Planning a woman’s medical management after her initial colposcopic assessment is primarily the duty of the colposcopist. It is appropriate to involve the woman, as a partner, in the decision-making process. Management usually depends on the final assessment after the colposcopic findings have been integrated with the pathology reports. Management plans also depend on whether or not the woman is pregnant. The management plan should be explicitly detailed in the medical record and communicated clearly to the patient at the earliest opportunity. Ideally, pathology reports (biopsy, endocervical curettage (ECC), loop electrosurgical excision procedure (LEEP) specimen, cytology) should be available to the colposcopist within three weeks of carrying out the colposcopy. Cryotherapy or LEEP are the two forms of therapy discussed in this manual (see Chapters 12 and 13
), but it must be emphasized each has specific indications for their use and should be used only when women fulfil all of the eligibility criteria for the specific therapy. A general plan of management that may be adapted in low-resource settings is shown in Figure 11.1
It is generally preferable to have the diagnosis of cervical intraepithelial neoplasia (CIN) firmly established before a decision on management is taken and any treatment offered. However, there may be exceptions to this rule. For example, in many settings, particularly developing countries, women may be offered treatment at their first colposcopy visit, based on colposcopic assessment to maximize treatment coverage (otherwise patients lost to follow-up would not receive treatment for lesions). If the decision is to treat with cryotherapy, a biopsy (or biopsies) may be directed before cryotherapy, as this type of treatment does not produce a tissue specimen for histological examination. A tissue sample taken before instituting ablative therapy will help to confirm the histological nature of the lesion treated a posteriori. Expert colposcopists also may use this approach to maximize treatment coverage and to minimize the number of clinic visits in some settings. However, this approach may result in a significant degree of overtreatment. Even though it is assumed that treatment methods such cryotherapy and LEEP are safe, and are unlikely to be associated with long-term sequelae and complications, the long-term implications of such overtreatment remains yet to be firmly established. On the other hand, it is likely that overtreatment may, to a certain extent, protect against future development of CIN, in view of the ablation of the transformation zone where the vast majority of CIN lesions occur.