Paul Callaway, MD

Colposcopy is frequently performed by family physicians and is regarded as a core procedural technique in many family practice residencies. Although colposcopic skills are frequently taught to and employed by family physicians, the clinical situations prompting gynecologic referral by skilled family physician colposcopists have not been widely studied. Pfenninger¹ reported that 28 of 200 patients (14%) requiring colposcopy in a family practice residency program received a referral to a gynecologist because of pregnancy, postmenopausal status, inadequate colposcopy, or the need for laser excision or conization. Conization accounted for approximately half of these referrals. Writing from the perspective of the practicing family physician offering colposcopy, Spoelhoeff² found he needed to refer 10 of 45 women (22%) for specialist gynecologic management. Reasons for referra in-cluded incomplete visualization of the transformation zone, significant discrepancy between cytology and histology, and high-grade lesions requiring laser or conization. One patient was referred because she had multiple previous treatments by a gynecologist. Both Pfenninger and Spoelhoeff treated cervical lesions cryosurgically, referring for any required conization. With the advent of loop electrical excision procedures (LEEP), many cases that previously required referral for conization can be managed in the physician’s office. LEEP has been widely taught in family practice residencies and family physicians are increasingly adopting it for management of cervical dysplasia. In this paper we summarize the referral experience of a family practice cervical dysplasia clinic operating within a residency program during a 6-year period in which LEEP was used as primary management for cervical dysplasia.

Methods

In 1993 the family practice residency program at Via Christi Regional Medical Center in Witchita, Kansas, began the Cervical Dysplasia Clinic. The clinic serves as a major training resource for second-year and third-year family practice residents who gain skills in colposcopy and LEEP under the close supervision of 2 faculty members highly experienced in these procedures. Although educational experience was an important clinic objective, all clinical management decisions were made by one of the 2 faculty supervisors, most often the senior author of this paper. Referrals to the clinic are solicited and received from sources throughout the state of Kansas, primarily from public health clinics and those serving the indigent. The Cervical Dysplasia Clinic serves approximately 60 women each year and maintains a database of patient information including referring cytology, histology, disposition, treatment, and follow-up. We report a descriptive analysis of that database for all patients seen between April 1993 and November 1999.

Results

During the study period, 283 patients were seen in the Cervical Dysplasia Clinic with referring cervical cytology that ranged from atypical squamous cells of undetermined significance (ASCUS) to high-grade squamous intraepithelial lesions. A few patients had normal cytology but were sent to the Cervical Dysplasia Clinic because of visible cervical abnormalities or previous abnormal cytology. At the time of analysis, data was complete on 272 of these individuals, and the cytologic and histologic findings for those patients are summarized in the Table. For a small number of patients management decisions were made without biopsy, most commonly because of the combination of low-grade cytology and benign-appearing colposcopy.

In accordance with evolving practice patterns and cost-benefit analysis,³ the majority of patients with biopsy-confirmed low-grade lesions were scheduled for observation without treatment. High-grade lesions were either treated, almost exclusively with outpatient LEEP within the family practice center, or referred to a gynecologist. All patients with unsatisfactory colposcopy were treated with LEEP conization, provided the transformation zone was confined to the cervix and glandular atypia (adenocarcinoma in situ) had been ruled out. Overall, 26 patients (9%) were referred to a gynecologist for definitive management. The most common reason for referral was the presence of an atypical transformation zone extending onto the vaginal fornix. Although one of these patients was treated with LEEP by the gynecologist to whom she was referred, the remaining patients were treated with a laser or a combination of a laser and LEEP. Five patients were referred to a gynecologist because of the presence of glandular atypia. On the basis of local gynecologic opinion, these patients required cold cone biopsies to eliminate any possibility of histologic heat artifact from a LEEP excision. Two patients had lesions requiring more extensive therapy than could be offered in the dysplasia clinic (perianal warts in one and vaginal intraepithelial neoplasm-grade 2 in a second). One patient had carcinoma in situ with possible invasion, and one had a psychiatric condition that required sedation of the patient in a minor surgical facility for safe surgical management.

Discussion

Although our 9% referral rate differs little from the 14% reported by Pfenninger, the reasons for the referrals have changed. For example, half the referrals by Pfenninger were for cold cone biopsies. In contrast, many LEEP procedures performed in the Cervical Dysplasia Clinic were LEEP cones. Referral for cold knife conization was limited to patients with glandular atypia on biopsy or endocervical curretage, or colposcopic impression of glandualr atypia. Pregnancy and the inability to visualize the entire transformation zone were 2 common reasons for referral in the series by Pfenninger, but they did not account for any referrals in our study. Patients with unsatisfactory colposcopy underwent diagnostic LEEP conization. The 3 pregnant patients in the study cohort were followed through pregnancy without referral. Biopsy of one of these patients showed cervical intraepithelial neoplasia - grade 3; the other 2 were not biopsied because of benign colposcopic findings and ASCUS cytology.

