This brochure summarises what Dr. Appanna may already have discussed with you.
You have been referred in to Dr Appanna because of having an abnormal smear.
What does this mean?
The cervical smear was done to detect very early changes in the cervix, which if left untreated may go on to form cancer. These changes are precancerous and treatment and good follow up almost always prevents the development of Cancer of the Cervix.
What does the cervix look like?
The cervix is the neck of the womb. It is a tube with a thick wall. It is the entrance to the womb. The outside of the cervix (ectocervix) is formed by thicker skin called stratified squamous epithelium, similar to skin elsewhere. The lining of the tube (endocervix) is formed by thin columnar epithelium, which is almost transparent and because of this, it appears red. The junction between these two areas is where any abnormality takes place.
What changes can be detected on the smear?
Inflammation or infection
This is common especially with women on the oral contraceptive pill. This inner thin lining of the cervix becomes exposed to the acid environment of the vagina making it appear inflamed. This may also lead to an increase in mucous secretion giving one a discharge, which usually is not offensive. If the discharge becomes discolored or smelly, infection may have intervened. This may also be associated with the use of tampons, which dry out the vagina making it more susceptible to infection.
The cytologist reports this when the cells do not look quite normal but he is unable to say whether there is in fact any abnormality on the smear. If your smear has this report, you would have been asked to have your smear repeated in 6 months. If this still atypical, you will have been referred in to me. Guidelines recommend that you should be seen within 6 months for this.
HPV (human papilloma virus) (wart virus)
There are almost 200 different strains of the wart virus. Some specific strains of this virus are associated with changes in the cervix. Many women have the HPV infection at some stage in their lives. Usually it disappears spontaneously. If you have HPV, you will therefore require to have smears more frequently.
Low Grade changes
These are mild changes in the cervix. This is also referred to as mild dysplasia and CIN 1. This smear is usually repeated in about 4 to 6 months. Sometimes this change disappears spontaneously. If it persists then you will have been referred in to me. Guidelines recommend that you should be seen within 6 months for this.
High Grade changes
These are more serious changes on the cervix, but are still not cancer. They may be referred to as severe dysplasia, CIN2, CIN 3 and CIN3 with glandular extension, or CIS (Carcinoma in Situ). If you have any of these changes, you will be referred to me. Guidelines recommend that you should be seen within 1 month for this.
Suspicion of Invasive disease
This is a very serious abnormality and may mean you have cancer. Guidelines recommend that you should be seen within 1 week for this.
What happens at my rooms?
Because of your abnormal smears, you will have referred in to me for a colposcopy. A smear is just a superficial scraping of cells, which is great for screening but does not give us an absolute diagnosis. A colposcopy is a procedure during which the cervix is examined using a microscope and different stains/dyes, which help me to determine exactly what the abnormality is. The procedure takes between 10 to 15 minutes. Usually a smear is taken and a pinch of tissue called a punch biopsy is taken and sent to the laboratory. This will usually give us a more accurate diagnosis and help to determine if any treatment is necessary. The results usually take about 7 to 10 days to return however can be done within 48 hours if we are very concerned.
What happens following this?
Because of the punch biopsy, you may have slight bleeding or a discharge for a few days. You may notice a scab come away. You should not have intercourse, use a tampon, or use a spa or swimming pool until the bleeding or discharge has settled as this may predispose to infection or bleeding. If the bleeding is more than a period, or the discharge becomes offensive, you may have an infection and should contact me. You will usually be contacted by our nurse Sandie, told that your results are back, and asked to return to discuss them. If you do wish that the results are told to you over the phone, please let them know, but they will be unable to do more than just give you the results. They are not able to discuss management of these results with you over the phone.
Will I require treatment?
This is totally dependant on your results. Some abnormal cells may clear up without treatment. If treatment is necessary it would depend on what the abnormality is, and where it appears on the cervix. I will discuss the options with you in some depth.
How will treatment be done?
I will usually recommend whether the procedure is done under local anaesthetic or general anaesthetic dependant on how well you coped with the colposcopy. Almost 75% of treatment is done under a local anaesthetic in my rooms. If the treatment is done under local anaesthetic this can be scheduled for any day. General anaesthetic procedures are performed in hospital on a Monday or Tuesday.
What are the treatment options?
1) Semms Coagulation
This treatment is for milder changes and involves a probe, which is heated up to approximately 120 degrees C and applied to the abnormal areas thereby destroying the abnormal areas. Others clinics use cryothearpy (freezing) for the same effect.
2) Lletz Loop
This removes the abnormal areas using an instrument designed to specifically for this purpose. The loop comes in different sizes and shapes which are decided upon dependant on the lesion. Others may use laser for the same purpose. Some types of laser treatment “evaporate” the abnormal area hence no specimen is sent for histology.
3) A Cold Knife Cone Biopsy
This biopsy is done under general anaesthetic.
What happens following treatment?
You will usually be placed on antibiotics. These are taken for up to 2 weeks after the procedure.
With the Semms Coagulation, a watery blood stained discharge is common and may last up to 4 weeks after the procedure.
With the Lletz loop and the Cold knife cone, a small amount of bleeding is common. This should not be heavier than a normal period.
You should not have intercourse, use a tampon, or use a spa or swimming pool until the bleeding or discharge has settled as this may predispose to infection or bleeding. If the bleeding is more than a period, or the discharge becomes offensive, you may have an infection and should contact me.
Very occasionally for no known reason some patients develop secondary bleeding when the scab comes away which can be anything between 7 to 14 days after surgery and occasionally even later. I the bleeding is heavy you should be seen immediately for this.
You will usually be reviewed 2 weeks following treatment and the cervix examined. Occasionally the antibiotics may be continued for a further period after this examination.
Long term follow up is planned at this visit. You are usually reviewed for a repeat colposcopy in 4 to 6 months with close follow up for 2 years before going onto yearly smears, which are usually done, at your GP’s. The chances of recurrence are usually the highest in the first two years following treatment.
With this regime, you are unlikely to develop cancer of the cervix no matter what stage of precancer you have had previously.
PERMISSION TO REPRODUCE THIS LEAFLET IS GIVEN AS LONG AS ACKNOWLEDGEMENT IS GIVEN TO MR.N.APPANNA