1. Basic Principles Of Colposcopy
Ayman Ewies
Consultant Gynaecologist
The Ipswich Hospital
24th April 2009

2. The Ipswich Hospital

3. History

4. 4
History of Pap Smears
 In 1923, Dr. George Papanicolaou
studied vaginal fluid in women to
observe cellular changes during
the menstrual cycle.
 Accidentally, he observed cells
from a woman who had cervical
cancer.
 In 1943, he and Herbert Traut
published the new technique.
 In the late 1950ies, Pap smear
screening started!

5. 5
History of Colposcope
 1925  Hinselman invented the Colposcope.
 1929  Levy increased magnification.
 1931  Emmerit introduced it to The USA.
 1954  Bolten set up 1st Colposcopic clinic in
The USA.

6. Pap Smear

7. 7
Limitations of Traditional PAP Smear
1. Unsatisfactory smears (blood,
mucous, etc.).
2. False positive rate: 2-5%.
3. False negative rate: 15-30%.
 Number of cells looked at is only
0.1 - 1% of the original sample.

8. 8
Liquid-Based Cytology (LBC)
 Cells collected in an alcohol-based solution.
 Cells separated from blood and mucus by centrifugation.
 Cells dispersed and transferred to a slide - single layer
cytology.
 ↓ Unsatisfactory smears by 78%.
 ↑ Detection of high grade CIN by 17-24%.
 ↑ sensitivity from 68 to 76%.
 ↑ specificity from 79 to 86%.
 Cost effective.

9. Liquid-Based Cytology (LBC)
Conventional Smear LBC
Same Patient

10. 10
Liquid-Based Cytology (LBC)
 However, a recent randomized study (Sykes, 2008)
found that the sensitivity for both LBC and
conventional smears:
– 81% for any epithelial abnormality.
– 92% for high grade lesions.
 LBC was significantly less likely to be reported as
unsatisfactory (2.7% v 9.1%).

11. Liquid-Based Cytology (LBC)

12. Liquid-Based Cytology (LBC)
..VideosLBC - Basic Principles - 2.12.mpg

13. What is Colposcopy?

14. 14
What is it all about?
 Naked-eye visualization will only detect invasive disease
but cannot differentiate pre-cancerous disease from the
normal cervix.
 Cervical cytology  may indicate the presence of
precancerous cells.
 Colposcopy fills the gap between naked eye and cyto-
pathology.
CYTOLOGY DISCOVERS THE CRIME
COLPOSCOPY LOCATES THE CULPRIT!

15. 15
Colposcope
 It is a binocular microscope that allows magnification (6-
40 fold) and illumination of the cervix.
 By applying various stains to the cervix, abnormalities can
be identified:
– Benign
– Precancerous
– Malignant changes
 Its primary use is to evaluate the cervix in case of abnormal
cervical smear as an aid to diagnosis, rather than as a
diagnostic tool itself.

16. ColposcopeColposcope
Jkshfui
fjsdijf

17. Video Clip 1 - 1:34 min
The Colposcope
..VideosClip 1 - The
Colposcope - 1.34 min.flv

18. 18
Indications
1. 3 consecutive unsatisfactory smears:
o Invasive cancers may be associated with inflammatory processes and bleed on
contact; therefore, women with persistent inadequate cytology should undergo
colposcopy.
2. 3 consecutive borderline nuclear (BN) abnormalities:
o The incidence of high grade CIN after single sample reporting BN change is
only 11%.
3. 1 BN change in endocervical cells:
o The incidence of cervical cancer and pre-invasive disease is 4-16% and 17-
40%, respectively.
4. 2 consecutive mild dyskariosis – ideally after 1:
o The incidence of high grade CIN after one mild dyskariotic smear is 40-53%.
5. 1 Moderate or severe dyskariosis.
o The incidence of high grade CIN after one moderate dyskariotic smear is 74-
77%.
o The incidence of high grade CIN after one severe dyskariotic smear is 80-90%.

19. 19
Indications
6. Smear suggestive of malignancy.
7. Glandular abnormalities.
o The incidence of cervical cancer and pre-invasive disease in these women is 40 – 43% and
20 – 28%, respectively.
8. Any degree of dyskariosis in those who underwent treatment for CIN and did
not return to routine recall.
9. PCB or IMB after age of 40 if cancer is suspected.
10. Suspicious cervix regardless of the smear report.
11. Repeated inflammatory cytology.
12. Cervical lesions e.g. condyloma acuminata which may have associated pre-
invasive or invasive disease.

