This document provides terminology and principles related to colposcopy. It defines terms like stratified squamous epithelium, columnar epithelium, metaplasia, ectropion, transformation zone, and dysplasia. It describes the normal appearance of the cervix during colposcopy, including features like original squamous epithelium, columnar epithelium, and blood vessels. It also outlines the colposcopy examination process and how tools like acetic acid and Lugol's iodine are used to detect cervical abnormalities.

1. Colposcopy
Principle and practice
DR WAI PHYO
M.B.,B.S, MMEDSC (OG), MRCOG (UK)
CONSULTANT OG

2. Questions
 Stratified non-keratinizing squamous epithelium
 Columnar Epithelium
 Metaplasia
 Ectropion or ectopy
Nabothian cysts
 Transformation zone
 Koilocytes
 Carcinoma in situ (CIS)
 Dysplasia
 Acetowhite
 Principles of Schiller’s (Lugol’s) iodine test
 CIN

3. Outline
 Terminology
 Colposcopic appearance of normal cervix
 The colposcopic examination
 Detection cervical neoplasias
 Treatment of cervical intraepithelial neoplasia
 Cases
 Quiz time
 References

4. Terminology

5. Stratified non-keratinizing squamous epithelium
 large area of ectocervix is covered by a stratified, non-keratinizing, glycogen-
containing squamous epithelium.
 Intermediate and superficial layer cells contain abundant glycogen in their
cytoplasm, which stains mahogany brown or black after application of
Lugol’s iodine and magenta with periodic acid-Schiff stain in histological
sections.
 Glycogenation of the intermediate and superficial layers is a sign of normal
maturation and development of the squamous epithelium. Abnormal or
altered maturation is characterized by a lack of glycogen production.

6. Squamous epithelium of the vagina
and ectocervix.
Superficial cell layer
Intermediate cell layer
Parabasal layer
Basal cell layer

7. Columnar Epithelium
 The endocervical canal is lined by the columnar epithelium (sometimes
referred to as glandular epithelium). It is composed of a single layer of tall
cells with dark-staining nuclei close to the basement membrane.
 Glycogenation and mitoses are absent in the columnar epithelium. Because
of the lack of intracytoplasmic glycogen, the columnar epithelium does not
change colour after the application of Lugol’s iodine or remains slightly
discoloured with a thin film of iodine solution.

8. Columnar cells
Stroma
Crypt opening
Columnar cells
Crypt
Microscopic features: The columnar epithelium comprises a single layer of columnar cells.
The epithelium invaginates in the cervical stroma to form crypts.

9. Metaplasia
 Metaplasia refers to the change or replacement of one type of epithelium by another.
 The metaplastic process mostly starts at the original squamocolumnar junction and
proceeds centripetally towards the external os through the reproductive period to
perimenopause.
 The physiological replacement of the everted columnar epithelium by a newly formed
squamous epithelium is called squamous metaplasia
 Squamous metaplasia is an irreversible process; the transformed epithelium (now
squamous in character) cannot revert to columnar epithelium.

10. Location of the squamocolumnar junction (SCJ) and transformation zone; (a) before
menarche; (b) after puberty and at early reproductive age; (c) in a woman in her 30s; (d) in a
perimenopausal woman; (e) in a postmenopausal woman

11. Ectropion or ectopy
Nabothian cysts
 Ectropion or ectopy is defined as the presence of everted endocervical columnar
epithelium on the ectocervix.
 Nabothian cysts are retention cysts that develop as a result of the occlusion of an
endocervical crypt opening or outlet by the overlying metaplastic squamous
epithelium

12. Nabo cysts
Vaginal acidity
Squamous
metaplasia
Crypt
opening
Nabothian
follicles

13. Ectropion
 The columnar epithelium extends onto the ectocervix for a variable
distance from the external os. The presence of columnar epithelium on the
ectocervix is called ectropion or ectopy.

14. Leukoplakia
 A white patch visible on the cervical epithelium even before application of
acetic acid is known as leukoplakia
 Leukoplakia can hide high-grade premalignant lesions or even cancer
underneath. All leukoplakia patches in the transformation zone of the cervix
should be biopsied or excised. Typically, leukoplakia appears as a white plaque
on the cervix, with a shiny, waxy surface and a sharp, raised margin.

