Learning from the experts. Colposcopies in Brazil.

Erica Skerrett

Overview Today Lewis, Luiza, and I went to Santa Marcelina, a public hospital, to interview an expert colposcopy. It was a teaching hospital, and so we got to observe several colposcopy procedures including a vaginal biopsy, cervical biopsy, a follow-up appointment after treatment, and then another general inspection. There were students with us, so everything was explained while it was happening, including the doctor's thought process and the colposcope settings.

What is the process or flow of a colposcopy procedure? Just seeing the doctor’s process across the variety of procedures was so helpful in helping me understand when/why different settings would be used. In addition, I learned more about what primary features of the vagina and cervix that first need to be assessed and that would then inform the doctor whether she should continue looking into a particular area. I can apply this knowledge when testing the image quality of the Callascope when used with acetic acid— does the image show the same areas of interest/suspicion as a colposcopy image? Even if the Callascope camera cannot zoom in, maybe, if the patient is also positive for high-risk HPV, we would want her to come in for a colposcopy to assess the cervix under green light or for mosaic features.

How may expert colposcopists in Brazil view the Callascope’s functionality and design? In between patients, we got to ask more specific about the Callascope. At first, the colposcopist was focused on its limitations (lack of zoom and how it doesn’t see the vaginal walls when fully inserted). This made a lot of sense after having seen how easily and quickly she was able to operate the colposcope (with just 1 hand!)—it was like an extension of her arm. In addition, most of the cases that were referred to her were more severe and required biopsy or treatment, which currently cannot be done through the Callascope inserter. We assured her that we weren't trying to replace the colposcope exam, when it’s clear that some patients need it, but we want to help alleviate additional burden or missed patients in the screening paradigm. She then said that for patients that are HPV neg but pap smear positive, it would be good to have an image of the cervix--if the image looked clear, then she wouldn't recommend colposcopy. The colposcopist said that the Calla design looked more intimidating than the small, clear speculum that they use in the clinic, especially the long length of the Callascope. However, she was extremely interested in trying it on a patient! (I had to push back because there's no IRB yet, but it was nice to know she was interested in it.) In the future, it will be good for us to compare patient perceptions of the Calla to the clear speculum—perhaps we can do this at the feminist clinic here in Sao Paulo, which helps women view their own cervix with a speculum and a mirror.

Some reflection On a more personal note, this was my first time witnessing these procedures being done on patients and that was really eye-opening. On one-hand, it's really terrifying to be next to a women that seems perfectly healthy, but then see that her cervix that has a lesion on it--I guess it makes me, as a woman, feel so much more vulnerable and worried for the women I love around me. (I also know it must be a much harder experience for the patient herself to potentially learn about her condition while she is in such a vulnerable position as opposed to being in a more comfortable and secure environment. I would love to see more studies on how we can make this entire process more physically and emotionally comfortable for women.) But on the other hand, I also feel really grateful to be living in a time when these procedures are in place and that treatment can be so simple and effective when caught early. Watching the procedures taking place on the screen above the patient's bed, instead of seeming gross, actually showed me how robust the cervix can be in terms of self-healing if the lesion is low-grade and also healing from treatment and biopsies.

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