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EVIDENCED-BASED CLINICAL MEDICINE : An Evidence-Based Update

Lee T. Dresang, MD

Colposcopy is a diagnostic procedure, most commonly used in the diagnosis of cervical intraepithelial neoplasia and lower genital tract carcinoma. In this article, evidence-based management strategies are updated with discussion of the 2001 American Society for Colposcopy and Cervical Consensus Guidelines. Practice management issues include methods to improve screening rates, coding and billing, and telemedicine. Textbooks, CD-ROMs, and courses are listed for new learners and experienced providers who want to update and sharpen their skills. (J Am Board Fam Pract 2005;18: 383–92.)

Worldwide, cervical cancer is the second leading of undetermined significance (ASC-US) and ASC- cause of cancer death among women.1 Introducing “cannot exclude high grade squamous intraepithe- programs to areas without them lial lesion” (ASC-H).5 ASC-H is an indication for results in a 60% to 90% reduction in cervical can- colposcopy. For ASC-US, providers may repeat cer rates within 3 years.2 In the United States, cervical cytology at 4 to 6 and 12 months, perform Papanicolaou (Pap) screening has been used since human papillomavirus (HPV) DNA testing, or pro- the 1940s and colposcopy since the 1970s.3 Cervi- ceed to immediate colposcopy. Colposcopy is rec- cal cancer remains the 10th leading cause of cancer ommended if the repeat cytology is ASC-US or death among US women with approximately greater, or HPV testing is positive for high risk copyright. 13,000 new cases and 4,100 deaths in 2002.2 This types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 59, and evidence-based update on colposcopy covers indi- 68).6 cations, technique, management recommendations, 2001 ASCCP Consensus Guidelines recom- practice management issues, and available re- mend HPV testing for management of ASC-US.4 sources. A 2002 cost-effectiveness study found reflex HPV testing for high risk DNA types for all ASC-US Indications for Colposcopy Pap results using liquid-based cytology “provides http://www.jabfm.org/ Recommendations for when to perform colposcopy the same or greater life expectancy benefits and is have changed with the 2001 American Society for more cost-effective than other management strat- Colposcopy and Cervical Pathology (ASCCP) egies.”7 Consensus Guidelines. Table 1 lists colposcopy in- dications, the most common being an abnormal Pap. Figure 1 illustrates recommendations for the Low Grade Squamous Intraepithelial Lesion and management of abnormal cytology according to High Grade Squamous Intraepithelial Lesion on 27 September 2021 by guest. Protected 4 2001 ASCCP Consensus Guidelines. Terminology Pap results were first classified as low grade squa- Atypical Squamous Cells mous intraepithelial lesion (LSIL) and high grade The 2001 subdivides atypical squamous intraepithelial lesion (HSIL) through the squamous cells (ASC) into atypical squamous cells 1988 Bethesda system; the LSIL/HSIL terminol- ogy remains unchanged in the 2001 Bethesda sys- 5 Submitted, revised, 1 April 2005. tem. LSIL refers to cervical intraepithelial neopla- From the University of Wisconsin Medical School, De- sia (CIN)-1/mild disease. HSIL incorporates the partment of Family Medicine, St. Luke’s Family Practice Residency, Milwaukee, Wisconsin. previous categories of CIN-2/moderate dysplasia, Conflict of interest: none declared. CIN-3/severe dysplasia and . The Corresponding author: Lee T. Dresang, MD, Associate Professor, 1230 W. Grant Street, Milwaukee, WI 53215 new LSIL/HSIL nomenclature is “a more reliable, (e-mail: [email protected]). reproducible way to classify lesions with malignant http://www.jabfp.org 383 J Am Board Fam Pract: first published as 10.3122/jabfm.18.5.383 on 7 September 2005. Downloaded from

Table 1. Indications for Colposcopy can be subdivided into large loop excision of the

