Abnormal Colposcopy Research Articles

Strength of correlations between colposcopic impression and biopsy histology

Objective The aim of this study was to determine the strength of the correlation between colposcopic impression and biopsy histology. Methods In an urban referral clinic, colposcopy and directed biopsy were performed between July 1, 1996, and December 31, 1999, by residents supervised by board-certified attending obstetrician–gynecologists. Impression and biopsy were graded as benign, suggesting condyloma or koilocytosis, cervical intraepithelial neoplasia (CIN) grades 1–3, or cancer. The significance of association was assessed by χ 2 testing and the strength by κ statistics. Results Colposcopies were performed on 2825 women, with colposcopic impression and biopsy grade known for 2112. Exact agreement was found in only 893 (37%) women, but results agreed within one grade in 1203 (75%). The association between impression and histology was significant ( P < 0.001), but the strength of the correlation was poor (0.20). The positive predictive value of any colposcopic abnormality for any histologic abnormality was 80%. The negative predictive value of a benign colposcopic impression was 68%. The sensitivity of colposcopy with a threshold of any lesion detected was 89%, and the specificity was 52%. The sensitivity for CIN 2/3 was 56%. Conclusion Colposcopy is imprecise, although useful in estimating lesion grade. Management decisions require biopsy.

Information leaflets, verbal information and women's knowledge of abnormal cervical smears and colposcopy

A cross-sectional audit by questionnaire was carried out on 100 consecutive colposcopy clinic patients. These women were first attenders, with cervical smears showings mild to severe dyskaryosis. This study assessed the delivery of information using educational leaflets and verbal counselling and the knowledge these women had in the key areas of cervical screening and colposcopy. Of the 82 patients whose questionnaires were analysed, 83% had received the educational leaflets, 61% received verbal information while 56% had received both. Of the 68 patients who had received the information leaflet, 97% read and understood it and 93% considered the information in it adequate. Overall, 91% of the patients knew which organ was being screened, 89% knew the implication of an abnormal smear and 88% were aware of the implication of defaulting from follow-up. Ten per cent of the women believed that an abnormal smear meant an early stage cancer, 54% were not aware of the effect of smoking on abnormal smears and biopsy results and only 24% were aware of follow-up plans in colposcopy. It appears that preclinic information through educational brochures and verbal counselling are achieving the desired effect by improving women's knowledge, but there is still scope for improvement. Verbal educational and written information needs to address the issues of follow-up in colposcopy and the implications of default as this may improve compliance. The number of women receiving both written and verbal information should increase from the current 56%.

Human papillomavirus infections and risks of cervical cancer: what do women know?

Human papillomavirus (HPV) is now known to be a risk factor for the development of cervical cancer. This study examines women's knowledge of cervical screening and dysplasia and HPV. The entire female work force of a medium-sized UK university received a questionnaire concerning knowledge of cervical screening, treatment for abnormalities and HPV. Four hundred women returned completed questionnaires. Knowledge of early cervical cancer detection and screening methods was good. However, risk factors for cervical cancer were not well known. Awareness and knowledge of HPV was very limited. Past experience of an abnormal smear result and colposcopy was significantly associated with good knowledge of cervical screening, but not with knowledge of HPV. It is essential to improve women's understanding of this area in the context of plans to include screening for HPV in the UK's national cervical screening programme.

An open-label noncomparative study to evaluate the vagina and cervix of NuvaRing® users

An open-label noncomparative study to evaluate the vagina and cervix of NuvaRing® users

The psychological impact of abnormal cytology and colposcopy.

The psychological impact of abnormal cytology and colposcopy.

