The assessment of cervical abnormality
Colposcopy is the best means of assessing cervical intraepithelial abnormality. Like most clinical decisions, whether to treat or not is a balance of risks. For low-grade squamous intraepithelial lesions (LSIL) the risk of progression to cancer is probably about 1% whereas for high grade lesions (HSIL-CIN3) it may be as high as 30%.
For these two ends of the spectrum the decision to treat or not is relatively easy, HSIL-CIN3 should almost always be treated and LSIL should usually not. The progression rates for HSIL-CIN2 are less well established and there is growing consensus that age should be included in the management equation. Relevant case characteristics will include age, parity, previous treatment, future fertility aspirations, likelihood of default, HPV testing, and any other available biomarker triage test results. Also, the TZ type and size will affect the risk of functional damage to the cervix (Figure 62.2).Safe treatment will mean a preliminary colposcopic examination by a properly trained colposcopist with adequate documentation of findings in a structured format. It should record the TZ type, the adequacy of the examination and an objective diagnostic score, for example, the Swede score (21) (Table 62.2). If the treatment is excisional then it should be performed under binocular colposcopic guidance to minimize excising excessive or insufficient tissue (22) and of inflicting excessive artefactual damage to the wound or the removed TZ. Treatment should accomplish complete eradication of the TZ and not just the lesion. Whether excising or destroying the TZ, ablation to a depth of 7 mm is considered optimal (23). This is because the deepest gland crypt can contain CIN as low as 4 mm (24) and destroying to 7 mm gives a sufficient degree of safety. A description of how to perform colposcopic examination and treatment is available elsewhere. Practical manuals, image atlases and structured training courses are also available (http:// www.ifcpc.org). Colposcopic examination should be undertaken in a systematic way using standard international nomenclature to record findings (25).
Excision or destruction of the transformation zone
Table 62.3 details the different methods of treatment. Where facilities allow, treatment should probably be excisional using electrosurgery (large loop excision of the transformation zone (LLETZ) aka the loop electrosurgical excision procedure (LEEP)). Histological examination allows assessment of the grade of abnormality, the