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124 Gynaecology and Colposcopy 2020 | NMH Annual Rep t cases to gynaecology services will continue to ensure adequate capacity for the anticipated greater numbers of referrals in the future due to the use of the more sensitive primary screening test (HPV). Of the abnormal screening test referrals, 136 (13%) of those seen were referred with high grade cytological abnormalities (high-grade squamous intraepithelial lesions (HSIL)) or worse. Of the low grade results, the referral smear was low grade squamous intraepithelial lesions (LSIL) in 386 women (32%) and atypical squamous cells of undetermined significance (ASCUS) in 429 women (31%). Appointments were allocated according to the grade of cytological abnormality aiming to work within the timeframes suggested by the CervicalCheck quality standards. Despite the reduced capacity, the service tried to meet the targets for the waiting times for new referrals. During the year, 114 out of the 136 (84%) of women with suspected high grade disease were offered appointments within the recommended four weeks after the receipt of the referral letter. For the 1,161 women with suspected low grade disease, 84% (973 out of 1,161) were offered appointments within the recommended eight weeks. An ongoing challenge is the number of appointments that were unattended without prior notice (defaulted). This year the improved rate of 7.4% for the service is within the recommended standard of <10%. The figure for new appointments was 7% compared to 9.9% for follow-up appointments, reflecting the long interval between follow-up appointments – twelve months. The sustained use of a text message reminder system has helped to minimize underutilized appointment slots. A diagnostic punch biopsy was performed in 1,599 cases and 453 excisional procedures were performed. Excisional treatments included 443 Large Loop Excision of the Transformation Zone (LLETZ) procedures (all but three performed as an outpatient) and 10 knife cone biopsies. In addition, 142 ablative procedures were performed in selected women using cold coagulation. The histology results are recorded in the table below; 642 biopsies recorded a diagnosis of high grade abnormalities including 10 cancers and 12 cases of adenocarcinoma in situ. In 57 women, the LLETZ was performed at the first visit (select and treat) of which, no Cervical Intra-epithelial Neoplasia (CIN) was detected in 11 cases (19%); four of these women were referred for clinical reasons with normal smears. Three women were referred with ASCUS, two with ASC-H (ASCUS-suspected high grade), one with borderline glandular abnormalities and one with HSIL. It is significant to note that these women tended to be older with an average age of 54 years and a range of between 46 and 71 years. In older women, the presence of a type 3 Transformation Zone (TZ) limits the value of the colposcopic assessment and balancing the risk of overtreatment with the risk of missing occult high grade CIN or cancer in this group of women remains an ongoing challenge. By comparison of the 765 women referred based on an abnormal screening test and low grade cytology, only ten underwent an excision at the first visit (1.3%) which was well within the target of <10%. Clinical pathological CPC review meetings continued monthly with review of the cytology, colposcopy and histology findings and these continue as a valuable addition to our service. The reduced staffing levels during the year impacted on the waiting times for results of tests performed at colposcopy. For histology, the median time for generation of a letter with the results was 3.5 weeks with compliance of the standard of within four weeks for 35% of women with a diagnostic punch biopsy and 37% of women with a LLETZ. For women who underwent follow up smear and HPV tests at colposcopy the median time to generate the results letter was 5.3 weeks with a range of up to 22 weeks with compliance of the standard for generation of the results of the cytology and HPV results in four weeks in only 32% of cases. The multidisciplinary colposcopy clinical governance committee met regularly and reviewed the quality of our service. The colposcopy information management system again provided most of the figures for this year's report and continues to be important in delivering improved communication of results and treatment plans. Structured training continued to be provided for trainees under the auspices of the British Society for Colposcopy and Cervical Pathology (BSCCP) which included web-based tutorials were held in preparation for the BSCCP Objective Structured Clinical Examination (OSCE) examination. *Number of biopsies performed and number of biopsies analyzed by pathology are not the same in any given time. As in previous years, the most severe abnormality is used for coding - a minority of cases have both squamous and glandular lesions present.