Colposcopy

1. Introduction to
Colposcopy

2. Indication for Colposcopy
Epithelial cell abnormalities
detected by cervical cytology
Positive high risk HPV DNA in
ASC-US triage
Suspicious cervical lesions
Vulvar or vaginal neoplasia
History of in-utero DES exposure
Sexual partner of patients with genital tract
neoplasia
Oncogenic Human Papillomavirus in
appropriate guideline algorithms
Unexplained vaginal bleeding
Post–coital bleeding
Positive screening test by Cervicography
or Speculoscopy

3. Basic Satisfactory Requirements of
Colposcopic Exam
Adequate Visualization
Entire TZ Zone seen
Abnormal areas seen in entirety
Endocervical Canal free of Dysplasia
No Evidence of Invasive Cancer
Abnormal Areas Biopsied
ECC Completed (Non-Pregnant patients)

4. Colposcopy - Objectives
Determines the presence of invasive cancer
Localizes the squamocolumnar junction
Identifies the most severe disease for biopsy
Evaluates the extent of disease

5. Instrumentation Procedure
Colposcope
Vaginal speculum
Endocervical speculum
Large & small swabs
Endocervical curette
Cervical biopsy forceps
Solutions:
Normal saline
Acetic Acid
Monsel’s

6. Instrumentation

7. Collin’s bivalve specula of different sizes Vaginal side wall retractor
Endocervical speculum Cervical punch biopsy forceps
with sharp cutting edges

8. A method of identifying
outer & inner borders of the transformation zone

9. Colposcopic Examination
Obtain Pap, cultures, KOH as Needed
Perform Cervical Colposcopic Exam
Use Green Filter, if needed
Mentally Map Cervical Landmarks and abnormal areas
Colposcopic magnification of 10X – 15X
Is Exam Satisfactory?

10. Look for
Satisfactory Colposcopy:
360 degree view of the T-zone
Proximal and distal extent of cervical lesions seen
Gross lesions or Pathology
Tumors
Infections
Don’t forget to check for vaginal and vulvar lesions

11. Collection of Target Biopsy
Select the most severe lesion
Sharp instruments
2-3 mm biopsy
Colposcopically assisted always!
Biopsy at the SCJ
Monsel's solution /cauterisation for
hemostasis

12. Satisfactory Colposcopy exam
360 degrees of squamocolumnar junction visualized
Proximal and distal extent of cervical lesions identified
Cytology, colposcopic impression and histology correlate

14. SCJ

15. Multiple nabothian cysts in the mature squamous
metaplastic epithelium occupying the ectocervix
Nabothian cyst with
regularly branching tree like
vessels

16. Normal vascular pattern

17. Definition
Vertical single loop intraepithelial capillaries
viewed end on in a demarcated area
Etiology
Normal vascular pattern
Abnormal modification of existing vascular
architecture
Arises from the normal original columnar
epithelial angioarchitecture
Punctation

18. Colposcopic Appearance
Red dots usually seen within
an area of acetowhite
epithelium
Variable with increasing
severity of disease
Increasing caliber of dot from
fine to coarse
Increasing intercapillary
distance

19. Coarse punctation
Coarse punctation before & after application of acetic acid

20. Differential and Significance
May result from inflammation, repair, viral effects,
neoplasia or the variant of fetal metaplasia (congenital
t-zone)
May represent normal to neoplasia
Vessel caliber and intercapillary distance predict the
severity
Average intercapillary distance is 100 microns
Increases with progressive neoplasia

21. Mosaic
Intra epithelial capillaries
encompassing blocks or buds forming
a mosaic, tile or “chicken wire” pattern
May be normal or abnormal
modification of existing vascular
architecture
Red, tile-like grid usually viewed within
acetowhite epithelium
Fine or coarse caliber
Variable intercapillary distance with
increasing severity of neoplasia

22. Mosaic: Differential and Significance
May be seen in the normal variant of fetal metaplasia
(congenital t-zone)
Represented in any level of neoplasia
May be observed in benign tissue (not aceto-white)
Caliber and intercapillary distance predict the severity of
disease

23. Atypical Vessels
Superficial blood vessels exhibiting bizarre
variation in caliber, course and branching
pattern
Develop in response to tumor angiogenesis
factor (TAF)
Result in chaotic, rapidly proliferating vessels
attempting to nourish rapidly in neoplastic
tissue
Lack systematic, uniform branching
Atypical
vessels patternِ

