Colposcopy guidance during COVID 19 pandemic

In the current COVID crisis, in line with screening programme guidance only women who have had a recent cervical smear suggesting high grade moderate+, BNC in endocervical cells or ?glandular neoplasia or suspicion of invasive disease should be seen for colposcopy.

If resources permit, then low grades can be seen, but can be deferred, if colposcopy services have reduced clinic capacity. Please see your local and national guidance for further information.

This is to minimise face to face consultations. Colposcopy clinics should consider virtual consultations and help lines to alleviate fears of women with low grade or minor cytological abnormalities, persistent HPV who will not be undergoing a diagnostic colposcopy in the short term.

Primary screening will have ceased in most areas to minimise face to face contact and to concentrate health resources on the pandemic. Therefore, the number of screening referrals will decrease in the near future.

In line with BGCS recommendations, “Two-week wait (2WW) referrals may need to be triaged at trusts, with the consent of the referring primary care professional, to prioritise patients who need to be seen urgently and investigated within the 2WW pathway. These deviations from standard 2WW pathways should be documented and reasons provided. Safety-netting mechanisms should be in place for patients whose referrals are downgraded. Consideration of initial virtual clinic appointments (telephone/video) or straight to test strategies can be made in order to minimise patients needing to physically attend hospital and may provide additional information to aid triage decisions. Ideally, virtual appointments should be performed so that friends/family can also attend, either remotely (e.g. mini videoconference or teleconference), or be with the patient, if this is feasible and in keeping with patient choice.”

Colposcopy leads should ideally make provision for a weekly rapid access clinic for suspected cervical cancers.

Colposcopy clinics should make a database of all screening patients who have not been seen but deferred, so a failsafe tracking system is in place, so that patients can be seen in the future when resources permit.

Colposcopy practice

Evidence suggests that the presence of COVID-19 is very low in the lower genital tract and also low in blood. It is therefore unlikely that smoke produced during a LLETZ procedure will contain COVID virus particles.

Laser ablation and excision should not be used due to vaporisation. Cold (thermal) coagulation can be performed but not as ‘see and treat’ therapeutic option.

By consensus we recommend:

In asymptomatic patients:

Gloves, apron and an appropriate mask be worn for colposcopy face to face consultation and examination. The minimum number of staff should be present during procedures. A serviced smoke extractor must be used for any LLETZ procedures.

Minimise use of coagulation procedures with diathermy, as this causes greater dispersal of vaporised particles.

In line with national guidance

In patients with symptoms suggestive of COVID infection: Defer colposcopy assessment until symptoms resolve or patient tested negative. It is worth considering telephoning patient prior to their appointment to assess, if they are at risk or have symptoms.

Consideration should be given to not ask patients to cough during biopsy other procedures, if that is your normal practice.

If patients have significant symptoms suggestive of cervical cancer and are symptomatic of Covid-19, then the whole colposcopy multi-disciplinary team should wear full personal protective equipment during consultation and examination.

Vacuum suction for treatments

Most Units should have an appropriately serviced laser vacuum suction device for treatments. Units should check their treatment filtration system and check it has been appropriately serviced. An example below – shows the vacuum extraction facility for colposcopy is – is a high efficiency filtration which is the key to successful plume removal.

Filtration is achieved in three stages – by air passing through a pre-filter and a two stage, high efficiency filter combining ULPA grade media and activated carbon. The product advice suggests the combined effectiveness of the total filtration package provides an efficiency of >99.9999995% at 0.01 micron. Corona virus particles measure from 0.08- 0.14um.

This may provide reassurance of usage of this vacuum extractor system. Appropriate PPE should be used even with usage of a serviced vacuum extraction system.

Updated guidance for patients

Updated guidance reflects the further spread of coronavirus within our population so that it is now reasonable to assume any patient may have coronavirus even if they don’t have symptoms.

Thus all staff should wear appropriate PPE and patients should be given a mask to wear during consultation and examination. Please also check local and national guidance.