Dysplasia: Procedures and Instruments
A Colposcopy Trainer to Simulate
Visualization and Biopsy of the Cervix
Heidi M. Felix, DHSc, PA-C, and Amy Lannen
BACKGROUND: Colposcopy is a common office pro-
cedure providing a magnified view of the cervix for the
evaluation of an abnormal cytology result. Traditionally the
procedure has been replicated in simulation training by
using a sausage or hotdog to represent the cervix and allow
for target biopsy. This is neither reusable nor sustainable.
Downloaded from http://journals.lww.com/greenjournal by BhDMf5ePHKbH4TTImqenVJFBcritpgyL0cVtIrWLuyHwDqbxbdWa/jD3FTVeyH81 on 12/12/2018
METHOD: We developed a cervix model comprised of
food coloring and ballistics gel. After cooling, the surface
was dotted with gel that can be activated by a black light
to mimic acetowhite changes. The cervix was placed into
an existing pelvic trainer and then piloted by attending
physicians and resident trainees in obstetrics and gyne-
cology and family practice.
EXPERIENCE: Sixteen physicians and residents were
surveyed after a simulated colposcopy. Twelve had
performed colposcopies and of those, eight stated that
the model was very comparable with the real procedure;
four stated the model was somewhat comparable. Three
had never performed a colposcopy but stated that model
was very or somewhat comparable with textbook or
journal photographs.
CONCLUSION: Our colposcopy trainer represents con-
tinued innovation in the field of simulation while being
sustainable and economic. We continue to work on
enhancing our model to be even more sophisticated
and offering additional training options.
(Obstet Gynecol 2018;132:1430–5)
DOI: 10.1097/AOG.0000000000002953
From the J. Wayne and Delores Barr Weaver Simulation Center, Mayo Clinic,
Jacksonville, Florida.
From the Corresponding author: Heidi M. Felix, DHSc, PA-C, J. Wayne and
Delores Barr Weaver Simulation Center, Mayo Clinic, 4500 San Pablo Road,
Jacksonville, FL 32224; email: Felix.heidi@mayo.edu.
Each author has indicated that she has met the journal’s requirements for author-
ship.
Received June 26, 2018. Accepted August 23, 2018. Peer review history is
available at http://links.lww.com/AOG/B175.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2018 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/18
1430 VOL. 132, NO. 6, DECEMBER 2018
Copyright ª by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
I n the United States, cervical cancer is the third most
commonly diagnosed gynecologic malignancy as
well as the third most common cause of death from
gynecologic cancer.1 The mainstay of screening is
the Pap smear to obtain cervical cytology and possi-
ble testing for high-risk human papillomavirus.
Abnormal results should be triaged to a colposcopy,
an examination under microscopy. In preparation
for visualization of the cervix, an acetic acid mixture
is painted on the cervix; abnormal cells will turn
“acetowhite.”2 However, accuracy and sensitivity
for performing this examination are limited, because
no specific training, competency, or standards
exist.3,4 There are no true data for how many colpos-
copies are performed each year by the variety of
practitioners who work in obstetrics, gynecology,
family medicine, and internal medicine, although
the estimates are in the hundreds of thousands.4 Pre-
viously reported task trainers using hot dogs, sau-
sage, and sponges were developed for purposes of
simulating this procedure, but fidelity is not neces-
sarily maintained.5
METHOD
Our model was constructed in a two-part process; part
one was the creation of the vaginal opening and part
two was the creation of the cervical os.
To create the vaginal opening, we started with
a decommissioned birthing trainer. We purchased a 6-
inch polyvinyl chloride tee joint and a matching
polyvinyl chloride end cap from a local hardware
store. We inverted the tee joint and attached it to the
simulated pubis using a Phillips head screw. We cut
the bottom off of one leg of a pair of pink children’s
ballet tights. We then fed that leg of the tights through
the bottom of the tee joint and attached it to the oppo-
site end of the tee joint by stretching it around the
inner edge and securing it with a rubber band. We
then opened and secured the waist portion of the
tights to the outer edge of a manikin to create the
vaginal opening. In our model we were able to use
OBSTETRICS & GYNECOLOGY
Fig. 1. Polyvinyl chloride joint being
outfitted into the pelvic trainer.
Felix. Colposcopy Simulation. Obstet
Gynecol 2018.