Abnormal Papanicolaou transformation zone (LLETZ) and LEEP coniza- ASC-US* tion, involving a deeper endocervical sample ASC-US twice through the use of a second loop. Cervical coniza- ASC-US with high risk HPV types ASC-H tion procedures (LEEP, , and cold-knife) can LSIL be diagnostic and/or therapeutic. The LEEP used HSIL AGC in a “see and treat” approach to HSIL is usually a Cervical lesion LLETZ, which is both diagnostic and therapeutic. Condyloma accuminata Polyp Vaginal lesion Atypical Glandular Cells Ulcers The 2001 Bethesda system replaced the term atyp- Vulvar lesion ical glandular cells of uncertain significance Genital warts Ulcer (AGUS) with the term atypical glandular cells Mole concerning for melanoma (AGC), with the subclassifications: not otherwise Follow-up LEEP, cryotherapy, cone specified (NOS), favor neoplasia, endocervical ad- Intrauterine exposure enocarcinoma in situ (AIS). The risk of premalig- Sexual partner with genital warts or condyloma accuminata nant or malignant disease is 9% to 41% for AGC Sexual abuse NOS Papanicolaou results vs 96% for AGC favor 11 * ASC-US, atypical squamous cells of undetermined signifi- neoplasia. All AGC Pap results should be evalu- cance; HPV, human papillomavirus; LSIL, low grade squamous ated with a colposcopy and endocervical sampling, intraepithelial lesion; HSIL, high grade SIL; AGC, atypical with the exception that women with atypical endo- glandular cells; LEEP, loop electrosurgical excision procedure. metrial cells should be initially evaluated with en- dometrial sampling. In the absence of atypical en- potential.”8 The SIL, CIN, and dysplasia terminol- dometrial cells, endometrial sampling is indicated copyright. ogy can be used for cytology (Papanicolaou) and for AGC results if the patient is over age 35 or 4 histology (biopsy) results. With the SIL terminol- bleeding irregularly. ogy of the Bethesda system, “CIN or dysplasia terminology can be used, either as a substitute for Sexual Abuse SIL or as an additional descriptor.”5 2001 ASCCP Colposcopy is often used for documenting sexual Consensus Guidelines principally use SIL termi- abuse. Some colposcopes allow photography. The nology for cytology results and CIN terminology hymen is carefully examined for signs of trauma. http://www.jabfm.org/ for histology results.4,9 The green filter can bring out avascular areas caused by scarring.12,13 Low Grade Squamous Intraepithelial Lesion Patients with LSIL cytology should be evaluated with a colposcopy. HPV testing is not recom- Cervical Polyp mended for LSIL cytology because 83% of patients “Polyps can be neoplastic, and may be the present-

10 on 27 September 2021 by guest. Protected with LSIL are positive for high risk HPV types. ing sign of cervical neoplasia or endometrial can- Repeat cytology is not recommended for LSIL. cer. They should be biopsied or removed for his- tologic evaluation.”14 If endocervical polyp origin High Grade Squamous Intraepithelial Lesion is not evident on colposcopy, a transvaginal pelvic HSIL cytology can be evaluated with colposcopy or ultrasound should be performed: some polyps pro- treated directly with a “see and treat” procedure truding from the may originate high in the such as loop electrosurgical excision procedure . (LEEP). Because a “see and treat” approach may lead to over-treatment, it is best reserved for pa- tients at risk for loss to follow-up.4 Suspicious Lesions of Genital Track Cervical treatment options include ablation pro- Suspicious lesions (including warts, plaques, and cedures (cryotherapy) and excisional procedures ulcers) of the genital track (cervix, , and (LEEP, laser, and cold-knife conization). LEEP ) should be investigated with colposcopy re-

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Figure 1. Recommendations for Management of Women with Cytological Abnormalities According to 2001 ASCCP Consensus Guidelines. on 27 September 2021 by guest. Protected gardless of Pap results. It is possible to have cancer sleeved cytobrush (Figure 3) as an alternative to an despite a normal Pap.15 endocervical curettage (ECC) and colposcopic technique in , adolescence, and meno- Technique pause are discussed below. A comprehensive review of anatomy, pathophysi- ology, and colposcopic technique is beyond the Cytobrush versus Endocervical Curettage scope of this paper, but can be obtained through A study since the 2001 ASCCP Consensus Guide- the resources listed in Tables 2 and 3. Figure 2 lines showed that a cytobrush with a sleeve (straw) illustrates the appearance of acetowhite changes, is more sensitive and less painful, with less speci- punctation, and mosaicism with the application of men inadequacy. A cytobrush is rotated 360 de- 3% to 5% . Evidence supporting the grees briskly 5 times and pulled back into the straw http://www.jabfp.org 385 J Am Board Fam Pract: first published as 10.3122/jabfm.18.5.383 on 7 September 2005. Downloaded from