Our study supports the conclusions of Pfenninger and Spoelhof that the majority of colposcopic care for women can be provided by family physicians. Our finding of low referral rates may be surprising because of significant patient preselection. The Cervical Dysplasia Clinic serves a statewide population of uninsured patients who have a high prevalence of cytologic and histologic abnormalities, including high-grade lesions. However, despite a patient population with more severe disease than that seen by the majority of family physicians, referral rates remained relatively low. Despite recent data confirming the safety and efficacy of cryotherapy,⁴ the use of LEEP for large and severe lesions has greatly expanded the family physician’s ability to manage lesions for which cryotherapy remains an unsatisfactory treatment.

Conclusions

Many of the reasons for referral before LEEP was developed are no longer impediments to definitive primary care management. Nonetheless, well-trained family physicians need to be aware of which lesions lie outside the scope of their skills and require referral.⁵ Learning to recognize the boundaries between generalist and specialist management should be one of the major goals of family medicine procedural training. In comparison with cryotherapy, LEEP is more demanding and should be performed only by physicians thoroughly trained in cognitive and technical aspects of electrosurgery. Family physicians lacking extensive LEEP experience should refer appropriately to colleagues skilled in this procedure.

Colposcopy is frequently performed by family physicians and is regarded as a core procedural technique in many family practice residencies. Although colposcopic skills are frequently taught to and employed by family physicians, the clinical situations prompting gynecologic referral by skilled family physician colposcopists have not been widely studied. Pfenninger¹ reported that 28 of 200 patients (14%) requiring colposcopy in a family practice residency program received a referral to a gynecologist because of pregnancy, postmenopausal status, inadequate colposcopy, or the need for laser excision or conization. Conization accounted for approximately half of these referrals. Writing from the perspective of the practicing family physician offering colposcopy, Spoelhoeff² found he needed to refer 10 of 45 women (22%) for specialist gynecologic management. Reasons for referra in-cluded incomplete visualization of the transformation zone, significant discrepancy between cytology and histology, and high-grade lesions requiring laser or conization. One patient was referred because she had multiple previous treatments by a gynecologist. Both Pfenninger and Spoelhoeff treated cervical lesions cryosurgically, referring for any required conization. With the advent of loop electrical excision procedures (LEEP), many cases that previously required referral for conization can be managed in the physician’s office. LEEP has been widely taught in family practice residencies and family physicians are increasingly adopting it for management of cervical dysplasia. In this paper we summarize the referral experience of a family practice cervical dysplasia clinic operating within a residency program during a 6-year period in which LEEP was used as primary management for cervical dysplasia.

Methods

In 1993 the family practice residency program at Via Christi Regional Medical Center in Witchita, Kansas, began the Cervical Dysplasia Clinic. The clinic serves as a major training resource for second-year and third-year family practice residents who gain skills in colposcopy and LEEP under the close supervision of 2 faculty members highly experienced in these procedures. Although educational experience was an important clinic objective, all clinical management decisions were made by one of the 2 faculty supervisors, most often the senior author of this paper. Referrals to the clinic are solicited and received from sources throughout the state of Kansas, primarily from public health clinics and those serving the indigent. The Cervical Dysplasia Clinic serves approximately 60 women each year and maintains a database of patient information including referring cytology, histology, disposition, treatment, and follow-up. We report a descriptive analysis of that database for all patients seen between April 1993 and November 1999.

Results

During the study period, 283 patients were seen in the Cervical Dysplasia Clinic with referring cervical cytology that ranged from atypical squamous cells of undetermined significance (ASCUS) to high-grade squamous intraepithelial lesions. A few patients had normal cytology but were sent to the Cervical Dysplasia Clinic because of visible cervical abnormalities or previous abnormal cytology. At the time of analysis, data was complete on 272 of these individuals, and the cytologic and histologic findings for those patients are summarized in the Table. For a small number of patients management decisions were made without biopsy, most commonly because of the combination of low-grade cytology and benign-appearing colposcopy.