Can pre-colposcopy sessions reduce anxiety at the time of colposcopy? A prospective randomised study

The main objective of this prospective randomised study was to evaluate whether offering pre-colposcopy group sessions reduces anxiety at the time of colposcopy. We also examined whether this strategy improved knowledge about abnormal smears and colposcopy and improved satisfaction with the colposcopy service provided. One hundred and forty-seven women undergoing colposcopy for the first time were randomised into two groups. The control group (n = 75) received conventional management. The study group (n = 72), in addition to conventional management, were invited to attend a pre-colposcopy group session led by a trained colposcopy nurse. Questionnaires were used to determine state anxiety inventory scores and knowledge scores at the time of randomisation, immediately before colposcopy and 6 weeks after the clinic visit. Satisfaction questionnaires were completed 6 weeks after the clinic visit. We found that women attending colposcopy clinics are anxious. Those women who attended the pre-colposcopy session had improved knowledge scores (P = 0·039) at the time of colposcopy and satisfaction (P = 0·037). However, the intervention failed to significantly reduce anxiety at the time of colposcopy (P > 0·05).

Aplicación del método "ver y tratar" en pacientes con citología LIE de alto grado y colposcopia con cambios mayores

INTRODUCCIÓN: El método de ver y tratar consiste en diagnosticar y tratar por medio de la radiofrecuencia (asa LEEP) en una sola visita médica las pacientes con citología y colposcopia alteradas. Esta opción terapéutica se podría ajustar a nuestras condiciones económicas, sociales y culturales.OBJETIVOS: Evaluar la eficacia terapéutica del método "ver y tratar" en pacientes con citología LIE de alto grado y colposcopia con cambios mayores, en la unidad hospitalaria de Castilla.MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo descriptivo de las historias clínicas de las pacientes sometidas al protocolo de "ver y tratar", las cuales tenían citología de alto grado y hallazgos colposcópicos de "cambios mayores" entre 1998 y 1999.RESULTADOS: Fueron sometidas a este protocolo 24 pacientes, 22 (91.7%) tuvieron algún grado de displasia en el resultado de anatomía patológica: NIC II en 5 pacientes, NIC III en 16 y 1 con NIC I. 2 pacientes se consideraron "sobretratadas", pues no se halló evidencia de NIC.Existieron 5 casos de pacientes (22.7%) que presentaban bordes del LEEP comprometidos, los cuales al hacerles el seguimiento solo uno requirió retratamiento con LEEP, el cual reportó NIC I.CONCLUSIONES: La aplicación del método "ver y tratar" en pacientes con citología de alto grado y hallazgos a la colposcopia con cambios mayores es una alternativa eficaz para manejar las pacientes y con una alta correlación patológica y baja tasa de sobretratamiento; que permite ahorrar recursos y dinero.

Collection devices for obtaining cervical cytology samples.

The false-negative rate of cervical smears varies between 1.5% and 55%. This variation may be partly due to differences in sampling device and technique. The objective of this review was to assess different cervical sampling devices for collecting endocervical cells, which are thought to be a surrogate for detection of abnormal cells and adequate smear rates. We searched the Cochrane Gynaecological Cancer Group trials register and MEDLINE up to July 1997. We also handsearched 16 journals. Randomised and quasi-randomised trials and non-randomised comparative studies comparing cervical smear collection devices in women attending for primary screening, colposcopy following an abnormal smear or colposcopy after treatment. Two reviewers independently abstracted data. Study quality was assessed. Thirty-four trials and six observational comparative studies were included. The Ayre spatula was shown to be less effective compared with extended tip spatulas for collecting endocervical cells in eight trials (odds ratio 2.25, 95% confidence interval 2.06 to 2.44). Use of a spatula with the cytobrush was more effective than spatula alone at collecting endocervical cells (odds ratio 3.33, 95% 3.05 to 3.63) and the same effect was present for adequate smear rates (odds ratio 1.51 95% 1.19-1.92). Extended tip spatulas were also superior for the detection of dyskaryosis in seven trials (odds ratio 1.21, 95% confidence interval 1.10 to 1.33). Based on data from two trials and three observational studies, smears that contained endocervical cells were more likely to detect dyskaryosis, particularly in severe disease. The proportion of smears with endocervical cells present increased with increasing severity of the disease. Extended tip spatulas of various designs appear to be better for collecting endocervical cells than the commonly used Ayre spatula. The most effective combination appears to be the cytobrush with an extended tip spatula. The rate of detection of endocervical cells appears to be a valid and convenient surrogate for the ability to detect dyskaryosis and for adequate smear rates. The ability of the extended tip spatula with the cytobrush compared with the extended tip spatula alone to detect disease, needs to be evaluated in a trial.