Table 2. Colposcopy Books

Category Reference Description Price

Introductory book Sellers JW, Sankaranarayanan R. Colposcopy 144 pages; introductory manual; may help $20.50 and treatment of cervical intraepithelial implementation in developing countries neoplasia, a beginners’ manual. Intl. Agency for Research on Cancer, 2003. Soutter P, Soutter WP. A practical guide to 272 pages; guide for those setting up a $158.82 colposcopy (Oxford Medical Publications). colposcopy clinic; ways of helping to Oxford University Press; 1997. minimize patient anxiety suggested Luesley D, Shafi M, Jordan J (editors). 164 pages; based on course run by the $67.50 Handbook of colposcopy, 1st Ed. British Society of Colposcopy and Lippincott, Williams & Wilkins Cervical Pathology; introduction for Publishers; 1996. beginners Atlas and textbook Baggish MS, Baggish M. Colposcopy of the 384 pages; textbook and atlas; color photos; $149.00 cervix, vagina, and vulva: a comprehensive discussion of colposcopy of the cervix, textbook. Mosby, Inc.; 2003. vagina and vulva followed by case illustrations Colposcopy: a medical dictionary, 152 pages; terms related to colposcopy; $34.95 bibliography, and annotated research bibliography, internet resources guide to internet references. Icon Health Publications; 2003. Prendiville W, Ritter J, Tatti S. (Editors). 160 pages; textbook and atlas; 120 color $79.95 Colposcopy: management options. WB photographs Saunders Company; 2003. Apgar S. Spitzer M, Brotzman GL, 512 pages; textbook and atlas; color photos; $99.00 Ignatavicius DD. Colposcopy: principles highlights correlations between cytology, and practice: an integrated textbook and colposcopy and histology atlas. 1st ed. WB Saunders Company, 2002. Burghardt E, Pickel H, Girardi F. Primary 168 pages; textbook and atlas; equipment, $61.62 care colposcopy: textbook and atlas, 1st training, exam techniques, normal and copyright. Ed. Thieme Medical Publishers; 2002. abnormal colposcopic findings, differential diagnosis and treatment Singer A, Monaghan JM, Chong S. Lower 323 pages; textbook and atlas; new section $230.95 genital tract precancer: colposcopy, on AIDS and chapter on pathology pathology and treatment, 2nd Ed. Blackwell Science Inc.; 2000.

before removing. This technique may prevent con- sions that do not appear severe in nature need not http://www.jabfm.org/ tamination of the endocervical sample with ecto- be biopsied. Serial cytology and colposcopy should cervical disease. Specimen inadequacy was 2% be performed throughout pregnancy with biopsy of compared with 22% with an ECC.16 worsening lesions or with cytology indicating inva- sive disease. It is important that patients return for 4 Colposcopy in Pregnancy a colposcopy at least 6 weeks after delivery.

ECC is contraindicated during pregnancy. Ectro- on 27 September 2021 by guest. Protected pion (eversion) of the cervix with migration of the transformation zone (eversion of endocervical epi- Colposcopy in Adolescents thelium) may lead to an increased percentage of In general, a diagnostic excisional procedure satisfactory colposcopies during pregnancy. When (LEEP, laser, or cold-knife conization) is recom- the everted columnar cells are exposed to the vag- mended for patients with HSIL cytology but a inal environment, they undergo metaplasia. This normal or CIN-1 histology. In adolescents, it is may increase the frequency of normal acetowhite acceptable to observe CIN-2 histology with repeat changes noted. The incidence of CIN is similar in colposcopy every 4 to 6 months for 1 year if the pregnant and non-pregnant women.17 endocervical sample is negative and the patient The purpose of colposcopy during pregnancy is accepts the risk of occult disease. If the HSIL Pap to detect severe dysplasia or cancer. Unless invasive result persists, a diagnostic excisional procedure is cancer is identified, treatment is unacceptable. Le- recommended.4