In accordance with evolving practice patterns and cost-benefit analysis,³ the majority of patients with biopsy-confirmed low-grade lesions were scheduled for observation without treatment. High-grade lesions were either treated, almost exclusively with outpatient LEEP within the family practice center, or referred to a gynecologist. All patients with unsatisfactory colposcopy were treated with LEEP conization, provided the transformation zone was confined to the cervix and glandular atypia (adenocarcinoma in situ) had been ruled out. Overall, 26 patients (9%) were referred to a gynecologist for definitive management. The most common reason for referral was the presence of an atypical transformation zone extending onto the vaginal fornix. Although one of these patients was treated with LEEP by the gynecologist to whom she was referred, the remaining patients were treated with a laser or a combination of a laser and LEEP. Five patients were referred to a gynecologist because of the presence of glandular atypia. On the basis of local gynecologic opinion, these patients required cold cone biopsies to eliminate any possibility of histologic heat artifact from a LEEP excision. Two patients had lesions requiring more extensive therapy than could be offered in the dysplasia clinic (perianal warts in one and vaginal intraepithelial neoplasm-grade 2 in a second). One patient had carcinoma in situ with possible invasion, and one had a psychiatric condition that required sedation of the patient in a minor surgical facility for safe surgical management.

Discussion

Although our 9% referral rate differs little from the 14% reported by Pfenninger, the reasons for the referrals have changed. For example, half the referrals by Pfenninger were for cold cone biopsies. In contrast, many LEEP procedures performed in the Cervical Dysplasia Clinic were LEEP cones. Referral for cold knife conization was limited to patients with glandular atypia on biopsy or endocervical curretage, or colposcopic impression of glandualr atypia. Pregnancy and the inability to visualize the entire transformation zone were 2 common reasons for referral in the series by Pfenninger, but they did not account for any referrals in our study. Patients with unsatisfactory colposcopy underwent diagnostic LEEP conization. The 3 pregnant patients in the study cohort were followed through pregnancy without referral. Biopsy of one of these patients showed cervical intraepithelial neoplasia - grade 3; the other 2 were not biopsied because of benign colposcopic findings and ASCUS cytology.

Our study supports the conclusions of Pfenninger and Spoelhof that the majority of colposcopic care for women can be provided by family physicians. Our finding of low referral rates may be surprising because of significant patient preselection. The Cervical Dysplasia Clinic serves a statewide population of uninsured patients who have a high prevalence of cytologic and histologic abnormalities, including high-grade lesions. However, despite a patient population with more severe disease than that seen by the majority of family physicians, referral rates remained relatively low. Despite recent data confirming the safety and efficacy of cryotherapy,⁴ the use of LEEP for large and severe lesions has greatly expanded the family physician’s ability to manage lesions for which cryotherapy remains an unsatisfactory treatment.

Conclusions

Many of the reasons for referral before LEEP was developed are no longer impediments to definitive primary care management. Nonetheless, well-trained family physicians need to be aware of which lesions lie outside the scope of their skills and require referral.⁵ Learning to recognize the boundaries between generalist and specialist management should be one of the major goals of family medicine procedural training. In comparison with cryotherapy, LEEP is more demanding and should be performed only by physicians thoroughly trained in cognitive and technical aspects of electrosurgery. Family physicians lacking extensive LEEP experience should refer appropriately to colleagues skilled in this procedure.

Colposcopy is frequently performed by family physicians and is regarded as a core procedural technique in many family practice residencies. Although colposcopic skills are frequently taught to and employed by family physicians, the clinical situations prompting gynecologic referral by skilled family physician colposcopists have not been widely studied. Pfenninger¹ reported that 28 of 200 patients (14%) requiring colposcopy in a family practice residency program received a referral to a gynecologist because of pregnancy, postmenopausal status, inadequate colposcopy, or the need for laser excision or conization. Conization accounted for approximately half of these referrals. Writing from the perspective of the practicing family physician offering colposcopy, Spoelhoeff² found he needed to refer 10 of 45 women (22%) for specialist gynecologic management. Reasons for referra in-cluded incomplete visualization of the transformation zone, significant discrepancy between cytology and histology, and high-grade lesions requiring laser or conization. One patient was referred because she had multiple previous treatments by a gynecologist. Both Pfenninger and Spoelhoeff treated cervical lesions cryosurgically, referring for any required conization. With the advent of loop electrical excision procedures (LEEP), many cases that previously required referral for conization can be managed in the physician’s office. LEEP has been widely taught in family practice residencies and family physicians are increasingly adopting it for management of cervical dysplasia. In this paper we summarize the referral experience of a family practice cervical dysplasia clinic operating within a residency program during a 6-year period in which LEEP was used as primary management for cervical dysplasia.

