History, examination and investigation

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History

History taking at a colposcopy consultation should be relevant, concise and accurately recorded.

Minimum clinical history

The colposcopist should obtain and record the following information:

  • primary reason for referral (usually from referring healthcare professional), e.g. abnormal screening test, post-coital bleeding, abnormal cervical appearance or other
  • screening history, previous colposcopies and treatments
  • parity
  • menstrual history or any abnormal bleeding
  • past gynaecological history including history of sexually transmitted infections (STIs)
  • past medical and surgical history with particular reference to immune-deficiency due to disease or treatment
  • current medication and allergies
  • smoking/tobacco use, current status
  • HPV vaccination status
  • relevant family history including diethylstilboestrol (DESDiethylstilbestrol) exposure.

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Examination

The colposcopist should perform a systematic examination of the lower genital tract, including the cervix, vagina, vulva, perineum and perianal area.

Macroscopic

After visual inspection of the vulva, perineum and perianal skin, the cervix should be identified using a bivalve speculum, and observed with the naked eye and then with the colposcope. The vagina can be inspected through the entire length on slow removal of a partially open speculum.

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Colposcopic

Cervix

The cervix should be examined under low-power magnification prior to application of acetic acid to:

  • exclude clinical invasive disease
  • note presence of inflammation, infection or atrophy.

Dilute acetic acid (3–5%) is applied to the cervix allowing for typing of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. and to determine the extent and degree of any abnormality.


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REC7.2: ColposcopyThe examination of the cervix and vagina with a magnifying instrument called a colposcope, to check for abnormalities. and acetic acid
Acetic acid should be applied for 2 minutes to allow sufficient time for aceto-white changes to become apparent. This is especially important when the lesion is low grade as it may take more time to become visible.

Application of aqueous Iodine (Lugol’s or Schiller’s solutions) before or after biopsy may assist in defining the external limits of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. and any vaginal extension or separate lesions. Iodine can be applied to outline the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. at the examination preceding therapy, and this is particularly useful when there is vaginal extension of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone..

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Remainder of lower genital tract (vagina, vulva, perineum & perianal area)

The vulva, perineum and perianal skin should be inspected and any abnormality noted. The upper vagina should be assessed at all colposcopies to avoid missing extension of cervical dysplasia or isolated lesions of vaginal intra-epithelial neoplasia (VAINVaginal intra-epithelial neoplasia).[1]

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REC7.3: ColposcopyThe examination of the cervix and vagina with a magnifying instrument called a colposcope, to check for abnormalities. and VAINVaginal intra-epithelial neoplasia
When the LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report predicts a squamous abnormality and there is no colposcopically visible cervical lesion, careful colposcopic examination of the vagina should be performed to exclude VAINVaginal intra-epithelial neoplasia, using acetic acid and Lugol’s Iodine.

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Anus and anal canal

Women who are diagnosed with cervical dysplasia or are immune- deficient are at increased risk of anal intra-epithelial neoplasia (AINAnal intra-epithelial neoplasia) and anal cancer. Anoscopy, its findings and subsequent management is outside the scope of this document. It is usually practised by specially trained colposcopists, sexual health physicians or colorectal surgeons.[2]

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Investigations

Cytology

It is not necessary to take a cervical sample for LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. at the time of colposcopy, except in exceptional circumstances outlined below.[3][4]
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REC7.4: Repeat LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. usually not necessary at time of colposcopy
It is not necessary to take a cervical sample for LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. at the time of colposcopy except in the following circumstances:

  • delay in attending for colposcopy > 3 months after referral LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory.
  • referral LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. is unsatisfactory
  • referral LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. is negative but lacks an endocervical component
  • prior LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. is not available because the HPV test was performed on a self-collected sample
  • the woman has developed symptoms suggestive of cervical cancer since undergoing her screening test.
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BiopsyRemoval of tissue for medical examination.

The colposcopically directed biopsy should be taken from the most abnormal area of the cervix. There is evidence that, in larger lesions, the higher-grade abnormality will be more centrally placed, that taking more than one biopsy will detect more high-grade disease and that taking random four-quadrant biopsies has the highest sensitivity for detecting cervical intraepithelial neoplasia (CINCervical Intraepithelial NeoplasiaRefers to abnormal changes in the cells on the surface of the cervix that are seen using a microscope (i.e. histologically-confirmed).CIN 1 – Mild dysplasiaCIN 2 – Moderate dysplasiaCIN 3 – Severe dysplasia to carcinoma in situ(The term CIN 2+ refers to CIN 2, 3, or invasive cervical cancer; CIN3+ refers to CIN 3 or invasive cervical cancer)CIN 2/3 refers to CIN 2 or CIN 3.) grade 2 or higher (CIN2+).[5][6][7][8][9] However, the random four-quadrant biopsy technique will cause more discomfort, is not usual practice and is not acceptable to the majority of women.

