Abnormal Pap Smear and Colposcopy: What It Means and What Happens Next

Colposcopy in Mumbai is performed by Dr. Vaishali Joshi, FRCOG, Senior Consultant Obstetrician & Gynaecologist at Kokilaben Dhirubhai Ambani Hospital, Andheri West, who is an accredited colposcopist of the British Society for Colposcopy and Cervical Pathology (BSCCP). An abnormal cervical smear is common and, in the overwhelming majority of cases, does not mean cancer. It means cells have changed in a way that warrants a closer look — which is precisely what the screening programme exists to find, early, while it is easily treatable.

Few letters cause as much alarm as one reporting an abnormal smear. So the most useful thing to say first is the thing that gets lost: cervical screening is not a test for cancer. It is a test designed to find changes that could, if left alone over many years, eventually become cancer. Finding them is the system working exactly as intended.

Cervical cancer is one of the few cancers that is genuinely preventable, because it has a long, detectable pre-cancerous phase. That is the whole basis of screening — and it is why an abnormal result, acted on, is a good outcome rather than a bad one.

What does an abnormal smear result mean?

Modern cervical screening usually combines two things: testing for high-risk human papillomavirus (HPV), the virus that causes almost all cervical cancer, and examining the cells themselves (cytology). Results are commonly reported as:

You may also see the terms CIN 1, CIN 2 and CIN 3 — cervical intraepithelial neoplasia. These describe how much of the thickness of the surface layer is affected on a biopsy: CIN 1 is mild and usually observed, CIN 2 and CIN 3 are higher grade and usually treated. None of them is cancer.

What is colposcopy?

Colposcopy is an outpatient examination in which the cervix is viewed under magnification using a colposcope — essentially a low-power microscope on a stand, positioned outside the body. Nothing about it enters further than a routine speculum examination.

What happens during the appointment

• You lie on a couch as for a smear, and a speculum is inserted to see the cervix.
• The colposcopist applies dilute acetic acid, and often iodine, to the cervix. Abnormal areas take up these solutions differently and become visible — this is what makes the examination possible. The acetic acid may sting slightly.
• The cervix is examined under magnification, usually for a few minutes.
• If an abnormal area is seen, a small biopsy is taken. Most women describe this as a brief pinch or a period-type cramp.
• The examination itself typically takes ten to twenty minutes.

Afterwards

You can go home immediately and return to normal activity the same day. If a biopsy was taken, expect light bleeding or a dark discharge for a few days — the iodine and the solution used to stop bleeding both cause this — and avoid intercourse, tampons and swimming until it settles. Biopsy results usually take a few days to a couple of weeks.

What treatment might follow?

If a biopsy confirms high-grade changes (CIN 2 or CIN 3), treatment removes or destroys the affected area of the cervix. The most common is LLETZ — large loop excision of the transformation zone — done under local anaesthetic in an outpatient setting, taking around fifteen minutes. A thin wire loop carrying an electrical current removes the abnormal area, which is then sent for examination to confirm the diagnosis and that it has been fully removed.

Treatment for high-grade changes is highly effective at preventing progression to cervical cancer. Afterwards you will need a test of cure, usually at six months, and then continuing surveillance.

A common and entirely reasonable question is whether treatment affects future pregnancy. A single, standard-depth LLETZ has a small effect on the risk of preterm birth; repeated or deep excisions have a greater one. This is a genuine reason not to over-treat low-grade changes that would probably resolve on their own — and a reason to have the procedure done by someone experienced enough to remove what is necessary and no more.

Why does BSCCP accreditation matter?

Colposcopy is an interpretive skill. The colposcopist is making a visual judgement about which areas are abnormal, how abnormal they are, where to biopsy and whether the whole transformation zone has been seen. Two colposcopists looking at the same cervix will not necessarily reach the same conclusion, and the consequences of getting it wrong run in both directions — missed high-grade disease on one side, unnecessary excision of a young woman's cervix on the other.

The British Society for Colposcopy and Cervical Pathology sets a formal training, assessment and revalidation standard for colposcopists in the United Kingdom, including minimum case numbers and audited practice. Dr. Joshi held BSCCP accreditation during her training and practice in the United Kingdom, which means her colposcopy practice was trained and assessed against that external standard rather than acquired informally. It is a reasonable thing to ask any colposcopist about.

When should cervical screening start, and how often?

Guidance varies between countries and programmes, and Indian practice does not follow a single national call-and-recall system in the way the UK does. Broadly, screening is recommended from the mid-twenties, repeated at intervals of three to five years depending on age and on whether HPV testing is used, and continued into the sixties.

Two points are more important than the exact interval. First, HPV-based screening allows longer gaps between tests than cytology alone, because a negative HPV test is highly reassuring. Second, HPV vaccination does not remove the need for screening — the vaccines cover the highest-risk types but not all of them.

The schedule Dr. Joshi recommends

• Start at 20 — or, if you become sexually active after 20, from that point.
• Co-testing is preferred — a Pap smear together with HPV testing.
• At minimum, a Pap smear every three years where co-testing is not available.
• Screening can stop after 65, provided you have been screened regularly up to that point.

This is a more cautious starting age than several international programmes, which begin at 25. It reflects practice in India, where there is no national call-and-recall system and women are far less likely to be screened automatically — so the opportunity is taken when a woman is in front of you.

If you have symptoms — bleeding between periods, bleeding after intercourse, bleeding after the menopause, or persistent unusual discharge — do not wait for your next scheduled smear. Those symptoms need assessment in their own right, whatever your screening history.

Aftercare following colposcopy treatment

If you have had treatment rather than a biopsy alone — LLETZ, LEEP or cold coagulation — the recovery is straightforward but there are a few things to expect and a few to avoid.

• Mild spotting and a dark brown discharge are normal for up to about four weeks. The discharge is heavier in the first week and settles gradually.
• Avoid intercourse, tampons and swimming during this period, to reduce the risk of infection while the cervix heals.
• Contact the clinic if bleeding becomes heavy, if there is offensive-smelling discharge, or if you develop a fever — these may indicate infection and are treatable.
• Attend your follow-up smear at the interval given in your letter. This is the test of cure and it is the step that confirms the treatment worked. It is also the appointment most commonly missed.

Frequently asked questions

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