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Table 3. Colposcopy CD-ROMs

CD-ROM Content Ordering Information Price

Brotzman G, Spitzer, Apgar Over 800 colposcopic American Society for $170 ASCCP members; B. Colposcopy image images linked to 31 key Colposcopy and Cervical $190 non-members library. National terms; demonstrate over Pathology, 20 West Procedures Institute; 3000 colposcopic features Washington Street; Suite 2003. 1, Hagerstown, MD 21740, 800-787-7227, http://www.asccp.org/ bookstore.shtml# Spitzer M, Jones H, Interactive tutorials and 26 American Society for $175 ASCCP members; Runowicz CD, Waggoner case presentations; 2001 Colposcopy and Cervical $195 non-members SE. Advanced colposcopy Bethesda system Pathology, 20 West American College of terminology Washington Street; Suite Obstetrics and 1, Hagerstown, MD Gynecology/American 21740, 800-787-7227, Society for Colposcopy http://www.asccp.org/ and Cervical Colposcopy; bookstore.shtml# 2002. American Academy of Video and audio clips, American Academy of $110 AAFP members; $140 Family Physicians. searchable text Family Physicians non-members Colposcopy for the family documents, interactive (AAFP), 11400 physician; 1998 test Tomahawk Creek Parkway, Leawood, KS 66211, 800-944-0000, http://www.aafp.org/x18319.xml Anderson M, Jordan JA, Module 1: cytology, www.amazon.com $325 Morse AR, Sharp F. colposcopy and histology; color 1000ف :Integrated colposcopy: Module 2 for colposcopists, images; Module 3: over histopathologists and 30 cases

cytologists. Lippincott, copyright. Williams & Wilkins Publishers; 1997.

Colposcopy after Menopause endocervical cells to result in a satisfactory exami- Postmenopausal atrophy can result in abnormal nation.4 cytology. A postmenopausal woman with an LSIL Pap result may undergo estrogen treatment fol- Follow-Up of Histology or Colposcopy Results http://www.jabfm.org/ lowed by repeat Pap every 4 to 6 months. Estrogen 2001 ASCCP Consensus Guidelines for managing cream is applied intravaginally each evening for 4 histology are depicted in Figure 4.9 weeks and stopped 1 week before repeat cytology. Postmenopausal patients with LSIL undergoing es- trogen treatment may return to annual Pap after 2 Unsatisfactory Examination normal results. An ASC or more severe abnormal- Management of an unsatisfactory colposcopic ex- ity on Pap after estrogen treatment should be eval- amination depends on cervical cytology and histol- on 27 September 2021 by guest. Protected uated with colposcopy. Recommended manage- ogy. An unsatisfactory examination following HSIL ment of HSIL cytology is not effected by warrants a diagnostic excisional procedure. In ad- menopausal status.4 dition, a diagnostic excisional procedure is recom- Because of hormonal changes, many postmeno- mended after an unsatisfactory examination with pausal women will have an unsatisfactory colpos- biopsy proven CIN-1, CIN-2, or CIN-3. If colpo- copy. A colposcopy is considered unsatisfactory if scopic histology is normal and cytology is less se- the entire transformation zone cannot be visualized vere than HSIL, repeating a Pap at 6 and 12 and if the distal end of a lesion extending into the months, HPV testing at 1 year, or a Pap and col- endocervical canal cannot be visualized. In post- poscopy at 1 year are all acceptable.9 An unsatis- menopausal women, the former is often true. Es- factory examination in a post-menopausal woman is trogen treatment described in the previous para- addressed in the Colposcopy after Menopause sec- graph will often cause enough ectropion of the tion above. http://www.jabfp.org 387 J Am Board Fam Pract: first published as 10.3122/jabfm.18.5.383 on 7 September 2005. Downloaded from

Figure 3. Cytobrush with Sleeve.

