white patch before a.a. application.
leukoplakia is caused by a layer of keratin on the epithelium.
Histologically, it shows hyperkeratosis or parakeratosis.
Several things can cause leukoplakia including HPV;
keratinizing CIN; keratinizing carcinoma; chronic trauma
from diaphragm, pessary, or tampon; & radiotherapy.
1. Thick white vaginal discharge: which is removed with a.a.
2.Retention cyst with dense epi. Lining:
there are vessels on the surface & it is iodine +ve.
biopsy is mandatory.
AWE is the most common abnormal colposcopic finding of
opaque, sharply delineated white or gray color after
application of 3 to 5 % a.a.
1. coagulates the proteins of the nucleus &
cytoplasm & makes the protein opaque & white.
2. dehydrates the cells, the cytoplasmic volume is
reduced & the reflection is increased.
variable, generally it appears after 20 secs &
disappears after 2 mins.
Effects of a.a.:
1.on the mucous: It coagulates mucous which can
then easily removed (mucolytic).
2.on the mature glycogen-producing epithelium:
no effect bec. The a.a. does not penetrate below the
outer one-third of the epithelium. The cells have very
small nuclei & a large amount of glycogen (not
3.on the col. epi.:
swell & become slightly opaque, particularly if the
beginning signs of metaplasia are present. So,it
makes its recognition easier.
4.on the immature metaplastic epi.:
Because they are very thin & have large nuclei. It is
not as white or opaque as CIN but instead appear
gray & filmy.
5.on dysplastic cells:
They contain large nuclei & large amounts of
chromatin( protein). They become white.
6.on gland openings of the TZ.:
are better outlined.
7.on puncutation & mosaic:
appear more prominent.
8.on vascular bed:
becomes less evident due to arteriolar spasm.
Causes of acetowhite epi.
healing or regenerating epi. ,
CIN & invasive cancer.
D.D.depend on colour, margin, surface, vessels &
elevated white patch before a.a application.
2. Acetowhitness of normal metaplastic epi.:
occurs quickly & fades quickly. It is also more difficult to
reestablish after fading by reapplication of a.a. The
surface is shiny & translucent. The margin is indistinct, &
AWE blend gradually with the adjacent more mature sq.
3. Acetowhitness of CIN.:
It takes more time to appear. The effect is hastened &
aided by second a.a application. A definite & distinctive
margin is usually present. The intensity is more marked
than with physiologic variants.The surface is thicker &
more opaque &less shiny.
Red dots over a whitish background.
It is produced when the central capillaries of the columnar
villi are preserved when CIN occurs. It corresponds to the
tops of the capillary loops that almost reach the surface of
. Fine: The dots are flat, small & close
together. It is caused by acanthosis, HPV
. Coarse: The dots are elevated, bigger &
more widely separated. ICD is irregular. In
extreme cases, the puncutation appears as
small papillae. It indicates high-grade SIL or
early invasive cancer.
1.Red puncutate vaginitis: Iodine test :uniform
coloring of the area & the dots are
-ve. In puncutation: the whole area is -ve.
2. Peticheal vaginitis: red dots are large & less
3. Hinselman papillary elevation: dots are white
& Iodine is +ve.
Small squares of whitish color separated by
It is produced when the vessels form a basket
around the blocks of abnormal epi. They may
arise from a coalescence of many terminal
puncutate vessels or from the vessels that
surround the cervical gland openings.
. Fine: The lines are fine & the fields are flat,
regular & small.
. Coarse: The lines are intense red &
pronounced & the fields are elevated,
irregular & bigger.
Puncutation & mosaic are often coexisting within
the ATZ & the causes are similar.
. Pseudomosaic: The squares are separated
by whitish lines more delicate & less defined
. Reticular TTZ.
. Geographic vaginitis :
They are an exaggeration of vascular abnormalities
described in puncutation & mosaic & occur as the lesion
becomes more severe in type.
They are irregular in size, shape, course & arrangement &
the ICD is greater than in normal epithelium. In benign
vascular patterns the branching is dichotomous or tree like
with large stems giving rise to smaller & smaller branches.
There is no particular pattern, the vessels being arranged in
a haphazard way. Atypical vessels show no decrease in
diameter of terminal branches & give rise to a coarse
network enclosing irregular avascular fields.
They are most characteristic of invasive cancer, but can
occur occasionally in high-grade SIL.
CIN & most HPV lesions fail to stain deeply when a solution
Schillers or Lugal,s iodine is applied because glycogen is
Certain subclinical HPV lesions containing glycogen
demonstrates less well-defined response, producing a
stippled or mosaic-like uptake of iodine that may be of value
in grading the significance of the disorder.
Iodine nonstaining is cause also by acanthotic epi..
Causes of the colposcopic abnormalities ( Campion et
Increased cellular & nuclear density. Abnormal intracellular
Abnormal keratin production in the neoplastic process
Punctation & Mosaic
Alteration in epithelial capillaries.
Mosaic formation due to:
1. transformation of normal metaplasia,
2.capillary proliferative effect of HPV,
3.tumor angiogenic factor in severe neoplastic
Specific alteration in epithelial capillaries, due to
angiogenesis, suggestive of invasive cancer.
Grading of abnormal colposcopic findings
a. Grade I (insignificant):
Flat, acetowhite epi. , Borders not necessarily
sharp; semitransparent with or without fine
caliber, regularly shaped vessels, often with ill-
defined patterns, absence of atypical vessels,
b. Grade II (significant):
Flat, aceto-white epi. of greater opacity with sharp
borders; with or without dilated-caliber, regularly
shaped vessels; defined patterns; absence of
atypical vessels; usually increased ICD.
c. Grade III (highly significant):
very white or gray opaque epi., sharply bordered;
dilated caliber, irregularly shaped, often coiled,
often atypical vessels, increased but variable ICD
& sometimes irregular surface - microexophytic
Grading based on 4 factors:
1. Surface pattern
2. Color tone.
4. Border of the lesion with normal tissue.
3. Reid s index
Colp.sign 0 1 2
Margin indistinct sharp peeling
Color snow white off white dull
Vessels thin absent
positive patial negative
4. Niekerk (1998)
Low grade High grade
•Acetowhite epithelium: shiny or snow dull, oyster white color
•Surface: flat irregular contour, microexophytic
•Demarcation: diffuse, irregular, sharp, straight line,
internal demarcation absent internal demarcation present
•Vessels: fine, regular shape, uniform coarse, dilated, increased ICD,
caliber, normal arborization, spaghetti bizarre, commas, corkscrews
changing calibers sharp bends
•Iodine: uniform mahogany brown mustard yellow, yellow or iodine -ve
Colposcopically suspect invasive cancer
Although rare. It is obvious after acetic acid
application with raised edge, irregular surface,
nodulation, ulceration, the mountain range
appearance & atypical blood vessels.