Methods

In 1993 the family practice residency program at Via Christi Regional Medical Center in Witchita, Kansas, began the Cervical Dysplasia Clinic. The clinic serves as a major training resource for second-year and third-year family practice residents who gain skills in colposcopy and LEEP under the close supervision of 2 faculty members highly experienced in these procedures. Although educational experience was an important clinic objective, all clinical management decisions were made by one of the 2 faculty supervisors, most often the senior author of this paper. Referrals to the clinic are solicited and received from sources throughout the state of Kansas, primarily from public health clinics and those serving the indigent. The Cervical Dysplasia Clinic serves approximately 60 women each year and maintains a database of patient information including referring cytology, histology, disposition, treatment, and follow-up. We report a descriptive analysis of that database for all patients seen between April 1993 and November 1999.

Results

During the study period, 283 patients were seen in the Cervical Dysplasia Clinic with referring cervical cytology that ranged from atypical squamous cells of undetermined significance (ASCUS) to high-grade squamous intraepithelial lesions. A few patients had normal cytology but were sent to the Cervical Dysplasia Clinic because of visible cervical abnormalities or previous abnormal cytology. At the time of analysis, data was complete on 272 of these individuals, and the cytologic and histologic findings for those patients are summarized in the Table. For a small number of patients management decisions were made without biopsy, most commonly because of the combination of low-grade cytology and benign-appearing colposcopy.

In accordance with evolving practice patterns and cost-benefit analysis,³ the majority of patients with biopsy-confirmed low-grade lesions were scheduled for observation without treatment. High-grade lesions were either treated, almost exclusively with outpatient LEEP within the family practice center, or referred to a gynecologist. All patients with unsatisfactory colposcopy were treated with LEEP conization, provided the transformation zone was confined to the cervix and glandular atypia (adenocarcinoma in situ) had been ruled out. Overall, 26 patients (9%) were referred to a gynecologist for definitive management. The most common reason for referral was the presence of an atypical transformation zone extending onto the vaginal fornix. Although one of these patients was treated with LEEP by the gynecologist to whom she was referred, the remaining patients were treated with a laser or a combination of a laser and LEEP. Five patients were referred to a gynecologist because of the presence of glandular atypia. On the basis of local gynecologic opinion, these patients required cold cone biopsies to eliminate any possibility of histologic heat artifact from a LEEP excision. Two patients had lesions requiring more extensive therapy than could be offered in the dysplasia clinic (perianal warts in one and vaginal intraepithelial neoplasm-grade 2 in a second). One patient had carcinoma in situ with possible invasion, and one had a psychiatric condition that required sedation of the patient in a minor surgical facility for safe surgical management.

Discussion

Although our 9% referral rate differs little from the 14% reported by Pfenninger, the reasons for the referrals have changed. For example, half the referrals by Pfenninger were for cold cone biopsies. In contrast, many LEEP procedures performed in the Cervical Dysplasia Clinic were LEEP cones. Referral for cold knife conization was limited to patients with glandular atypia on biopsy or endocervical curretage, or colposcopic impression of glandualr atypia. Pregnancy and the inability to visualize the entire transformation zone were 2 common reasons for referral in the series by Pfenninger, but they did not account for any referrals in our study. Patients with unsatisfactory colposcopy underwent diagnostic LEEP conization. The 3 pregnant patients in the study cohort were followed through pregnancy without referral. Biopsy of one of these patients showed cervical intraepithelial neoplasia - grade 3; the other 2 were not biopsied because of benign colposcopic findings and ASCUS cytology.

Our study supports the conclusions of Pfenninger and Spoelhof that the majority of colposcopic care for women can be provided by family physicians. Our finding of low referral rates may be surprising because of significant patient preselection. The Cervical Dysplasia Clinic serves a statewide population of uninsured patients who have a high prevalence of cytologic and histologic abnormalities, including high-grade lesions. However, despite a patient population with more severe disease than that seen by the majority of family physicians, referral rates remained relatively low. Despite recent data confirming the safety and efficacy of cryotherapy,⁴ the use of LEEP for large and severe lesions has greatly expanded the family physician’s ability to manage lesions for which cryotherapy remains an unsatisfactory treatment.

Conclusions

Many of the reasons for referral before LEEP was developed are no longer impediments to definitive primary care management. Nonetheless, well-trained family physicians need to be aware of which lesions lie outside the scope of their skills and require referral.⁵ Learning to recognize the boundaries between generalist and specialist management should be one of the major goals of family medicine procedural training. In comparison with cryotherapy, LEEP is more demanding and should be performed only by physicians thoroughly trained in cognitive and technical aspects of electrosurgery. Family physicians lacking extensive LEEP experience should refer appropriately to colleagues skilled in this procedure.