CIN-1 When colposcopy is satisfactory, observation or treatment of biopsy confirmed CIN-1 is acceptable. Acceptable observation options include: (1) repeat Pap at 6 and 12 months, (2) HPV testing at 12 months, and (3) repeat Pap and colposcopy at 12

months. Acceptable treatment modalities include: copyright. (1) cryotherapy, (2) laser ablation, and (3) LEEP. Endocervical sampling is recommended before ab- lation of CIN-1.9

CIN-2,3 Observation with biopsy confirmed CIN-2,3 is un- acceptable, except in special circumstances includ- http://www.jabfm.org/ ing adolescents with CIN-2 and pregnant patients. Figure 2. Cervix before and after Application of Acetic When colposcopy is satisfactory and the endocer- Acid. vical sample is negative, excision and ablation are acceptable. With recurrent CIN-2,3, excisional modalities are preferred. In immunosuppressed in- Normal dividuals, such as those with the human immuno-

Additional testing is indicated after a normal col- deficiency virus, biweekly, topical vaginal 5-flu- on 27 September 2021 by guest. Protected poscopy to help avoid missed pathology. A satisfac- orouracil may be used after treatment to reduce the tory colposcopy negative for dysplasia following risk of recurrent cervical dysplasia.9 HSIL, AGC favor neoplasia (FN) or endocervical AIS warrants a diagnostic excisional procedure, Cancer preferably a cold-knife cone for AGC FN and AIS. A woman with micro or invasive cancer on colpo- Repeat Pap every 4 to 6 months until 4 consecutive scopic directed biopsy should be referred to an negative results are obtained is the recommended appropriate specialist. follow-up of a normal, satisfactory colposcopy after AGC NOS cytology. The same examination, fol- Practice Management lowing ASC or LSIL cytology, warrants repeating a Colposcopy practice management issues include Pap at 6 and 12 months, HPV testing at 1 year, or strategies to increase Pap screenings, follow-up of a Pap and colposcopy at 1 year.9 results, and coding and billing.

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Figure 4. Management of Colposcopic Findings.

Increasing Pap Screenings when indicated. Of US women with cervical can- Screening with Pap to know when colposcopy is cer, 50% have never had a Pap and another 10% indicated is as important as providing colposcopy have not had a Pap in the 5 years before diagno- http://www.jabfp.org 389 J Am Board Fam Pract: first published as 10.3122/jabfm.18.5.383 on 7 September 2005. Downloaded from

Table 4. Colposcopy ICD-9 Codes24 any abnormal results. Tracking systems can alert

ICD-9 Code Description patients to the need for an appointment and can alert providers to patients who may otherwise be 078.11 Condyloma accuminata lost to follow-up with dangerous consequences. 078.19 Genital warts 616.50 Vulvar ulcer 616.8 Cervical ulcer Telemedicine and Rural Practice 622.1 Abnormal Papanicolaou test Telecolposcopy involves a local provider taking 622.7 Polyp of cervix colposcopic images (still and/or video) which are 624.8 Vulvar mole no specific diagnosis transmitted electronically to an expert colposcopist 654.60 Abnormality of cervix in pregnancy for interpretation and recommendations. The dis- 995.53 Sexual abuse V01.7 Sexual partner with genital warts or condyloma tant reading of the images may be real-time or 20 accuminata delayed. Barriers to telecolposcopy include: “the initial cost of capitalization, reimbursement, and licensing challenges, as well as the threat of mal- 21 18 practice.” - sis. Evidence supports patient reminders as one In remote rural areas, colposcopy per way of increasing Pap rates.19 formed by local providers is less costly than tele- medicine with expert consultation.22 However, colposcopists’ and patients’ satisfaction with tele- Computerized Tracking Systems colposcopy is high. In one study, over 95% of Many health systems are able to track whether women who lived more than 25 miles from a re- registered patients are up to date on their Pap ferral center would rather have telecolposcopy lo- screening and whether they have followed up on cally than to drive to the referral center.23 copyright. Table 5. Colposcopy CPT codes25–27