20. 20
 At least 90% of women with 3 BN or 2 mild dyskariotic smears should
be seen in colposcopy clinic within 8 weeks of referral.
 At least 90% of women with moderate or severe dyskaryosis should be
seen in colposcopy clinic within 4 weeks of referral.
 At least 90% of women with glandular neoplasia and possible invasion
should be seen colposcopy clinic within 2 weeks of referral.
 At least 90% of women with BN change in endocervical cells should be
seen in colposcopy clinic within 8 weeks of referral.
 At least 90% of women with Borderline ?high grade should be seen in
colposcopy clinic within 8 weeks of referral.
Waiting Times

21. 21
Instruments Required
1. Cervical sampling devices: Ayres spatula, Aylesbury spatula, cervex
brush and cytobrush.
2. Glass slides (plus fixative) or container (liquid based) for cytology.
3. Cusco’s speculae.
4. 3 small pots containing saline, acetic acid (3-5%) and Lugol’s iodine
(1% iodine, 2% potassium iodide, 97% distilled water).
5. Cotton wool balls.
6. Sponge holding forceps.
7. Cotton-tip and jumbo swabs.

22. 22
Instruments Required
8. Kogan’s endocervical canal speculum.
9. Punch biopsy forceps.
10. Pots with formalin for specimens.
11. Haemostatic substance e.g. Monsel’s solution (ferrous subsulphate)
dried to a thick paste and silver nitrate sticks.
12. Fine needle (27 gauze size), dental syringe & cartridge of local
anesthetic with vasoconstrictor (e.g. citanest containing prilocaine
hydrochloride 3% with octapressin).
13. Selection of loops and diathermy balls (3-5 mm diameter).

23. Instruments Required
Sampling Devices
Ayres Spatula
Aylesbury Spatula
Cervex BrushCytobrush

24. Instruments Required
Kogan’s endocervical canal speculum

25. Instruments Required
Punch Biopsy Forceps

26. Instruments Required
Dental Syringe

27. Loops & Diathermy Balls

28. Video Clip 2 - 2:36 min.
Colposcopy Setup Procedure
..VideosClip 2 - Colposcopy
Setup Procedure - 2.36 min.flv

29. Practical Tips

30. 30
Practical Tips
 Women are examined in the lithotomy position.
 Colposcopy is best carried out on days 10-14 of the cycle
when the cervical mucous is clear and not tenacious.
 Colposcopic assessment is difficult when there is
significant vaginal bleeding.
 Low and medium magnification is used for initial
assessment, while high magnification (20-fold+) is used to
detect the finer details of vascular patterns.
 A green filter highlights blood vessel patterns.

31. 31
Practical Tips
 If a smear is required , this should be taken before the application of
acetic acid.
 The acetic acid is left in contact with the cervix for 10 seconds.
 Lugol’s iodine may be used to delineate atypical epithelium (Schiller’s
test):
– Normal squamous epithelium contains glycogen  Mahogany brown (-ve
Schiller’s test).
– Columnar epithelium contains little or no glycogen  fails to take up the
iodine stain (+ve Schiller’s test).
– Atypical squamous epithelium contains little or no glycogen  fails to
take up the iodine stain (+ve Schiller’s test).

32. 32
Practical Tips
Colposcopy is a subjective tool  recognizing different
patterns and their corresponding histological abnormalities is
dependent upon the experience.
Draw a picture of findings.

33. Video Clip 3 - 6:18 min
The Colposcopic Procedure
..VideosClip 3 - Colposcopic
Procedure - 6.18.flv

34. Colposcopic Appearance of Normal Cervix

35. 35
Colposcopic Assessment
Assessment of women presenting with abnormal cervical
cytology relies on colposcopic assessment of the TZ.
The 2 sites of possible colposcopic abnormality reside
within the epithelia and the vasculature of the cervix.
The knowledge of the appearance of the 3 types of normal
epithelia and their relationship is of considerable importance.
Recognizing what is normal is an essential prerequisite
before being able recognize abnormalities

36. 36
The Normal Cervix
 The cervix is dynamic, undergoing changes from
fetus until old age.
 The size and shape of the cervix vary amongst
individual and at different stage of an individual’s
life e.g.
– Pregnancy  large, soft & ↑ vascularity.
– Menopause  atrophic changes.
– Nulliparous  circular external os.
– Multiparous  slit-like transverse external os.

37. The Normal Cervix
Nulliparous
PostmenopausalMultiparous
SCJ
Pregnancy

38. 38
The Normal Cervix
 The cervix contains 2 types of epithelia:
1. Stratified squamous  lines the ectocervix.
2. Simple columnar  lines the endocervix.