In general, biopsy of abnormal areas should be encouraged, but many experienced colposcopists do not always biopsy a lesion that appears to be low grade, especially in young women, when the referral cytology predicts pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.. For less experienced colposcopists, biopsy of a suspected low-grade lesion is appropriate to confirm the diagnosis and exclude high-grade abnormalities. Adjunctive technologies may assist in identifying the most abnormal areas but these are not widely used in Australia at this time (see Supplement. Colposcopy technologies and documentation).



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REC7.5: BiopsyRemoval of tissue for medical examination. of high grade lesions
The cervix should be biopsied when the LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction is pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system. or HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). and the colposcopic appearance shows major change (see IFCPCThe International Federation of Cervical Pathology and Colposcopy definition above) and the abnormal TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. is visible (Type 1 or Type 2 TZType 2 TZ: the upper limit of the TZ is partly or wholly visible in the canal and is completely visible around 360 degrees).

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REC7.6: BiopsyRemoval of tissue for medical examination. visible lesion if suspicious for invasion when T3 TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. colposcopy
In some situations, when there is a visible high-grade lesion on the ectocervix but there is a T3 TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. (lesion extends into canal out of visual range), it may be reasonable to take a cervical biopsy of the visible lesion if there is any suspicion of superficially invasive or invasive carcinoma.

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REC7.7: BiopsyRemoval of tissue for medical examination. of low-grade lesions is encouraged but not always necessary
Women with a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system. or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. and a colposcopic impression of low-grade disease or less may not always require a biopsy. However, biopsy is accepted practice for confirmation of the colposcopic impression and exclusion of high-grade disease, and should be encouraged, especially for less experienced colposcopists.

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Endocervical curettage

Endocervical curettage (ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix) as an outpatient investigation is practised frequently in the USA and rarely in Australia. There is a lack of evidence to support its routine use in clinical practice.[10] There is a lack of prospective studies evaluating the utility of ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix performed at the time of diagnostic colposcopy. However, the findings of a recent retrospective study[11] suggest that ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix may be useful in predicting cervical cancer. The study included 455 women who had ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix at the time of colposcopy for an incompletely visible endocervical lesion, atypical glandular cells on smear or discrepancy between colposcopic impression and cytological abnormality.

The ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix was performed by two expert colposcopists who used a Kevorkian curette to sample four endocervical quadrants. They analysed the reliability of ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix in detecting high-grade CIN (CIN2/3) and cervical cancer, and concluded that ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix had a high sensitivity in the diagnosis of endocervical pre-cancerous lesions and cancer. ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix resulted in a diagnosis of cancer in 96% of cases, either directly from the analysis of ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix tissue or from that of the cone biopsy made necessary by the ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix findings of a pre-cancerous lesion. They also concluded that, in some situations, a negative ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix could safely allow a period of surveillance and reduce the number of unnecessary treatments. The authors recognised that, because they were very experienced colposcopists, it may not be possible to extrapolate their results to all colposcopists.

It is possible, despite a lack of evidence, that ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix could be used in Australian practice, particularly when there is a discrepancy between referral LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction (low-grade squamous intraepithelial lesion (LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.), possible high-grade squamous intraepithelial lesion (pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system.), or high-grade squamous intraepithelial lesion (HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).)) and colposcopy in the presence of a Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal. ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix may provide reassurance that there is no significant endocervical lesion and that an immediate diagnostic excision could be deferred and be replaced by short-term surveillance.

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Imaging

Women who are referred for evaluation of abnormal glandular cytology, especially those with atypical glandular cells or endocervical cells of undetermined significance, may not always have a detectable lower genital tract abnormality.[12] In this situation, imaging of the upper genital tract could be performed. Imaging may detect gross disease of the fallopian tube, ovary and of the endometrium in postmenopausal women, as these sites may be giving rise to the abnormal glandular cells. Further investigation, such as endometrial sampling, to exclude an endometrial origin for atypical glandular cells, may be required.

