By Rebecca H. Allen, MD, MPH

Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI

Dr. Allen reports she is a Nexplanon trainer for Merck, and has served as a consultant for Bayer and Pharmanest.

SYNOPSIS: This German randomized, controlled trial of 225 women naïve to colposcopy found that video colposcopy did not reduce patient anxiety during the procedure. However, the authors found that the real-time video feed increased participants’ understanding of their disease.

SOURCE: Hilal Z, Alici F, Tempfer CB, et al. Video colposcopy for reducing patient anxiety during colposcopy: A randomized controlled trial. Obstet Gynecol 2017;130:411-419.

This is a randomized, controlled trial conducted at two sites in Germany of video colposcopy among women presenting for their first colposcopy. Investigators recruited adult non-pregnant women without HIV or known depression or anxiety disorders. One male gynecologist at each site performed all the colposcopies. The researchers administered to participants the State-Trait Anxiety Inventory, a questionnaire that consists of 40 items that measure baseline (trait) and situational (state) anxiety. A higher score indicates higher anxiety levels, with a score of more than 40 typically representing clinically significant symptoms. All women received a pamphlet on cervical dysplasia, human papillomavirus infection, and the colposcopy procedure. Women randomized to video colposcopy were able to see the colposcopy performed on their cervix on a 45-inch video screen. The colposcopic findings were discussed with the patient while she viewed the screen, and the video was turned off prior to any biopsies. Women who were randomized to the comparison group did not have video colposcopy and any findings were discussed with them after the procedure. No Monsel’s solution or other hemostatic agents were applied, and the speculum was removed after the biopsies were taken. Afterward, participants filled out the State-Trait Anxiety Inventory once more to assess their situational anxiety, pain, and satisfaction levels. Women randomized to video colposcopy also filled out a questionnaire assessing their level of anxiety and discomfort watching the video feed as well as whether they felt the images helped them understand their disease better. The primary endpoint was the change in situational anxiety before and after the procedure.

A total of 225 women met inclusion criteria and were enrolled in the study, 114 to video colposcopy and 111 in the control group. After excluding nine women for protocol violations, 216 women were included in the analysis. There was no difference between the two groups in baseline anxiety, age, parity, or education level. There was no difference between the two groups in terms of the primary outcome (change in anxiety -10.3 vs. -10.3; P = 0.50); essentially, both groups had an equal reduction in anxiety post-procedure. There was also no difference in pain scores during the procedure, pain scores 10 minutes after the procedure, or satisfaction with the procedure. In multiple regression analyses controlling for study group, study center, age, body mass index, parity, level of education, presence of chronic allergies (which the authors thought would be associated with comfort with the medical system because of frequent visits), and smoking, smoking was the only independent variable that consistently was associated with change in anxiety score. Baseline anxiety levels also were not related to any anxiety-reducing effect of video colposcopy. For women who watched the video, there was negligible discomfort or anxiety but a high rating for its importance in understanding their disease.


Proven interventions to reduce pain and anxiety during colposcopy are few. Understandably, women are very anxious when presenting for colposcopy, as many are under the false belief they already have cervical cancer. Past studies have evaluated music, informational pamphlets, and educational videos for reducing patient anxiety. A 2011 Cochrane review on the subject concluded that music was the best intervention to reduce anxiety.1 A previous study on video colposcopy was not included in the Cochrane review because it was quasi-randomized and allocation concealment was poor.2 Nevertheless, this study of 81 women showed a benefit to video colposcopy in reducing anxiety. The authors of the current study wanted to test video colposcopy again in a larger trial for its effect on anxiety.

In this study, the authors showed that video colposcopy did not reduce anxiety in patients undergoing the procedure. This study has several strengths, including limiting the number of colposcopists, randomization, and an objective measure of anxiety. Both groups had a reduction in anxiety post-procedure, which makes sense. It would have been interesting if they had analyzed the data according to the severity of the referral Pap smear to see if that influenced anxiety levels. The authors did note that patients believed that video colposcopy helped them understand their disease and it certainly is not harmful. I found it fascinating that German practice seems to be to not apply any hemostatic agents after cervical biopsy.

Other interventions studied for pain and anxiety during colposcopy include visual distraction with a ceiling picture, topical anesthetics, injected anesthetics, and forced coughing with the biopsy. Visual distraction using a light diffuser with a pleasant picture over the ceiling light was found to reduce procedure pain slightly (median pain score of 1 vs. 2 on a 0 to 10 scale) but not anxiety.3 A 2012 Cochrane review concluded that oral analgesia treatments, such as nonsteroidal anti-inflammatory drugs, topical lidocaine/prilocaine cream, and lignocaine or benzocaine sprays, were ineffective strategies for pain control during colposcopy.4 Injected lidocaine is effective in reducing pain with cervical biopsy but probably is no more effective than forced coughing, and the injection prolongs the procedure.5,6 In sum, it is not necessary to run out and buy a video colposcopy system for your office to improve patients’ pain and anxiety with colposcopy. However, it is certainly helpful for patient, resident, and student education.


  1. Galaal K, Bryant A, Deane KH, et al. Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database Syst Rev 2011;12:CD006013.
  2. Walsh JC, Curtis R, Mylotte M. Anxiety levels in women attending a colposcopy clinic: A randomised trial of an educational intervention using video colposcopy. Patient Educ Couns 2004;55:247-251.
  3. Carwile JL, Feldman S, Johnson NR. Use of a simple visual distraction to reduce pain and anxiety in patients undergoing colposcopy. J Low Genit Tract Dis 2014;18:317-321.
  4. Gajjar K, Martin-Hirsch PP, Bryant A. Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment. Cochrane Database Syst Rev 2012;10:CD006120.
  5. Schmid BC, Pils S, Heinze G, et al. Forced coughing versus local anesthesia and pain associated with cervical biopsy: A randomized trial. Am J Obstet Gynecol 2008;199:641.e1-3.
  6. Bogani G, Serati M, Cromi A, et al. Local anesthetic versus forced coughing at colposcopic-guided biopsy: A prospective study. Eur J Obstet Gynecol Reprod Biol 2014;181:15-19.