39. 39
The Normal Cervix
Squamous Epithelium
 There are 2 types:
1. Original:
 Multi-layered, Smooth & pink.
 Does not stain white with acetic acid.
 Stains brown with Lugol’s iodine.
2. Transformed (metaplastic):
 Gland openings may be visualized on
colposcopic assessment.
 If these openings get blocked 
Nabothian follicles.

40. 40
The Normal Cervix
Columnar Epithelium
 It appears red* and velvety.
 At colposcopy, it has a typical grape-like structure.
 It turns to white with 3-5% acetic acid application.
 It stains yellow with Lugol’s iodine.
 It may present on ectocervix: “ectopy or ectropion”.
*Single layered  allows visualization of vasculature beneath the epithelium.

41. 41
The Normal Cervix
Squamo-columnar junction (SCJ)
 It is the border between the stratified squamous epithelium
and columnar epithelium.

42. The Normal Cervix
Squamo-columnar junction (SCJ)
Puberty & PregnancyAdolescence Adult
TZ
Menopause
TZ
-Pre-pubertal  SCJ is inside the external os.
-After the menarche  ectropion “eversion of columnar epithelium into the vagina”.
-Adulthood  SCJ at the external os due to physiological metaplasia.
-Postmenopausal  inversion of the cervix.

43. 43
The Normal Cervix
Squamo-columnar junction (SCJ)
 2 types are described:
1. The original (native) SCJ:
 This is present from birth.
 The exact location of the SCJ varies between individuals and at
various stages in an individual’s life.
2. The acquired (new) SCJ:
 At the time of puberty  cervix and uterus enlarge  cervical
eversion  more of the columnar epithelium is exposed to the
high vaginal acidity  metaplasia  new SCJ at the junction
of the metaplastic area and columnar epithelium.

44. The Normal Cervix
Squamo-columnar junction (SCJ)
TZ
Columnar
Squamous

45. 45
The Normal Cervix
Squamo-columnar junction (SCJ)
TZ = the area between new and original SCJ
External os
New SCJ
Metaplasia
Original SJC
mature
immature

46. 46
The Normal Cervix
Squamous Metaplasia
 It is the replacement of columnar epithelium by stratified squamous
epithelium.
 Various stages from immature to mature may be recognized on
colposcopic examination  inexperienced colposcopist may confuse
immature metaplasia with abnormality.
 It is a normal, irreversible, physiological process.
 Its maximum occurrence is during times of high oestrogenic
stimulation e.g. adolescence, while taking COC, and during the 1st
pregnancy.

47. 47
The Normal Cervix
Squamous Metaplasia
 Colposcopic features suggestive of metaplastic change:
1. Smooth surface with fine, uniform-calibre vessels.
2. Slight aceto-white change with application of acetic
acid.
3. No or partial brown staining with application of
Lugol’s iodine.

48. The Normal Cervix
Squamous Metaplasia

49. The Normal Cervix
Squamous Metaplasia

50. 50
The Normal Cervix
Transformation Zone (TZ)
 It is the area between the original and new SCJ.
 It contains columnar and squamous metaplastic epithelium
of varying maturity.
 It is of variable shape and width.
 Recognition of the TZ and its varying stages of metaplasia
is mandatory for colposcopic practice.
 TZ is a dynamic region of the epithelium and deviation to
abnormality occurs within the unstable metaplastic
epithelium.

51. 51
The Normal Cervix
Transformation Zone (TZ)
 Components of a normal TZ may be:
– Islands of columnar epithelium surrounded by metaplastic
squamous epithelium, gland openings and Nabothian cysts.

52. 52
The Normal Cervix
Transformation Zone (TZ)
 Components of a normal TZ may be:
– Islands of columnar epithelium surrounded by metaplastic
squamous epithelium, gland openings and Nabothian cysts.
TZ at periphery & a patch on the anterior lip
gland openings

53. The Normal Cervix
Transformation Zone (TZ)
Active TZ at periphery & a separate
area on the anterior lip
8 month later, TZ is progressing

54. The Normal Cervix
Transformation Zone (TZ)
Polypoid ectropion with coarse
papillae
Advanced transformation of the ectropion

55. The Normal Cervix
Transformation Zone (TZ)
When TZ is advanced, various shades of
brown may appear according to the
maturity of metaplastic epithelium
This TZ has a stippled appearance
with iodine due to the various stages
of maturity of metaplastic epithelium

56. 56

57. 57

58. 58

59. 59

60. 60

61. 61

62. 62

63. Variations of Normal Cervix

64. 64
The Normal Cervix
Ectropion
 It relates to the eversion of the columnar epithelium so that it is visible
in the vaginal portion of the cervix.
 Although a physiological phenomenon, it can cause confusion in
colposcopic assessment, especially if large and fragile.

