Colposcopy examination

colposcopic examination and its interpretation

1. colposcopy DR. R. ARCHANA AND DR. POOJA FINAL YEAR , MBBS LHMC

2. History; First described by HANS HINSELMAN of germany in 1925 as a screening tool for cervical cancer .

3. WHAT IS COLPOSCOPY? Colposcopy is a gynecological procedure that illuminates and magnifies the vulva , vaginal walls, and uterine  cervix  in order to detect and examine abnormalities of these structures

4. Why is colposcopy done ? Colposcopy is usually done if:   Pap smear  is abnormal, or When the cervix looks abnormal during the collection of a Pap smear. Even if a Pap smear result is normal, colposcopy is ordered when the cervix appears visibly abnormal patient who presents with postcoital vaginal bleeding. . The purpose of the colposcopy is to determine what is causing the abnormal looking cervix or the abnormal Pap smear so that appropriate treatment can be given

5. . Preparation Patients should not douche, use tampons, or have sexual intercourse for 24 hours before colposcopy . Patients should empty their bladder and bowels before colposcopy for comfort. For mild cramps or a sharp pinching when the tissue is removed ibuprofen can be taken the night before and the morning of the procedure (no later than 30 minutes before the appointment). Patients who are pregnant or allergic to aspirin or ibuprofen can instead take pcm

6. . Pregnant women may undergo colposcopy if they have an abnormal Pap test; special precautions, however, must be taken during biopsy of the cervix.

7. How is colposcopy done? A  colposcope  is a microscope. The instrument has a range of magnification lenses. color filters :detect tiny abnormal blood vessels on the cervix. The colposcope is used to examine through the vaginal opening

8. Typical Mayo tray set-up for colposcopy . From left to right: cotton balls, Monsel's solution, saline, vinegar, Lougal's iodine, cotton-tipped applicators, rectal swabs (Texas Q-tips), Ring forceps, vaginal speculum, biopsy forceps, ECC curette, endocervical speculum. Additional possible items not shown include benzocaine solution, side-wall retractors, and cervix brush

9. The first step of the procedure is examining the vulva and vagina for signs of genital warts or other growths.   A Pap smear is then taken. Examine at the squamocolumnar junction

10. What special tests are done during colposcopy ? Three special tests are done during colposcopy : Acetic acid wash, Use of color filters, and Sampling (biopsy) of tissues of the cervix. .

11. acetic acid, diluted 3% to 5%. It washes away mucus  and allows abnormal areas to be seen more easily stains the abnormal areas white. called " acetowhite lesions.“ Sometimes, however, normal areas can also stain white, but these areas have vague or faint borders Acetic acid staining Lugol's solution or Schiller's solution :Normal cells will generally take up the iodine stain (and turn brown) in a uniform manner, whereas severe precancers and cancerous areas will not.

12. . Helps in examining capillaries in the area of the squamocolumnar junction. Blue or green filtered light can cause abnormal capillaries to become more obvious, usually inside an acetowhite area. Normal capillaries are slender and spaced out evenly. In contrast, abnormal capillaries can appear as red spots (thickened capillaries seen on end) or can produce a pattern resembling hexagonal floor tiles . The worse the cervical disease, the thicker and more widely spaced out are the capillaries.. Thus, when cancer eventually develops, capillaries take on odd shapes, like punctuation marks . Use of color filters

13. The biopsy of abnormal areas is a critical part of colposcopy because treatment will depend on how severe the abnormality is on the biopsy sample. As part of the biopsy procedure,  endocervical curettage (sampling of the tissues within the endocervical canal, or the opening of the cervix to the uterine cavity) is often performed. Biopsy of the cervix

14. Tischler cervical biopsy forceps: A. Standard surgical instrument grips, B. "Pistol grip" Kogan endocervical speculum. Blades typically come in 2mm, 4mm (shown here) or 6mm sizes. The blades may be inserted into the cervical os and gently opened to allow better visualization

15. Aftercare If a biopsy was done, there may be a dark vaginal discharge afterwards. After the sample is removed, Monsel's solution applied to the area to stop the bleeding. When this mixes with blood, it creates a black fluid that looks like coffee grounds. This fluid may be present for a couple of days after the procedure. It is also normal to have some spotting after colposcopy . Pain-relieving medication can be taken to lessen any postprocedural cramping. Patients should not use tampons, douche, or have sex for at least a week after the procedure (or until the doctor says it is safe) because of the risk of infection.

16. Risks Patients may have bleeding or infection after biopsy. Bleeding is usually controlled with a topical medication. If colposcopy is performed on a pregnant patient, there is a risk of premature labor. A patient should call her doctor right away if she notices any of the following symptoms: heavy vaginal bleeding (more than one sanitary pad an hour) fever, chills, or an unpleasant vaginal odor lower abdominal pain

17. Interpretation INTERPRETATION

18. Colposcopic diagnosis of cervical neoplasia depends on mainly 4 features ACETOWHITINING MARGIN AND SURFEACE CONTOUR OF ACETOWHITE AREA VASCULAR FEATURE & COLOUR CHANGE AFTER APPLICATION OF IODINE SOLUTION

19. SENSTIVITY -87% TO 99% to diagnose cervical neoplasia SPECIFICITY- 23% TO 87%

20. COLPOSCOPIC VIEW VASCULATURE-best seen before application of acetic acid ABNORMALITIES ARE Punctuation Mosaic pattern & Atypical vessels