Hyperspectral diagnostic imaging of the cervix: report on a new investigational device.

To describe our experience with a noncontact in vivo fluorescence imaging device for the detection and localization of cervical intraepithelial neoplasia (CIN). Sixty-two women with abnormal Papanicolaou (Pap) smears, and 4 women with normal Pap smears, were recruited to undergo fluorescence imaging of the cervix during colposcopy. After topically applying dilute acetic acid, the surface of the cervix was scanned with 365 nm ultraviolet light for about 12 sec. Colposcopy and biopsies of visualized lesions were then performed. The fluorescence emission curves generated by normal cervical tissue and various states of cervical pathology were inspected and assigned relative scores of 1-5 based on the height and slope of the curves at peak fluorescence emissions. A score of 1 indicated a curve with high magnitude and distinct peak, and a score of 5 described a curve of low magnitude and rounded/flattened peak. Scores of 2-4 represented curves with incremental changes of about 25% in the height of the curve between scores of 1 and 5. Biopsies were classified as high grade (HG, CIN 2/3), low grade (LG, HPV/CIN 1), or nondysplastic (ND). Among women with abnormal Pap smears, only those who had biopsies with concordant interpretations by two independent pathologists were included in the descriptive analysis. All of the patients with normal Pap smears were included. A total of 35 women were included in the analysis. Of 62 women with abnormal Pap smears who underwent fluorescence imaging and colposcopy, 31 met the inclusion criteria. Among these 31 women, Pap smears consisted of 6 atypical squamous cells of undetermined significance (ASCUS), 16 low-grade squamous intraepithelial lesions (LGSILs), and 9 high-grade squamous intraepithelial lesions (HGSILs). Of the 4 women with normal Pap smears, 1 had an abnormal colposcopy and a nondysplastic biopsy. Among all 35 women, 42 total biopsies were included, consisting of 11 HG, 25 LG, and 6 ND. Normal squamous tissue generated a score of 1, normal metaplastic tissue a score of 2 or 3, and normal columnar tissue of score of 5 in 35/35 (100%) women. Among the 11 HG lesions, 8 had a score of 4 and 2 had a score of 5. One case was uninterpretable due to a low signal-to-noise ratio. Among the 25 LG lesions, 15 had a score of 3, 6 had a score of 4 or 5, 2 had a score of 1, and 2 cases were uninterpretable. HG lesions generated spectra distinct from normal tissue in 8/10 (80%) evaluable cases, but LG lesions generated spectra indistinguishable from that of normal metaplastic tissue. Further modifications to this technique are needed before an objective, reproducible, and discriminatory scoring system can be developed. ▪.

Hyperspectral Diagnostic Imaging of the Cervix: Report on a New Investigational Device

