa: Lippencott, Williams and Wilkins; 2000:1.  Back to cited text no. 1
    
2.
Mesher D, Tristram A, Castanon A, Beer H, Ashman S, Fielder H, et al. Single negative colposcopy: Is it enough to rule out high-grade disease? J Med Screen 2011;18:160-1.  Back to cited text no. 2
    
3.
Verma I, Jain V, Kaur T. Application of Bethesda system for cervical cytology in unhealthy cervix. J Clin Diagn Res 2014;8:OC26-30.  Back to cited text no. 3
    
4.
Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2020;24:102-31.  Back to cited text no. 4
    
5.
Wright TC Jr., Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D, et al. 2006 consensus guidelines for the management of women with abnormal cervical screening tests. J Low Genit Tract Dis 2007;11:201-22.  Back to cited text no. 5
    
6.
Penna C, Fambrini M, Fallani MG, Pieralli A, Scarselli G, Marchionni M. Laser CO2 conization in postmenopausal age: Risk of cervical stenosis and unsatisfactory follow-up. Gynecol Oncol 2005;96:771-5.  Back to cited text no. 6
    
7.
Castle PE, Smith KM, Davis TE, Schmeler KM, Ferris DG, Savage AH, et al. Reliability of the Xpert HPV assay to detect high-risk human papillomavirus DNA in a colposcopy referral population. Am J Clin Pathol 2015;143:126-33.  Back to cited text no. 7
    
8.
Dogan K, Guraslan H. Colposcopic evaluation of pre- and post-menopausal women with abnormal cervical cytologies. Middle Black Sea J Health Sci 2016;2:14-9.  Back to cited text no. 8
    
9.
Dresang LT. Colposcopy: An evidence-based update. J Am Board Fam Pract 2005;18:383-92.  Back to cited text no. 9
    
10.
Saad RS, Kanbour-Shakir A, Lu E, Modery J, Kanbour A. Cytomorphologic analysis and histological correlation of high-grade squamous intraepithelial lesions in postmenopausal women. Diagn Cytopathol 2006;34:467-71.  Back to cited text no. 10
    
11.
Piccoli R, Mandato VD, Lavitola G, Acunzo G, Bifulco G, Tommaselli GA, et al. Atypical squamous cells and low squamous intraepithelial lesions in postmenopausal women: Implications for management. Eur J Obstet Gynecol Reprod Biol 2008;140:269-74.  Back to cited text no. 11
    
12.
Jemal A, Tiwari RC, Murray T, Ghafoor A, Samuels A, Ward E, et al. Cancer statistics, 2004. CA Cancer J Clin 2004;54:8-29.  Back to cited text no. 12
    
13.
Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2013;17:S1-27.  Back to cited text no. 13
    
14.
ASCUS-LSIL Traige Study (ALTS) Group. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am J Obstet Gynecol 2003;188:1383-92.  Back to cited text no. 14
    




 

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