Historic events related to colposcopy
1925: Invention of colposcope (Hinselman)
1928: Schiller test
1938: Acetic acid test (Hinselman)
1939: Green filter (Kratz)
1940: Pap test
1942: First photographs of cervix (Treite)
1980: Laser surgery
1988: Computer-aided colposcope
1989: LLETZ (Prendiville & Cullimore)
1991: Pap Net
2000: Telecolposcopy (Harper et al)Aboubakr Elnashar
low power stereoscopic microscope.
Its fundamental parts are 3:
1. An optical system that offers magnification
between 6 & 40.
The focal length is between 20 & 30 cm.
2. An axial illumination system (tungsten or
3. A mounting device that permits easy
movements of the apparatus.
It is fitted with 3:
1.Green filter for easier observation of the vessels
2.Camera for photography
3.Monocular teaching arm.
a.Self-retaining vaginal speculum
b. Endocervical speculum
c. Dressing forceps
d. Equipments for biopsy:
punch biopsy forceps,
single toothed tenaculum,
solutions to stop the bleeding,
e. Equipments for cytology:
fixatives Aboubakr Elnashar
New optical lenses,
fiberoptic light sources &
Manipulation according to physician,s preference.
Telecolposcopy (Harper et al,2000)
Indications of colposcopy
1. Part of any gynecologic examination
2. Primary screening for cervical cancer.
3. Clinically suspicious cervix.
4. Abnormal Pap smear.
5. Evaluation & treatment of CIN.
6. Follow up after conservative therapy of CIN.
7. Postcoital bleeding.
8. Patients with external vulval warts
9. Evaluation of sexual assault victims.
More sensitive & more cost effective than
When access to cytopathology is difficult
(Cecchini et al,1997).
•Portable colposcopy in rural areas is cost
effective & highly acceptable (Martin et al,1998).
Recent recommendations of FIGO for management of abnormal
Persistent inflam., persistent ASCUS, LSIL, HSIL, AGCUS,Invasive
Normal or LSIL HGSIL Invasive
6 mo smear x 2 LEEP Appropriate TT
1.Inspection of unprepared cervix
2.Inspection of the cervix after application of
3.Inspection with green filter
4.Inspection after application of acetic acid
5.Inspection after application of Lugol s
.± Exposure of the lower cervical canal (endocervical
.± Biopsy: from that part with greatest degree of
1. Punch. False negative rate up to 54% (Buxton et
al,1991) Multiple biopsies
Excisional techniques are superior to destructive
2. Loop excision
3.Endocervical curette: ECB has replaced ECC
Colposcopy evaluates changes in the: terminal
surface epithelium after application of acetic acid.
Colposcopy is based on evaluation of the
transformation zone (T.Z).
1.Normal & benign: branched, hairpin &
network. It is tree like branching
2.Preinvasive & invasive: Mosaic, punctation &
I.Normal fine capillary network
II.Increased as in vaginitis
III. Dilated as in ATZ G1
IV. Irregular as in ATZ G2 &3
V. Atypical as in invasive cancer.
.Inter-capillary distance (ICD):
Increased in preinvasive & invasive lesions.
Decreased in inflammatory lesions
Measured by comparing with that of adjacent
normal epithelium or colpophtograph.
.Whiteness after acetic acid:
.Density of whiteness
.Time needed for whiteness to appear &
.Sharpness of demarcation
.Presence of punctation or mosaic
.Negativity of Iodine test: beneficial test.
.Appearance of gland opening.
.Surface extent of the lesion:
The larger the colposcopic lesion, the more likely
it is to be high grade
large CIN 3 lesions are more likely to have areas
of micro-invasion than small lesions.
The size of the lesion being considered to be a
more important prognostic indicator for invasion
than histological grading
1.Can be applied at each gynecologic
2.Immediate & exact diagnosis
3.Determine the site & the extent of the lesion
4.The method is not very expensive.
5.The method can be learned by every physician
through self-study or continuing education.
6.Differentiate between inflammatory atypia &
neoplasia, between invasive & non-invasive
7.HPV are best detected by colposcopy.
8.Helps to avoid unnecessary smear, biopsy,
9.Cytologic smears may be obtained under
10.Good for follow-up.
Inadequate for detection of
International Federation of Cervical Pathology & Colposcopy
Normal: Original squamous epithelium
Normal transformation zone
Abnormal: Acetowhite epithelium Punctation
Iodine negative Atypical vessels
Suspect invasive cancer:
SCJ not visible, severe inflam or atrophy, invisible cervix
Nonacetowhite micropapillary surface, exophytic condyloma,
inflammation, atrophy, ulcer
Colposcopy of the vulva
1.Examination after smearing with a water soluble
2. Prolonged acetic acid test
3.Toludine blue test: little clinical value.
* The junction between the glycogen bearing
vaginal epithelium & keratin producing vulval
epithelium: high risk for intraepithelial neoplasia.
*Abnormalities: diffuse acetowhite, localized