the existing snaps and external genitalia to secure the
tights (Fig. 1). You would need additional materials to
secure the tights and to create labia if using a box.
This process simulates the vaginal opening by creat-
ing a smooth path from the outside of the trainer
through a fixed opening that is only able to stretch
a fixed distance. Alternatively, to simplify the trainer,
a sturdy cardboard box could be used instead of the
decommissioned birthing trainer. Cut a hole approx-
imately 3 inches up from the bottom of one side of the

Fig. 2. Ballistics gel cervixes before

being placed into the trainer.
Felix. Colposcopy Simulation. Obstet
Gynecol 2018.

VOL. 132, NO. 6, DECEMBER 2018 Felix and Lannen Colposcopy Simulation 1431

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
cardboard box. Make sure the hole is slightly smaller
than the external diameter of the polyvinyl chloride.
Gently push the end of the polyvinyl chloride tee joint
into the opening you created.
To create the cervical os, we began by melting
ballistics gel in a small slow cooker over several hours.
The gel is widely available and costs less than $20/lb.
Our cervical os model weighs 0.5 ounces. We
recommend purchasing a small slow cooker that is
dedicated to melting ballistics gel. Once the gel is fully
melted, it is ready to mold. Use caution when working
with melted ballistics gel because it can cause severe
burns. Using a metal spoon, we carefully scooped gel
into a cake pop mold, overfilling one space. We added
a few drops of red food coloring and mixed thor-
oughly and rapidly. The gel cools and solidifies very
quickly so be sure to work fast. Once the gel begins
cooling, you can sculpt the top of the os using your
hands to create a divot in the center and wavy outer
edges. Work with the gel until it has cooled com-
pletely to be sure you have the correct shape (Fig. 2).
Once cooled, we inserted the gel os into the end cap
(Fig. 3). If the os does not fit snugly, a few drops of
melted ballistics gel can be added to the bottom of the
end cap to help secure the os in place. The end cap is
then secured to the polyvinyl chloride tee joint. If the
parts are matching sizes, there should be a snug fit
without any additional fasteners (Fig. 4). The cervical
os was dotted with additional black light gel that be-
comes activated with a black light. These spots will

Fig. 3. Ballistics gel cervix in the end

of the polyvinyl chloride cap before
being placed in the trainer.
Felix. Colposcopy Simulation. Obstet
Gynecol 2018.

1432 Felix and Lannen Colposcopy Simulation OBSTETRICS & GYNECOLOGY

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Fig. 4. Speculum view of the cervix
before colposcopic examination.
Felix. Colposcopy Simulation. Obstet
Gynecol 2018.

then become the “acetowhite” changes seen under the
green light of the colposcope and subsequently biop-
sied (Fig. 5). Multiple biopsies can be taken from one
os without it appearing damaged.
EXPERIENCE
This survey was deemed exempt by our institutional
review board. This task trainer was reviewed by all
available gynecologists and family medicine attend-
ings at our institution who had colposcopy experience
before implementation in training sessions with
family medicine residents. Each attending had
a minimum of 10 years of colposcopy experience. A
survey tool (Box 1) was created by the author with
input from a gynecologist at our institution and was
provided to attendings and residents after using the
task trainer (Table 1). Sixteen physicians and resi-
dents were surveyed after a simulated colposcopy that
included visual inspection and biopsies. The learners
participated in a simulation that included instruction
on the use of a colposcope, getting accustomed to
viewing through the lenses, holding the speculum,
and performing biopsies under the colposcope. An
attending was present with the learner to answer
any questions and provide immediate feedback after
completion of the simulation. Twelve had performed
colposcopies; of those, eight stated that the model was
very comparable with the real procedure and four
stated that it was somewhat comparable. Three had
never performed a colposcopy but stated the model
was very or somewhat comparable with textbook and
journal photographs. This task trainer is now being