Objective. To describe our experience with a noncontact in vivo fluorescence imaging device for the detection and localization of cervical intraepithelial neoplasia (CIN). Materials and Methods. Sixty-two women with abnormal Papanicolaou (Pap) smears, and 4 women with normal Pap smears, were recruited to undergo fluorescence imaging of the cervix during colposcopy. After topically applying dilute acetic acid, the surface of the cervix was scanned with 365 nm ultraviolet light for about 12 sec. Colposcopy and biopsies of visualized lesions were then performed. The fluorescence emission curves generated by normal cervical tissue and various states of cervical pathology were inspected and assigned relative scores of 1-5 based on the height and slope of the curves at peak fluorescence emissions. A score of 1 indicated a curve with high magnitude and distinct peak, and a score of 5 described a curve of low magnitude and rounded/flattened peak. Scores of 2-4 represented curves with incremental changes of about 25% in the height of the curve between scores of 1 and 5. Biopsies were classified as high grade (HG, CIN 2/3), low grade (LG, HPV/CIN 1), or nondysplastic (ND). Among women with abnormal Pap smears, only those who had biopsies with concordant interpretations by two independent pathologists were included in the descriptive analysis. All of the patients with normal Pap smears were included. Results. A total of 35 women were included in the analysis. Of 62 women with abnormal Pap smears who underwent fluorescence imaging and colposcopy, 31 met the inclusion criteria. Among these 31 women, Pap smears consisted of 6 atypical squamous cells of undetermined significance (ASCUS), 16 low-grade squamous intraepithelial lesions (LGSILs), and 9 high-grade squamous intraepithelial lesions (HGSILs). Of the 4 women with normal Pap smears, 1 had an abnormal colposcopy and a nondysplastic biopsy. Among all 35 women, 42 total biopsies were included, consisting of 11 HG, 25 LG, and 6 ND. Normal squamous tissue generated a score of 1, normal metaplastic tissue a score of 2 or 3, and normal columnar tissue of score of 5 in 35/35 (100%) women. Among the 11 HG lesions, 8 had a score of 4 and 2 had a score of 5. One case was uninterpretable due to a low signal-to-noise ratio. Among the 25 LG lesions, 15 had a score of 3, 6 had a score of 4 or 5, 2 had a score of 1, and 2 cases were uninterpretable. Conclusions. HG lesions generated spectra distinct from normal tissue in 8/10 (80%) evaluable cases, but LG lesions generated spectra indistinguishable from that of normal metaplastic tissue. Further modifications to this technique are needed before an objective, reproducible, and discriminatory scoring system can be developed. ▪

A clinical review of borderline glandular cells on cervical cytology.

To review the diagnoses and diagnostic pathway of women presenting with borderline glandular cells on cervical cytology. To outline the basis of clinical approach of these women. Retrospective review. Forty-three women referred to the hospital department over a 32-month period. Review of the casenotes for the demographic data, previous cervical cytology and/or histology report, indication for the smear resulting in borderline glandular cells, colposcopic findings, diagnostic and/or treatment procedures, final diagnosis and current status. The average age was 36.7 years. Twenty-four women (56%) had clinically significant lesions: seven women (16%) presented with cancers, of which one was endometrial in origin, and 17 (40%) with intraepithelial neoplasia (CIN and cervical glandular intraepithelial neoplasia (CGIN)). Sixty-seven percent of all clinically significant lesions were of squamous origin. Thirty-seven had histological diagnosis, while six went on to cytological surveillance. Colposcopy was the most significant predictor for clinically significant lesions (P < 0.05). Punch biopsies and loop excisions were diagnostic when based on abnormal colposcopic findings. Brush cytology was appropriate follow up for asymptomatic, premenopausal women with no colposcopic abnormality. In addition, endometrial sampling was recommended in the peri- and postmenopausal women. Borderline glandular cells have a high incidence of clinically significant lesions. Immediate referral for colposcopy and assessment is strongly recommended in women with two borderline glandular smears to avoid delays in potential cancer diagnosis.

High risk human papillomavirus in women with normal cervical cytology prior to the development of abnormal cytology and colposcopy.

To study the significance of the presence of high risk human papillomavirus (HPV) in women with initially normal cervical cytology for the development of abnormal cytology and an abnormal colposcopic impression. Prospective, observational study Sixty-eight women with cytomorphologically normal smears and at least one positive HPV test result were evaluated every six months by cytology, colposcopy and HPV testing. The endpoint of the study was abnormal cervical cytology. The median time of follow up from the first positive HPV test was 34 months. A total of 17 women developed abnormal cytology, of whom 16 (94%) had persistence of a high risk HPV infection. Women with persistent high risk HPV were more likely to develop abnormal cervical cytology than women without high risk HPV (hazard ratio 28.2, 95% CI 3.72-215.2); they also had an increased risk of developing an abnormal colposcopic impression (hazard ratio 4.4, 95% CI 1.69-11.7). Among the 17 women with abnormal cytology, high grade dysplasia was histopathologically demonstrated in eight women. Persistent presence of high risk HPV in normal cervical smears is associated with a significantly increased risk of developing abnormal cytology and to a lesser degree with developing an abnormal colposcopic impression.