Medicare Prof Fee When Medicare Prof Fee When Medicaid WI CPT Code Description of Examination Performed in Facility Performed in Clinic Physician Fee

56820 Colposcopy of the vulva 81.73 106.36 —* 56821 with biopsy(s) 112.93 143.45 —* 57420 Colposcopy of the entire vagina, with 86.86 111.48 —* cervix if present 57421 with biopsy(s) 120.61 152.17 —* http://www.jabfm.org/ 57452 Colposcopy of the cervix including upper 81.73 108.44 —* vagina 57454 With biopsy(s) of the cervix and 126.85 153.21 90.47 endocervical curettage 57455 With biopsy(s) of the cervix 109.65 140.17 —* 57456 With endocervical curettage 102.68 132.51 —*

57460 With loop electrode biopsy(s) of the 158.96 325.81 294.88 on 27 September 2021 by guest. Protected cervix 57461 With loop electrode conization of the 187.96 357.57 —* cervix 57500 Biopsy, single or multiple, or local 56.4 132.36 56.20 excision of lesion, with or without fulguration (separate procedure) 57505 Endocervical curettage 85.24 98.08 59.80 57511 Cryocautery, initial or repeat 125.91 141.87 67.90 57522 Loop electrode excision 230.93 289.21 298.00 58100 Endometrial sampling (biopsy) 84.68 105.84 54.69 99170 Colposcopy of perineum 85.96 127.58 132.52

* No fee listed in schedule; fee based on individual consideration, medical consultant. Note: fees are for Wisconsin. A geographic adjustment factor (GAF) between 0.84 and 1.30 is multiplied by a national figure to calculate state value.