24. ASSOCIATED WITH CANCER UNTIL PROVEN OTHERWISE
May be observed in areas of immature metaplasia
Colposcopically directed biopsy is mandatory
Atypical Vessels:
Differential and Significance

25. Post Menopausal Cervix:
Epithelium is pale, brittle, lacks lusture,
shows sub-epithelial petichiae, SCJ not
visualized
The entire new SCJ is visible
colposcopic examination is satisfactory.
the TZ is fully visualized. The metaplastic
squamous epithelium is pinkish-white
compared to the pink original squamous
epithelium

26. Squamous metaplasia
Earliest colposcopic changes in
immature squamous metaplasia
(after 5% AA) in which tips of
columnar villi stain white &
adjacent villi start fusing together
Prominent white line corresponds to
the new SCJ & tongues of immature
Squamous metaplasia a) with crypt
openings at 4-8 o’clock positions
b) after application of AA

27. Immature squamous metaplastic epithelium (narrow arrow)
on the polyp with intervening areas of columnar epithelium
a) after application of AA
The endocervical polyp &
the immature squamous metaplasia
surrounding the os partially take up
iodine.

28. Leukoplakia
Usually benign
May obscure an underlying
neoplasia
Therefore, all patches
observed before application of
acetic acid must be biopsied
Hyperkeratosis ( Leukoplakia)

29. Geographic satellite lesion
condyloma low-grade lesion

30. Thin acetowhite lesion with
geographic margins in the upper
lip. Histology indicated CIN 1
Moderately dense acetowhite
lesions with irregular margins in
the anterior & posterior lips ( CIN
1)

31. circumorificial acetowhite CIN 1
lesion with irregular margin & fine mosaics

32. Moderately dense acetowhite lesions with well
defined margins & coarse punctations in the
anterior lip & in 3 o’clock position (CIN 2 lesion
Dense well defined acetowhite
area with regular margins &
coarse mosaic ( CIN 2 lesion )

33. A dense acetowhite lesion with varying colour
intensity &
coarse mosaics (a) in a CIN 2 lesion
Acetowhite lesions with coarse punctation
(a) & mosaics (b) in a CIN 2 lesion

34. A circumoral dense opaque acetowhite area with
coarse mosaics ( CIN 3 lesion)
A dense acetowhite lesion with regular
margin & coarse,
irregular punctation in a CIN 3 lesion.

35. Modified
Reid
Score

37. Early invasive cancer: note the raised irregular mosaics with umbilication (a), breaking
mosaics (b), surface irregularity & the atypical vessels after the application of 5% AA
Preclinical invasive
Carcinoma

38. Atypical
Vessels
patternِ
Note the irregular surface contour with
mountains & valleys appearance with
atypical blood vessels in the dense
acetowhite area
Invasive cervical cancer

39. A dense acetowhite lesion in the endocervical canal visible after stretching
the os with a long dissection forceps (adenocarcinoma in situ)
Glandular lesions

40. Adenocarcinoma in situ: The tips of some of the columnar villi turn densely
white compared to the surrounding columnar villi after the application of acetic
acid (arrow). The nabothian cysts turn white after the application of AA

41. the greyish white dense acetowhite lesion with
character writning-like atypical blood vessels(a)
The elongated, dense acetowhite lesion with
irregular surface in the columnar epithelium
with atypical blood vessels (a)
Adenocarcinoma:

42. Reddish “angry-looking”, inflamed columnar
epithelium with loss of the
villous structure & with inflammatory exudate
(before application of 5% AA)
Inflammatory lesions of the
Uterine Cervix
Chronic cervicitis: This cervix is
extensively inflammed with a reddish
appearance &
bleeding on touch, there are ill-
defined, patchy acetowhite areas
scattered all over the cervix after the
application of AA

43. TV after Acetic acid
T.V. After Lugol’s
Multiple red spots (a) suggestive of Trichomonas
vaginalis colpitis ( strawberry appearance), after
application of 5% AA
Trichomonas vaginalis colpitis
after application of Lugol’s iodine
(leopard-skin appearance)

44. Lines of treatment
No treatment
Follow up
LEEP
Cryotherapy
Laser
Cone biopsy
Hysterectomy