65. The Normal Cervix
Ectropion

66. The Normal Cervix
Ectropion
Bizarre shaped, non-suspicious iodine yellow areas

67. 67
The Normal Cervix
Normal Menopause
 Oestrogen deficiency produces significant changes to
cervix:
1. ↓ vasculature and interstitial fluid.
2. Flattening of the endocervical epithelium.
3. TZ recedes within cervical canal ↑ rate of inadequate smears.
4. Thinning of the squamous epithelium ↑ susceptibility to minor trauma
 subepithelial petechiae.
5. Poorly glycogenated epithelium.
6. ↓ mucous production.

68. 68
The Normal Cervix
Colposcopic appearance of menopausal cervix
1. Colposcopy is difficult because of:
1. Atrophic changes
2. Discomfort
2. Examination is more likely to be unsatisfactory as the SCJ
recedes and the TZ may not be visualized in its entirety.
3. The use of Kogan’s endocervical speculum may help
visualizing the lower 1 cm of the cervical canal; however,
this may be difficult if the os is stenosed.

69. 69
The Normal Cervix
Colposcopic appearance of menopausal cervix
4. Acetic acid may not give significant effect because of lack
of vasculature and thinning of the epithelium.
5. Lugol’s iodine can give patchy yellow appearance because
of lack of glycogen (in older women, it may be uniformly
yellow because of complete absence of gylcogen).

70. The Normal Cervix
Normal Menopause
-The menopausal cervix stains light brown to yellow with iodine
-The dark spots are due to subepithelial haemorrhages (petechiae)

71. 71
The Normal Cervix
Normal Menopause
 The use of local vaginal oestrogen for 2-4 weeks  may
reverse some of the atrophic changes  improve
appearance of TZ 
1. ↓ rate of unsatisfactory colposcopy.
2. May reverse borderline cytological abnormalities.

72. 72
The Normal Cervix
Pregnancy and Puerperium
 Colposcopy is difficult as pregnancy advances (no much
changes in the 1st trimester) because of:
1. Cervix gets enlarged and softer.
2. Eversion of the endocervical canal due to increased vascularity
and interstitial oedema.
3. Polypoid appearance of the columnar epithelium due to the
hypertrophy of the villi and the decidual changes.
4. TZ is enlarged with marked active metaplasia.
5. Thick tenacious mucous production.
6. ↑ Vascularity  acetowhite reactions of CIN (density, mosaicism
and punctation) are more pronounced  overdiagnosis.

73. 73
The Normal Cervix
Pregnancy and Puerperium
 Smears taken during pregnancy and early puerperium
(within 6 weeks) are usually of suboptimal quality because
of:
1. Epithelial changes and enlarged TZ.
2. Progestogenic effect  clumping of the cells 
difficult analysis on a conventional smear.
3. Decidual changes  large cells  may be confused
with dyskariosis or glandular abnormality.

74. 74
The Normal Cervix
Pregnancy and Puerperium
 The main aim of colposcopy is to rule out invasive disease
and help pursue conservative management until after
delivery.
 If there is no suspicion of invasive disease  conservative
management with cytology and colposcopy each trimester
 re-evaluation 8-12 week postpartum.

75. 75
The Normal Cervix
Pregnancy and Puerperium
 Treatment of CIN is almost never indicated during
pregnancy.
 Biopsies should only be undertaken if there is suspicion
of invasive disease.
 Punch biopsies are not recommended since they are
usually insufficient to rule out invasive process.
 The biopsy should be a cone performed in theatre (risk of
significant haemorrhage, infection, preterm labour and/or
miscarriage).

76. 76
The Normal Cervix
Nabothian Cysts
They occur when cervical gland openings get covered  mucous
collection within.
Biopsy is not justified.
They do not require any treatment.

77. Colposcopy Flow Chart

78. Colposcopy Flow Chart
See & Treat
Cervical biopsy
Apply acetic acid 3-5% Suspicious cervix  manage accordingly
Identify SCJ
SCJ seen SCJ not seen
No lesion visualizedLesion visualized
Assess site, size & degree
± Schiller’s test
Colposcopy deemed satisfactory Colposcopy deemed unsatisfactory
Gross inspection of cervix to its entirety
Look for leukoplakia or abnormal vessels
Use green filter

79. To be a good colposcopist you have to persevere!