Cervical intraepithelial neoplasia in pregnancy

To determine the progression/regression rate of cervical intraepithelial neoplasia in pregnancy and to describe the number of patients requiring treatment for cervical neoplasia during or following the pregnancy. A retrospective analysis of 305 pregnant women with abnormal cervical cytology was performed. The colposcopic, cytologic and histologic findings of repeated examinations during pregnancy and of the subsequent examination eight weeks postpartum were registered and compared. All smears were obtained by cotton bud and Cytobrush. Colposcopy was performed using standard techniques and cervical biopsies were taken in case of colposcopic abnormalities. Endocervical curettage was omitted during pregnancy. At postpartum evaluation colposcopy, directed biopsies and endocervical curettage were performed in all cases. One hundred and two patients (33%) were followed only by cytology and colposcopy. The remaining 203 patients (67%) had one to four colposcopically directed biopsies during the pregnancy. Comparing the initial histology in pregnancy to the postpartum histologic evaluation 25% showed spontaneous regression while 75% of the women exhibited progression (28%) or persistence (47%) in the severity of cervical neoplasia. Two patients were treated by cervical conization in early pregnancy and 143 women (53%) were treated within the first year after the pregnancy. In the postpartum period microinvasive carcinoma was diagnosed in two patients, but no women advanced to more serious stages of cervical cancer. The high persistence rate of cervical intraepithelial neoplasia in pregnancy leads us to recommend a liberal use of colposcopically directed biopsies during pregnancy and to ensure a high follow-up rate in the postpartum period.

Abstracts: Autumn 1999

Abstracts: Autumn 1999

Histologic and Immunologic Associations of an HPV16 Variant in LoSIL Smears

Background.Human papillomavirus type 16 variants have been described and may have different biologic activities: this has implications for the design of HPV vaccines.Objectives.The aim of this study was to see if the HPV16 variant E-G 131 can be detected in women with preinvasive disease and to consider the histological and immunological implications of such infection.Design.A prospective observational cross-sectional study on a cohort of women with minor cervical cytological abnormalities was performed.Methods.Samples were tested for HPV DNA by polymerase chain reaction and restriction enzyme digestion. Blood samples were tested for antibodies to HPV16 virus-like particles (VLP) and to determine class I HLA types. Women found to have abnormal colposcopy were treated by large-loop excision of the transformation zone on a see-and-treat basis.Results.Two hundred forty-one women were included in the study. Infection with the variant was detected in 20.9% of cases and was not associated with any specific HLA type. These cases were more likely to have high-grade CIN than those with wild-type HPV16 or no HPV16 (χ2= 18.85,P< 0.001). There were significant differences in seropositivity to HPV16 virus-like particles between the three groups (χ2= 32.43,P< 0.001).Conclusions.The E-G 131 variant may have increased oncogenic potential by evading host immune responses, but its identification is only weakly predictive of high-grade disease in stepwise logistic regression. The lack of seropositivity to HPV16 VLP has implications for the design of prophylactic vaccines based on VLP to HPV16.

A Matched Prospective Study of Human Immunodeficiency Virus Serostatus, Human Papillomavirus DNA, and Cervical Lesions Detected by Cytology and Colposcopy

Objective: To compare the prevalence and type of human papillomavirus (HPV) infections in the genital tract of human‐immunodeficiency‐virus‐ (HIV) seropositive and ‐seronegative women matched for cytology and to examine prospectively the relationship of HPV DNA, colposcopic findings and cervical squamous intraepithelial lesions (SIL) in these matched seropositive and seronegative cohorts.Methods: A matched prospective study of HIV‐seropositive and ‐seronegative women undergoing cytologic screening, colposcopy, and testing for HPV DNA and other infections at each visit.Results: Twenty‐three HIV‐seropositive women were matched with 23 seronegative women by cervical cytology reading, lifetime number of sexual partners, age, and follow‐up length. Fourteen pairs of these women had follow‐up visits every 4 months, for 56 and 53 total visits in seropositive and seronegative women, respectively. After matching, the groups had a similar overall prevalence ofHPV DNA and ofHPV oncogenic (high risk) types at baseline. On follow up, HIV‐seropositive women were more likely than seronegative women to develop SIL (38% vs. 10%), less likely to have negative cytology (34% vs. 60%, overall P = 0.03), more visits with HPV DNA detected (68% vs. 40% P = 0.04), and more visits with multiple HPV DNA types detected (18% vs. 0%, P = 0.02). Colposcopic lesions in the seropositive women were more likely to have sharp borders or mosaicism or to be thick white (P = 0.009).Conclusions: After matching for baseline Papanicolaou smear readings, these data suggest that over time seropositive women have more visits that yield abnormal cytology, more persistent HPV DNA detection, and more colposcopic abnormalities than seronegative women. Infect. Dis. Obstet. Gynecol. 7:158–164, 1999.