VOL. 132, NO. 6, DECEMBER 2018 Felix and Lannen Colposcopy Simulation 1433

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
 Box 1. Survey Tool
1. Are you an attending?
 Yes—if yes, proceed to question 3
 No—if no, fill out question 2
2. What year are you in residency?
 PGY1
 PGY2
 PGY3
 PGY4
 Chief
3. Have you ever performed a colposcopy (assisted or
unassisted)?
a. If yes, was this comparable to your prior
experience?
i. Very comparable
ii. Somewhat comparable
iii. Neutral
iv. Not comparable
b. If no, how does this compare with journal or
Fig. 5. Colposcopic view of the cervix. Bright spots repre- textbook photographs?
sent the simulated “acetowhite” changes. i. Very comparable
Felix. Colposcopy Simulation. Obstet Gynecol 2018. ii. Somewhat comparable
iii. Neutral
incorporated into all subsequent training sessions for iv. Not comparable
4. Do you feel that this model prepares you for an
family medicine residents as a result of the fidelity.
actual colposcopy?
a. Yes
DISCUSSION b. Somewhat
c. No
This trainer represents a sustainable and reusable 5. Would you recommend this model to your
means of training physicians, residents, and advanced colleagues?
practice providers to develop skills to perform colpos- a. Yes
copies. Use of this model can accompany other b. No
instructional methods such as the review of normal 6. What would you do to improve this model?
and abnormal colposcopic photographic images. The PGY, postgraduate year.
cervix that was created can be further enhanced by
the addition of exophytic lesions, deeper colors,
smaller or larger size, and can be reused multiple has been biopsied too many times. Limitations to this
times. Furthermore, the cervix can be melted back model are the inability to use energy on the created
down and reshaped after it has been decided that it cervical os.

Table 1. Fidelity Results

Performed Colposcopy
Year Before? Fidelity Textbook and Journal Photographs Prepares Recommend
Attending Yes Very comparable Yes Yes
Attending Yes Very comparable Yes Yes
Attending Yes Very comparable Yes Yes
Attending Yes Very comparable Yes Yes
3 Yes Somewhat comparable Yes Yes
3 Yes Somewhat comparable Yes Yes
3 Yes Very comparable Yes Yes
2 Yes Very comparable Yes Yes
2 No Somewhat comparable Yes Yes
3 Yes Somewhat comparable Yes Yes
2 No Very comparable Yes Yes
2 Yes Very comparable Yes Yes
2 No Very comparable Yes Yes
2 Yes Very comparable Yes Yes
2 Yes Somewhat comparable Yes Yes

1434 Felix and Lannen Colposcopy Simulation OBSTETRICS & GYNECOLOGY

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
REFERENCES
1. Frumovitz M. Invasive cervical cancer: epidemiology, risk factors,
clinical manifestations, and diagnosis. Available at: https://www.up-
todate.com/contents/invasive-cervical-cancer-epidemiology-risk-fac-
tors-clinical-manifestations-and-diagnosis. Retrieved June 25, 2018.
2. Feltmate C, Feldman S. Colposcopy. Available at: https://www.up-
todate.com/contents/colposcopy?source5search_result&search5
colposcopy&selectedTitle51;63. Retrieved June 25, 2018.
3. Waxman AG, Conageski C, Silver MI, Tedeschi C, Stier EA,
Apgar B, et al. ASCCP colposcopy standards: how do we per-
VOL. 132, NO. 6, DECEMBER 2018
Copyright ª by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
form colposcopy? Implications for establishing standards. J Low
Genit Tract Dis 2017;21:235–41.
4. Wentzensen N, Massad LS, Mayeaux EJ Jr, Khan MJ, Wax-
man AG, Einstein MH, et al. Evidence-based consensus recom-
mendations for colposcopy practice for cervical cancer
prevention in the United States. J Low Genit Tract Dis 2017;
21:216–22.
5. Manley KM, Park CH, Medland VL, Appleyard TL. The train-
ing value of a low-fidelity cervical biopsy workshop. Simul
Healthc 2015;10:116–21.
Felix and Lannen Colposcopy Simulation 1435