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When cervical cancer is suspected from an abnormal cervical smear, clinical history or physical examination, further investigations are needed to confirm the diagnosis. These may include:

  1. Colposcopy
  2. Punch biopsy or target biopsy
  3. Cone biopsy

(i)Colposcopy

Colposcopy is required when abnormality is detected by cervical smear. Colposcopy is like a microscope put near the vagina to allow more detailed examination of the cervix. It is usually done in a gynecological out-patient clinic. The examination usually takes about 20-30 minutes. You need to lie down on your back on a couch similar to that for cervical smear. A speculum will be used to open the vagina. The cervix will be stained by acetic acid. The extent and severity of the lesion are identified and appropriate treatment will be provided. Under the guidance of colposcopy, a piece of the lesion will be removed (called a biopsy) and sent to the laboratory for detailed examination. When the biopsy result is available, you will be offered treatment accordingly. Unlike cervical smear, colposcopy (with biopsy) is a diagnostic test (rather than a screening test) to confirm the diagnosis, which can help in choosing the appropriate treatment. Also, colposcopy needs special equipment to perform and requires more expertise.

Abnormalities found in biopsy are categorized into several entities: cervical intraepithelial neoplasia (CIN), carcinoma in situ and invasive carcinoma.

CIN 1, or mild cell changes, means one third of the thickness of the skin covering the cervix has abnormal cells. This is similar to LSIL in cervical smear. Majority of CIN 1 will regress to normal on its own, but sometimes treatment is needed if the lesion is extensive. If treatment is not necessary, you probably need to repeat a cervical smear in 3-6 months to see if the lesions have regressed. About 15% of these cases will progress to more severe lesions and require treatment later.
CIN 2 (moderate cell changes) or CIN 3 (severe cell changes) means two thirds and full thickness of the cervix has abnormal cells, respectively. These lesions correspond to HSIL in cervical smear. Treatment is usually necessary as 5-12% of them will progress to cancer.
Carcinoma in situ is well contained within the skin covering the cervix. It will become cancer when it breaks through the bottom layer of the skin covering the cervix into the underlying tissue.
Invasive carcinoma means cancer which possesses the ability to invade surrounding structures and spread to other organs.

(ii)Punch biopsy or target biopsy

Under the guidance of colposcopy, a small piece of tissue with lesion is obtained (biopsy), which is then sent to the lab for examination. Local anaesthetic will be injected into the cervix before biopsy is taken. After the procedure, some pain, bleeding or discharge may occur, which could usually be controlled using simple measures such as pain-killers.

(iii) Cone biopsy

If the area of the lesion is large or the doctor cannot see the abnormal area clearly with colposcopy because the abnormal cells are high up in the cervical canal, a ring of tissue will be removed and sent to the lab for examination to make sure the whole cancer is removed. This is a minor operation and usually done under general anaesthesia. You will probably need to stay overnight in the hospital.

After the operation, some gauze may be packed inside your vagina to stop the bleeding which may persist for a few days. You may experience some menstruation-like pain which can be reduced by taking painkiller prescribed by your doctor.

When you go home, you should rest for the first week, but you do not have to stay in bed. Avoid doing heavy housework or carry heavy loads. Avoid vigorous exercise or sexual activity for 4-6 weeks.

   
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