Teaching and Training Colposcopy

The colposcope itself is a simple instrument, even for beginners. The eyepieces are adjusted individually. The instrument is focused by moving the swivel arm to the working distance for the particular scope. It is usually unnecessary to use the fine focus. Magnification × 10 is quite adequate for routine work; higher magnification is needed only to study details. Smaller enlargements can be used for imaging the entire cervix. Colpophotography is straightforward and produces high-quality pictures. The cervix has to be well exposed and the camera focused.

Although the colposcope is straightforward to use, proficiency in colposcopy requires a knowledge of colposcopic concepts and an appreciation of cervical pathology. Once a working knowledge of colposcopic findings has been acquired from a textbook, atlas, or teaching slides, it is helpful to work with an experienced colposcopist who can demonstrate and explain the exam and findings. Obtaining a biopsy should be demonstrated and then practiced. Courses where individual problems can be discussed with the faculty are available at entry and advanced levels.

Video systems are very helpful for teaching colposcopy. Video nicely shows the dynamics of changes after application of acetic acid and iodine. Video also lets the patient follow the examination.

Improvement takes practice. We use the colposcope at every speculum examination. By doing this, the practitioner gains an easy routine and does not find colposcopy unnecessarily time-consuming. Routine colposcopy expedites the appreciation of benign findings in women of all ages, and familiarity with benign findings makes one more alert to those that are no longer benign. It is logical to start with the study of ectopy and continue with the protean manifestations of the transformation zone. We believe this approach fosters an understanding of the dynamics of the events at the cervix, which, if they take a wrong turn, can lead to atypia and neoplasia.

Certain colposcopic findings are easy to categorize either as benign or as highly suspicious, but in between there is a wide spectrum of appearances that can be challenging to interpret. The same applies to cytology. The degree of confidence depends on the examiner’s skill and experience. Biopsying questionable findings is part of the learning curve and avoids serious mistakes. By correlating colposcopic findings with histologic findings, the practitioner will gain confidence and take fewer biopsies. The chance of missing a significant finding is considerably reduced by concomitant cytology and human papillomavirus testing.

In recent years, there have been national and international efforts to improve and standardize training in colposcopy.

Colposcopy plays a pivotal role in cervical cancer screening. It enables treatment of premalignant lesions, but, of equal importance, it prevents needless intervention. Cervical screening saves lives, but the vast majority of women screened are well and would never develop cervical cancer. It is axiomatic that there is potential for harm. Treating all women with abnormal smears would prevent the development of cervical cancers, but this would be at great cost. Colposcopy is therefore primarily about selection.

Colposcopic performance depends on the observer as well as on the clinical context in which the examination takes place. As noted earlier, the authors of this book recommend routine colposcopy as part of the gynecologic examination. While certainly good for experience, this approach is not feasible in all settings. Colposcopic findings are subjective and the related management decisions require problem-solving skills and experience. A colposcopist needs diagnostic and management skills, which necessitate both adequate training and a sufficient workload to maintain skills.

The indications for colposcopy vary from country to country due to differences in health care models, but its core objective is the same, namely, to detect preinvasive cervical changes so as to allow treatment and thereby prevent the development of invasive cancer. The International Federation of Cervical Pathology and Colposcopy (IFCPC) and the European Federation for Colposcopy (EFC) have recognized that adequate training was the key to ensuring high-quality colposcopy.