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ICD-9 Codes and CPT-4 Codes and Charges 6. Wright T, Schiffman M, Solomon D, et al. Interim Please see Tables 4 and 5 for colposcopy-related guidance for the use of human papillomavirus DNA outpatient codes and charges. testing as an adjunct to cervical cytology for screen- ing. Obstet Gynecol 2004;103:304–9. 7. Kim JJ, Wright TC, Goldie SJ. Cost-effectiveness of alternative triage strategies for atypical squamous Resources cells of undetermined significance. JAMA 2002;287: Colposcopy resources include books (Table 2) and 2382–90. CD ROMs (Table 3). The American Academy of 8. The cervix: colposcopy: high grade cervical intraepi- Family Physicians (AAFP) and ASCCP regularly thelial neoplasia: cytology, histology, and colpos- hold colposcopy courses, which can be found on copy. American Society for Colposcopy and Cervical their respective web sites: www.aafp.org and www. Pathology. http://www.asccp.org/edu/practice/cervix/ colposcopy/highgrade.shtml. Site last visited March asccp.org. The ASCCP offers a Colposcopy Men- 28, 2005. torship Program, which requires a minimum of 25 9. Wright TC Jr, Cox JT, Massad LS, Carlson J, supervised colposcopies, with at least three high- Twiggs LB, Wilkinson EJ. 2001 Consensus guide- grade findings, and successful completion of a writ- lines for the management of women with cervical ten and slide examination. Documentation of suc- intraepithelial neoplasia. Am J Obstet Gynecol 2003; cessful program completion is awarded, but there is 189:295–304. no certification for colposcopy. 10. The ASCUS-LSIL Study (ALTS) Group. A ran- domized trial on the management of low-grade in- traepithelial lesion cytology interpretations. Am J Conclusions Obstet Gynecol 2003;188:1393–400. Colposcopy is an important component of cervical 11. Levine L, Lucci JA, Dinh TV. Atypical glandular cells: new Bethesda terminology and management cancer screening. An evidence-based approach to guidelines. Obstet Gynecol Survey 2003;58: colposcopy requires familiarity with 2001 ASCCP 399–406. copyright. Consensus Guidelines. By following these guide- 12. Britton H, Hansen K. Sexual abuse. Clin Obstet lines and reviewing new evidence as it develops, Gynecol 1997;40:226–40. family physicians can play a valuable role in cervical 13. Hobbs C, Wynne J. Use of colposcope in examina- cancer screening with Papanicolaou tests and col- tion for sexual abuse. Arch Disease Childhood 1996; poscopies, an approach that has reduced cervical 75:539–42. cancer rates by 75% in the United States. 14. The cervix: colposcopy: colposcopic appearance of benign lesions. American Society for Colposcopy and Cervical Pathology. http://www.asccp.org/edu/ References practice/cervix/colposcopy/benign.shtml. Site last http://www.jabfm.org/ 1. Koliopoulos G, Martin-Hirsch P, Paraskevaidis E, visited March 28, 2005. Arbyn M. HPV testing versus cervical cytology for 15. Dresang LT. Cervical cancer with a normal Pap. screening for cancer of the uterine cervix. Cochrane WMJ 2003;102:4. Gynaecological Cancer Group. Cochrane Database 16. Boardman LA, Meinz H, Steinhoff MM, Heber of Systematic Reviews, 2004. WW, Blume J. A randomized trial of the sleeved 2. US Preventive Services Task Force. Screening for cytobrush and the endocervical curette. Obstet Gy- cervical cancer: recommendations and rationale. necol 2003;101:426–30. on 27 September 2021 by guest. Protected American Family Physician 2003;67:1759–66. 17. Palle C, Bangsboll S, Andreasson B. Cervical intra- 3. Spitzer M, Apgar B, Brotzman G, Krumhoz BA. epithelial neoplasia in pregnancy. Acta Obstet Gy- Residency training in colposcopy: a survey of pro- necol Scand 2000;79:306–10. gram directors in obstetrics and gynecology and fam- 18. Nuovo J, Melnikow J, Howell L. New tests for ily practice. Am J Obstet Gynecol 2001;185:507–13. cervical cancer screening. Am Fam Physician 2001; 4. Wright TC Jr, Cox JT, Massad LS, Twiggs LB, 64:780–6. Wilkinson EJ. Consensus guidelines for the manage- 19. Tseng DS, Cox E, Plane MB, Hia KM. Efficacy of ment of women with cervical cytological abnormal- patient letter reminders on cervical cancer screening. ities. JAMA 2001;287:2120–9. A meta-analysis. J Gen Intern Med 2001;16:563–8. 5. Solomon D, Davey D, Kurman R, et al. Forum 20. Ferris DG, Litaker MS, Macfee MS, Miller JA. Re- Group Members. Bethesda 2001 Workshop. The mote diagnosis of cervical neoplasia: 2 types of tele- 2001 Bethesda System: terminology for reporting colposcopy compared with . J Fam results of cervical cytology. JAMA 2002;287:2114–9. Pract 2003;52:298–304. http://www.jabfp.org 391 J Am Board Fam Pract: first published as 10.3122/jabfm.18.5.383 on 7 September 2005. Downloaded from

21. Susman J. Telemedicine marches on: the efficacy of 24. Puckett CD. The educational annotation of ICD-9- remote telecolposcopy (Editorial). J Fam Pract 2003; CM, 5th Ed. Reno (NV): Channel Publishing Ltd.; 52:264. 2003. 22. Bishai DM, Ferris DG, Litaker MS. What is the 25. American Medical Association. Current Procedural least costly strategy to evaluate cervical abnormali- Terminology: 2004. Chicago (IL): AMA Press; 2003. ties in rural women? Comparing telemedicine, local 26. Medicare Fees based on Medicare Part B Physi- practitioners, and expert physicians. Med Decis cian Fee Schedule. http://www.wpsic.com/medicare/ Making 2003;23:463–70. provider/pricing_fees.shtml. Site last visited March 23. Harper DM, Moncur MM, Harper WH, Burke GC, 28, 2005. Rasmussen CA, Mumford MC. The technical per- 27. Medicaid Fees based on WI Medicaid Fee Schedule. formance and clinical feasibility of telecolposcopy. J http://dhfs.wisconsin.gov/medicaid4/maxfees/maxfee. Fam Pract 2000;49:623–7. htm#medicaid. Site last visited March 28, 2005. copyright. http://www.jabfm.org/ on 27 September 2021 by guest. Protected

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