Macroscopic prediction of cervical dysplasia at colposcopy for see-and-treat patient selection: a systematic review

Johanna A A Damen; Jacob Pieter Hoogendam; Demy L Idema; Marle E Lokerse; Pauline Heus; Kevin Jenniskens; Isabelle M L P Kamm; Marissa J M Traets; René Spijker; Ronald Zweemer; Lotty Hooft

doi:10.1016/j.ejogrb.2026.115330

Macroscopic prediction of cervical dysplasia at colposcopy for see-and-treat patient selection: a systematic review

Johanna A A Damen^*
, Jacob Pieter Hoogendam
, Demy L Idema
, Marle E Lokerse
, Pauline Heus
, Kevin Jenniskens
, Isabelle M L P Kamm
, Marissa J M Traets
, René Spijker
, Ronald Zweemer
, Lotty Hooft

^*Corresponding author for this work

Research output: Contribution to journal › Review article › peer-review

Abstract

OBJECTIVE: In see-and-treat protocols, women referred to colposcopy are treated with a loop electrosurgical excision procedure at the first visit when findings suggest high-grade cervical intraepithelial neoplasia (CIN), making accurate colposcopic diagnosis essential. This systematic review evaluates colposcopy guidelines and supporting evidence to identify macroscopic indicators that should guide patient selection for see-and-treat management to minimize over- and undertreatment.

METHODS: TRIP and Google Scholar were searched in January 2021 to identify guidelines describing colposcopic indicators. In April 2025, MEDLINE and Embase were searched for primary studies reporting diagnostic accuracy or interrater agreement of these indicators. Embase was also searched for prediction models for colposcopic impression, and Scopus and Web of Science for studies citing the Reid Index and Swede score. Two reviewers independently selected studies. One reviewer extracted study characteristics, quality (adapted QUADAS-2), and results, which were verified by a second reviewer. Findings were summarized narratively.

RESULTS: Six guidelines were included. Eight indicators were mentioned in at least three guidelines: visibility of the squamocolumnar junction, colposcopic impression, acetowhite lesion, lesion location, lesion size, Lugol's staining, vascular patterns, lesion border and surface. Thirty-nine primary studies were included. Combinations of indicators to reach a colposcopic impression showed overtreatment rates of 6.3-56.5% for CIN2/moderate dysplasia and 9.9-72.5% for CIN3. Undertreatment occurred in 7.6% of women with normal colposcopic impression but CIN3 or cervical cancer on histopathology.

CONCLUSIONS: There is substantial heterogeneity in guideline-recommended colposcopic indicators with limited supporting evidence. See-and-treat protocols may lead to considerable overtreatment and a risk of clinically relevant undertreatment.

Original language	English
Article number	115330
Journal	European Journal of Obstetrics, Gynecology and Reproductive Biology
Volume	325
Early online date	19 Jul 2026
DOIs	https://doi.org/10.1016/j.ejogrb.2026.115330
Publication status	E-pub ahead of print - 19 Jul 2026

Access to Document

10.1016/j.ejogrb.2026.115330Licence: CC BY

PIIS0301211526003982Final published version, 1.84 MBLicence: CC BY

Cite this

Damen, J. A. A., Hoogendam, J. P., Idema, D. L., Lokerse, M. E., Heus, P., Jenniskens, K., Kamm, I. M. L. P., Traets, M. J. M., Spijker, R., Zweemer, R., & Hooft, L. (2026). Macroscopic prediction of cervical dysplasia at colposcopy for see-and-treat patient selection: a systematic review. European Journal of Obstetrics, Gynecology and Reproductive Biology, 325, Article 115330. Advance online publication. https://doi.org/10.1016/j.ejogrb.2026.115330

@article{aae5746ae97d448d8d6baa46fb58d772,

title = "Macroscopic prediction of cervical dysplasia at colposcopy for see-and-treat patient selection: a systematic review",

abstract = "OBJECTIVE: In see-and-treat protocols, women referred to colposcopy are treated with a loop electrosurgical excision procedure at the first visit when findings suggest high-grade cervical intraepithelial neoplasia (CIN), making accurate colposcopic diagnosis essential. This systematic review evaluates colposcopy guidelines and supporting evidence to identify macroscopic indicators that should guide patient selection for see-and-treat management to minimize over- and undertreatment.METHODS: TRIP and Google Scholar were searched in January 2021 to identify guidelines describing colposcopic indicators. In April 2025, MEDLINE and Embase were searched for primary studies reporting diagnostic accuracy or interrater agreement of these indicators. Embase was also searched for prediction models for colposcopic impression, and Scopus and Web of Science for studies citing the Reid Index and Swede score. Two reviewers independently selected studies. One reviewer extracted study characteristics, quality (adapted QUADAS-2), and results, which were verified by a second reviewer. Findings were summarized narratively.RESULTS: Six guidelines were included. Eight indicators were mentioned in at least three guidelines: visibility of the squamocolumnar junction, colposcopic impression, acetowhite lesion, lesion location, lesion size, Lugol's staining, vascular patterns, lesion border and surface. Thirty-nine primary studies were included. Combinations of indicators to reach a colposcopic impression showed overtreatment rates of 6.3-56.5\% for CIN2/moderate dysplasia and 9.9-72.5\% for CIN3. Undertreatment occurred in 7.6\% of women with normal colposcopic impression but CIN3 or cervical cancer on histopathology.CONCLUSIONS: There is substantial heterogeneity in guideline-recommended colposcopic indicators with limited supporting evidence. See-and-treat protocols may lead to considerable overtreatment and a risk of clinically relevant undertreatment.",