One-step management of cervical lesions

Objective: To test the value of diagnosing and treating cervical lesions at the first colposcopic visit using large loop excision of the transformation zone (LLETZ) based on abnormal colposcopic findings as compared with punch biopsies followed by subsequent therapy accordingly. Patients and Methods: Among 1255 patients with a clinically suspicious cervix, 119 patients with abnormal and satisfactory colposcopy were divided into two groups. In group A (53 patients) multiple cervical punch biopsies were taken. In group B (66 patients), LLETZ under local paracervical anesthesia was done. Results: Cervical intraepithelial neoplasia was diagnosed in 25 and 29 cases, condyloma acuminatum in seven and six cases, granulomatous cervicitis including tuberculous and bilharzial cervicitis was diagnosed in two and four cases in groups A and B, respectively. Endocervical adenocarcinoma was diagnosed in two cases in group B whereas microinvasive squamous cell carcinoma was diagnosed in one case in each group. Histopathologic assessment of the specimens obtained in group B revealed minimal coagulation artifact, adequate biopsies and free margins in all but three cases (4.5%) who needed further treatment by hysterectomy. In group B, only one case was complicated by a second hemorrhage and the overtreatment rate was 30.3%. On follow-up visits 20 patients (38%) and 59 patients (89%) were satisfied with the procedure in both groups, respectively. Further treatment was required in 29 cases in group A (55%) after initial assessment of punch biopsies and in three cases in group B (4.5%). Persistent abnormal colposcopic findings at follow-up visits 3 months after diathermy coagulation were seen in five patients (9.4%) in group A. Conclusions: LLETZ at the first colposcopic visit is a practical and fast method of treating most cervical lesions with limited complications and has the advantage of eliminating a second session of treatment. These advantages, particularly in developing countries, may outweigh the high overtreatment rate of this procedure. Many cervical lesions can be properly treated using large loop excision of the transformation zone at the first colposcopic visit. This may help save time and resources, especially in developing countries.

A study of treatment failures following large loop excision of the transformation zone for the treatment of cervical intraepithelial neoplasia.

To examine the long term efficacy of large loop excision of the transformation zone (LLETZ) in the treatment of cervical intraepithelial neoplasia (CIN) and to evaluate the relative diagnostic merits of colposcopy and cytology in the follow up of these women. A retrospective examination of cytology, colposcopy and histology records of the first 1000 women treated with LLETZ in Aberdeen from 1989 to 1991. Colposcopy Clinic Aberdeen Royal Infirmary, Grampian Region, Scotland. Nine hundred and seventy-seven women (97.7%) were seen for follow up at least once and 317 were followed for as long as four years. This comprises 2812 woman years of follow up. The incidence of recurrent CIN was 27/1000 woman years and the cumulative rate of recurrence at four years was 10.1 per 100 women. Twenty-eight of the 59 women (47%) with abnormal colposcopy and proven CIN had a concurrent smear that did not show dyskaryosis. LLETZ is an effective from of treatment for CIN. Colposcopy was useful in the follow up of these women and expedited the treatment of persistent disease. We recommend that any follow up protocol should include a colposcopic assessment and cytological follow up for at least four years following treatment. Further data are required to determine the risk of recurrence beyond this time.