21. Cont……. Normally afferent & efferent capillaries within the villi of columnar epithilium become compressed during metaplastic process & not incorporated within the newly form epithiliumr Instead they form a fine network below the basement membrane When CIN develop as a result of of HPV infection afferent and efferent capillary system incorporate in to the diseased dysplastic epithelium.. This form the basis of punctate mosaic blood vessels

22. Cont……. PUNCTATE PATTERN-terminating vessels in stromal papillae underlying the thin epithelium appear as black point in a stippling pattern on colposcopy called PUNCTATE AREAS MOSAIC PATTERN- epithilium appear as individually small large round , polygonal,regular or irregular blocks. This pattern appear cause of interconnecting blood vessel in stromal papilla which is observed as cobbled area.

23. FINE PUNCTATION fine punctuation refer to looped capillaries viewed end on that appear to be of fine calibre and located close to one another, producing a delicate stippling effect Fine mosaics are a network of fine- calibre blood vessels . found in low-grade (CIN 1) lesions.

24. COARSE PUNCTATION Coarse punctation coarse mosaic are formed by vessels having larger calibre and larger intercapillary distances, occur in more severe neoplastic lesions CIN 2, CIN 3 lesions and early preclinical invasive cancer . Sometimes, the two patterns are superimposed in an area so that the capillary loops occur in the centre of each mosaic ‘tile’. This appearance is called umbilication

25. LEUKOPLAKIA Leukoplakia or hyperkeratosis is a white well demarcated area on the cervix The white colour is due to the presence of keratin . Usually leukoplakia is idiopathic, but it may also be caused by chronic foreign body irritation, HPV infection or squamous neoplasia . it should be biopsied to rule out high-grade CIN or malignancy

26. CONDYLOMA Condylomata are multiple, exophytic lesions, that are infrequently found on the cervix, but more commonly in the vagina or on the vulva They present as soft pink or white vascular growths with multiple , fine, finger-like projections on the surface , before the application of acetic acid. Under the colposcope , condylomata have a typical appearance, with a vascular papilliferous or frond-like surface , each element of which contains a central capillary. the surface of a condyloma may have a whorled, heaped-up appearance with a brain-like texture, known as an encephaloid pattern densely hyperplastic . These lesions may be located within, but are more often found outside the transformation zone condyloma is whiter. . Condylomatous lesions may not take up iodine stain or may stain only partially brown.

27. CONDYLOMATA- .. Fig showing geographical satellite lesion far away from squamocolumnar junction FIG2 showing exophytic condyloma in the cervix after application of acetic acid

28. Colposcopic viev after application of 5% acetic acid solution Degree to which the epithelium takes up acetic acid correlated with the color tone or intensity the surfacre shine and the duration of the effect and in turn with the degree of neoplastic change in lesion LOW GRADE LESION -appears less dense less extensive thin and irregular margin or of angular margin with fine punctatin /mosaic HIGH GRADE LESION -appears dense poaque grey white aceto white areas with coarse punctationor mosaic and wid regular and well demarcated borders. These lesion often involve both lips and harbour atypical vessels

29. IT IS A GEOGRAPHICAL SATELLITE LESION AFTER APPLICATION OF 5% ACETIC ACID FAR AWAY FROM SQUAMOCOLUMNAR JUNCTION SUGGESTIVE OF LOW GRADE LESION

30. FIG-1.. Showing a circumorificial acetowhite cin-1 lesion with irregular margin and fine mosaic FIG-2.. involves bith ant. And post. Lip,moderatly dense FIG-3.. mild dense acetowhite lesion with fine mosaic

31. CIN -2 lesion fig1 show.. moderately dense acetowhite lesion with well defined margin and coarse punctation in the ant. Lip and 3 ‘o clock position fig 2 dense well defined acetowhite are with regular margin and coarse mosaic fig3 acetowhite lesion with coarse punctation

32. CIN3 LESION FIG1..shows a circumorificial dense opaque acetowhite area with coarse mosaic FIG2..shows dense acetowhite lesion with regular margin and coarse irregular punctation fig3.. dense acetowhite lesion with raised and rolled out margin

33. CERVICITIS- inflamed with a reddish appearance bleeding on touch there are ill defined patchy aceto white areas

34. AFTER APPLICATION OF IODINE Normal vaginal and cervical squamous epithilium and mature metaplastic epithilium contain glycogen rich and thus take up iodine stain turns black or brown but Dysplastic epithilium contains little or glycogen thus does not stain with iodine remains mustard saffron yellow Immature metapplasia partially stains cause columnar epithilium does not take iodine. Condylomatous lesion does not take iodine

35. CIN1 MUSTARD YELLOW IODINE NEGATIVE AREA WITH IRREGULAR MARGIN

36. CIN2 MUSTARD YELLOW IODINE NEGATIVE AREA IN ANTERIOR LIP

37. CIN 3 (A)DENSE SAFFRON YELLOW IODINE NEGATIVE AREA (B) DENSE MUSTRD YELLOW IODINE NEGATIVE AREA IN THE UPPER LIP

38. condyloma Fig. showng Lesion doesnot takes iodine

39. MODIFIED REID COLPOSCOPIC INDEX