author = "Damen, \{Johanna A A\} and Hoogendam, \{Jacob Pieter\} and Idema, \{Demy L\} and Lokerse, \{Marle E\} and Pauline Heus and Kevin Jenniskens and Kamm, \{Isabelle M L P\} and Traets, \{Marissa J M\} and Ren{\'e} Spijker and Ronald Zweemer and Lotty Hooft",

year = "2026",

month = jul,

day = "19",

doi = "10.1016/j.ejogrb.2026.115330",

language = "English",

volume = "325",

journal = "European Journal of Obstetrics, Gynecology and Reproductive Biology",

issn = "0301-2115",

publisher = "Elsevier Ireland Ltd",

}

Damen, JAA, Hoogendam, JP, Idema, DL , Lokerse, ME , Heus, P , Jenniskens, K, Kamm, IMLP, Traets, MJM, Spijker, R, Zweemer, R & Hooft, L 2026, 'Macroscopic prediction of cervical dysplasia at colposcopy for see-and-treat patient selection: a systematic review', European Journal of Obstetrics, Gynecology and Reproductive Biology, vol. 325, 115330. https://doi.org/10.1016/j.ejogrb.2026.115330

TY - JOUR

T1 - Macroscopic prediction of cervical dysplasia at colposcopy for see-and-treat patient selection

T2 - a systematic review

AU - Damen, Johanna A A

AU - Hoogendam, Jacob Pieter

AU - Idema, Demy L

AU - Lokerse, Marle E

AU - Heus, Pauline

AU - Jenniskens, Kevin

AU - Kamm, Isabelle M L P

AU - Traets, Marissa J M

AU - Spijker, René

AU - Zweemer, Ronald

AU - Hooft, Lotty

PY - 2026/7/19

Y1 - 2026/7/19

N2 - OBJECTIVE: In see-and-treat protocols, women referred to colposcopy are treated with a loop electrosurgical excision procedure at the first visit when findings suggest high-grade cervical intraepithelial neoplasia (CIN), making accurate colposcopic diagnosis essential. This systematic review evaluates colposcopy guidelines and supporting evidence to identify macroscopic indicators that should guide patient selection for see-and-treat management to minimize over- and undertreatment.METHODS: TRIP and Google Scholar were searched in January 2021 to identify guidelines describing colposcopic indicators. In April 2025, MEDLINE and Embase were searched for primary studies reporting diagnostic accuracy or interrater agreement of these indicators. Embase was also searched for prediction models for colposcopic impression, and Scopus and Web of Science for studies citing the Reid Index and Swede score. Two reviewers independently selected studies. One reviewer extracted study characteristics, quality (adapted QUADAS-2), and results, which were verified by a second reviewer. Findings were summarized narratively.RESULTS: Six guidelines were included. Eight indicators were mentioned in at least three guidelines: visibility of the squamocolumnar junction, colposcopic impression, acetowhite lesion, lesion location, lesion size, Lugol's staining, vascular patterns, lesion border and surface. Thirty-nine primary studies were included. Combinations of indicators to reach a colposcopic impression showed overtreatment rates of 6.3-56.5% for CIN2/moderate dysplasia and 9.9-72.5% for CIN3. Undertreatment occurred in 7.6% of women with normal colposcopic impression but CIN3 or cervical cancer on histopathology.CONCLUSIONS: There is substantial heterogeneity in guideline-recommended colposcopic indicators with limited supporting evidence. See-and-treat protocols may lead to considerable overtreatment and a risk of clinically relevant undertreatment.

AB - OBJECTIVE: In see-and-treat protocols, women referred to colposcopy are treated with a loop electrosurgical excision procedure at the first visit when findings suggest high-grade cervical intraepithelial neoplasia (CIN), making accurate colposcopic diagnosis essential. This systematic review evaluates colposcopy guidelines and supporting evidence to identify macroscopic indicators that should guide patient selection for see-and-treat management to minimize over- and undertreatment.METHODS: TRIP and Google Scholar were searched in January 2021 to identify guidelines describing colposcopic indicators. In April 2025, MEDLINE and Embase were searched for primary studies reporting diagnostic accuracy or interrater agreement of these indicators. Embase was also searched for prediction models for colposcopic impression, and Scopus and Web of Science for studies citing the Reid Index and Swede score. Two reviewers independently selected studies. One reviewer extracted study characteristics, quality (adapted QUADAS-2), and results, which were verified by a second reviewer. Findings were summarized narratively.RESULTS: Six guidelines were included. Eight indicators were mentioned in at least three guidelines: visibility of the squamocolumnar junction, colposcopic impression, acetowhite lesion, lesion location, lesion size, Lugol's staining, vascular patterns, lesion border and surface. Thirty-nine primary studies were included. Combinations of indicators to reach a colposcopic impression showed overtreatment rates of 6.3-56.5% for CIN2/moderate dysplasia and 9.9-72.5% for CIN3. Undertreatment occurred in 7.6% of women with normal colposcopic impression but CIN3 or cervical cancer on histopathology.CONCLUSIONS: There is substantial heterogeneity in guideline-recommended colposcopic indicators with limited supporting evidence. See-and-treat protocols may lead to considerable overtreatment and a risk of clinically relevant undertreatment.

U2 - 10.1016/j.ejogrb.2026.115330

DO - 10.1016/j.ejogrb.2026.115330

M3 - Review article

C2 - 42492476

SN - 0301-2115

VL - 325

JO - European Journal of Obstetrics, Gynecology and Reproductive Biology

JF - European Journal of Obstetrics, Gynecology and Reproductive Biology

M1 - 115330

ER -

Macroscopic prediction of cervical dysplasia at colposcopy for see-and-treat patient selection: a systematic review

Abstract

Access to Document

Fingerprint

Cite this