Patient-based evaluation of a colposcopy information leaflet

Summary A questionnaire survey of new patients attending the colposcopy clinic of a teaching hospital was carried out. The intention was to evaluate the information leaflet routinely sent to women who have been referred for colposcopy because of abnormal cervical smear results and use the findings to propose changes that will make the leaflet more suitable, effective and patient-friendly. The majority of the respondents received (90%), read (90%) and understood most or all (96%) of the information leaflet. Patients who received the leaflet performed better in the knowledge quiz than those who did not (P 0.0001). Of the 111 patients who received and read the leaflet 50 (45%) found it reassuring or very reassuring and 58 (52%) thought it made them less anxious. On the contrary 20 (18%) patients found the leaflet worrying or very worrying and 33 (30%) thought it made them more anxious. Overall, 91 (82%) patients found the leaflet helpful or very helpful and 99 (89%) were satisfied with the information provided. The commonest difficulties with the leaflet identified by patients concerned the use of abbreviations and technical terms. We found the leaflet to be a useful method of providing information for patients before colposcopy. Whilst the leaflet appeared to have a major impact on patients' knowledge about abnormal smears and colposcopy, its effect in reducing anxiety was less pronounced.

Follow-up of abnormal pap smears in a hospital based adolescent clinic

Background An increasing number of adolescents have abnormal Pap smears, and little is know about factors which influence compliance with recommendations for repeat Pap smears and referrals for colposcopy. Methods Data was collected on all patients who were receiving health care in a hospital based comprehensive adolescent clinic and who had an abnormal Pap smear between July 1, 1994 and June 30, 1995. Demographic and clinical data included age, race, ethnicity, insurance status, prior abnormal Pap smears and colposcopy (between 1992 and July 1. 1994), Pap smears at follow-up, results of colposcopy, number of scheduled and kept appointments, and number of reminders (telephone calls, letters). Follow-up data was then collected through December 1, 1995. Data was analyzed using SPSS statistical software. Results 107 adolescents (mean age 18.2 ± 2.4 Years; range 11–23 years) had an abnormal Pap during the year. The adolescents were of mixed ethnicity and payor status: 29% were white, 61% black, 5% other, 6% unknown; 14% were Hispanic. 27% had Medicaid, 37% private insurance, 16% self-pay, 8% free care, 6% other, 6% missing data. The results of the index Pap smear was: 90 (84%) Atypia, 17 (16%) SIL LG. Of the 64 (60%) who had a second Pap smear, 32 (50%) were normal, 18 (28%) Atypia and 12(22) SIL LG. Of the initial 108 patients, the index Pap was the first abnormal Pap for 85 (79%) of the patients; 22 had had a previous abnormal Pap (15 atypias, 5 SIL LG, 2 SIL HG) and 11 had had a previous colposcopy. 80 patients had no prior colposcopy and atypia on the index Pap smear. Of these, 50 had a second Pap smear. The second Pap revealed 27 (54%) normal, 13 (26%) atypia, and 10 (20%) SIL LG. In all 52 (49%) patients were referred to the hospital's colposcopy clinic but only 28 actually had colposcopy despite outreach. Among those with no prior colposcopy and atypia on the index Pap, 32 patients were ultimately referred and only 17 kept the appointment. Following colposcopy patients kept an average of 2.1 visits and missed 1.1 visits. For both follow-up for repeat Pap smears and colposcopy, there are no difference by race, insurance status, age, Pap smear result, prior referral for colposcopy, or number of letters. The only significant factor for keeping a referral to colposcopy clinic was a visit to the adolescent clinic after notification of the abnormal Pap result and prior to the colposcopy appointment (77% v 38%)(p = .006). Conclusions Adolescents with abnormal Pap smears have high rates of failing to keep appointments for follow-up Pap smears and colposcopy. Because demographics factors did not define a group of adolescents at particular risk of noncompliance, interventions that target all adolescents with abnormal Paps need to be designed and tested. A visit to an Adolescent Program to explain the abnormal Pap smear and the reason for referral aided compliance. To improve surveillance more information needs to be gathered from the adolescents’ perspectives on reasons that follow-up appointments are not kept.