However, in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears., LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. is only carried out following a positive oncogenic HPV test result. Therefore, the detection (via the screening episode) of abnormal glandular cells from extra-cervical sites will be reduced, given that endometrial, tubal and ovarian pathology is not HPV-related. However, such abnormal glandular cells could be present coincidentally, unrelated to the positive oncogenic HPV test result (see Chapter 11. Management of glandular abnormalities).


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REC7.8: Upper genital tract imaging
Upper genital tract imaging should be considered in cases where no lower genital tract abnormality is detected at colposcopy after referral with abnormal glandular cytology (including atypical glandular cells or endocervical cells of undetermined significance). In some women, further investigation, such as endometrial sampling to exclude an endometrial origin for atypical glandular cells, may be required.

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Documentation

High-quality patient management requires meticulous documentation of the woman’s medical record. The results of consultations, examinations and treatments must be recorded – preferably electronically, as this will facilitate the submission of colposcopy data to the National Cancer Screening RegisterA database of identifiable persons containing defined demographic and health information, established for a specific purpose. In the case of cervical screening or other cancer screening registers, the purpose includes inviting eligible persons for screening, sending reminders when they are overdue for screening, follow up of abnormalities, statistical reporting and research. (see Colposcopy data required for the National Cancer Screening Register). It is useful to keep an annotated diagram of the cervix and vagina or keep a digitally captured image.

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References

  1. Golbang P, Scurry J, de Jong S, McKenzie D, Planner R, Pyman J, et al. Investigation of 100 consecutive negative cone biopsies. Br J Obstet Gynaecol 1997 Jan;104(1):100-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8988706.
  2. Robison K, Cronin B, Bregar A, Luis C, DiSilvestro P, Schechter S, et al. Anal Cytology and Human Papillomavirus Genotyping in Women With a History of Lower Genital Tract Neoplasia Compared With Low-Risk Women. Obstet Gynecol 2015 Dec;126(6):1294-300 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26551180.
  3. Kourounis GS, Michail GD, Ravazoula P. A second Pap smear during colposcopy: is it really worth it? Eur J Gynaecol Oncol 2004;25(4):475-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15285307.
  4. Mao C, Balasubramanian A, Koutsky LA. Should liquid-based cytology be repeated at the time of colposcopy? J Low Genit Tract Dis 2005 Apr;9(2):82-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15870528.
  5. Buxton EJ, Luesley DM, Shafi MI, Rollason M. Colposcopically directed punch biopsy: a potentially misleading investigation. Br J Obstet Gynaecol 1991 Dec;98(12):1273-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1777461.
  6. Baldauf JJ, Dreyfus M, Ritter J, Philippe E. An analysis of the factors involved in the diagnostic accuracy of colposcopically directed biopsy. Acta Obstet Gynecol Scand 1997 May;76(5):468-73 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9197451.
  7. Pretorius RG, Zhang WH, Belinson JL, Huang MN, Wu LY, Zhang X, et al. Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of cervical intraepithelial neoplasia II or worse. Am J Obstet Gynecol 2004 Aug;191(2):430-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15343217.
  8. Underwood M, Arbyn M, Parry-Smith W, De Bellis-Ayres S, Todd R, Redman CW, et al. Accuracy of colposcopy-directed punch biopsies: a systematic review and meta-analysis. BJOG 2012 Oct;119(11):1293-301 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22882742.
  9. Gage JC, Hanson VW, Abbey K, Dippery S, Gardner S, Kubota J, et al. Number of cervical biopsies and sensitivity of colposcopy. Obstet Gynecol 2006 Aug;108(2):264-72 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16880294.
  10. Goksedef BP, Akbayir O, Numanoglu C, Corbacioglu A, Guraslan H, Bakir LV, et al. Evaluation of endocervical canal in women with minimal cervical cytological abnormalities. J Low Genit Tract Dis 2013 Jul;17(3):261-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23422642.
  11. Akladios C, Lecointre L, Baulon E, Thoma V, Averous G, Fender M, et al. Reliability of Endocervical Curettage in the Diagnosis of High-grade Cervical Neoplasia and Cervical Cancer in Selected Patients. Anticancer Res 2015 Jul;35(7):4183-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26124376.
  12. Kim SS, Suh DS, Kim KH, Yoon MS, Choi KU. Clinicopathological significance of atypical glandular cells on Pap smear. Obstet Gynecol Sci 2013 Mar;56(2):76-83 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24327985.
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