15. Transformation zone
 This region of the cervix where the columnar epithelium has been replaced and/or is being
replaced by the new metaplastic squamous epithelium is referred to as the transformation zone.
 It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal
end and proximally by the furthest extent that squamous metaplasia has occurred as defined by
the new squamocolumnar junction
 During early embryonic life, the cuboidal epithelium of the vaginal tube is replaced by the
squamous epithelium, which begins at the caudal end of the dorsal urogenital sinus.
 if this process is arrested for some reason or incomplete, the original squamocolumnar junction
will be located distal to the external os or may rarely be located on the vaginal walls, particularly
involving the anterior and posterior fornices. ( CONGENITAL TRANSFORMATION ZONE)

16. Transformation zone

17. Transformation zone

18. Terminology
 Koilocytes are atypical cells with a perinuclear cavitation or halo in the cytoplasm indicating
the cytopathic changes due to HPV infection.
 Carcinoma in situ (CIS) was those lesions in which the undifferentiated carcinomatous cells
involved the fullthickness of the epithelium, without disruption of the basement membrane.
 The term dysplasia was designate the cervical epithelial atypia that is intermediate between
the normal epithelium and CIS.

19. Acetowhite
 The effect of acetic acid depends upon the amount of nuclear proteins and cytokeratins
present in the epithelium. When acetic acid is applied to normal squamous epithelium, little
coagulation occurs in the superficial cell layer, as this is sparsely nucleated.
 Though the deeper cells contain more nuclear protein, the acetic acid may not penetrate
sufficiently and, hence, the resulting precipitation is not sufficient to obliterate the colour of
the underlying stroma. Areas of CIN undergo maximal coagulation due to their higher
content of nuclear protein and prevent light from passing through the epithelium.

20. Acetowhite
 The acetowhite changes associated with immature metaplasia and inflammatory changes
quickly disappear, usually within 30-60 seconds.
 Acetowhitening associated with CIN and invasive cancer quickly appears and persists for
more than one minute. The acetic acid effect reverses much more slowly in high-grade CIN
lesions and in early pre-clinical invasive cancer than in low-grade lesions, immature
metaplasia and sub-clinical HPV changes. It may last for 2-4 minutes in the case of high-
grade lesions and invasive cancer.

21. Principles of Schiller’s (Lugol’s) iodine test
 Iodine is glycophilic and hence the application of iodine solution results in uptake of iodine in
glycogen-containing epithelium.
 If there is shedding (or erosion) of superficial and intermediate cell layers associated with
inflammatory conditions of the squamous epithelium, these areas do not stain with iodine
and remain distinctly colourless in a surrounding black or brown background.
 Areas of CIN and invasive cancer do not take up iodine (as they lack glycogen) and appear as
thick mustard yellow or saffron-coloured areas.
 Areas with leukoplakia (hyperkeratosis) do not stain with iodine. Condyloma may not, or
occasionally may only partially, stain with iodine. We recommend the routine use of iodine
application in colposcopic practice as this may help in identifying lesions overlooked during
examination with saline and acetic acid and will help in delineating the anatomical extent of
abnormal areas much more clearly, thereby facilitating treatment.

22. CIN
 CIN 1 there is good maturation with minimal nuclear abnormalities and few mitotic figures.
Undifferentiated cells are confined to the deeper layers (lower third) of the epithelium. Mitotic
figures are present, but not very numerous. Cytopathic changes due to HPV infection may be
observed in the full thickness of the epithelium.
 CIN 2 is characterized by dysplastic cellular changes mostly restricted to the lower half or the
lower twothirds of the epithelium, with more marked nuclear abnormalities than in CIN 1. Mitotic
figures may be seen throughout the lower half of the epithelium.
 In CIN 3, differentiation and stratification may be totally absent or present only in the superficial
quarter of the epithelium with numerous mitotic figures. Nuclear abnormalities extend
throughout the thickness of the epithelium. Many mitotic figures have abnormal forms.

23. Traditional algorithm for screen-positive cases.

26. Colposcopic appearance of normal
cervix

27. Squamous epithelium
 The original squamous epithelium is the native epithelium (which was
present at birth) of the ectocervix. It is smooth and pink and does not
change after application of acetic acid. In a mature cervix, the original
squamous epithelium is seen at the periphery and is continuous with the
vaginal epithelium.
 The colour of the original squamous epithelium changes to dark
mahogany brown after application of Lugol’s iodine, because of the
staining of the intracellular glycogen in the superficial layers by iodine.

28.  The columnar epithelium lines the endocervix. In the normal cervix, the
columnar epithelium is just visible near the external os. It appears as a red
patch at the centre of the cervix after the cervix is cleaned with normal
saline.

29.  The columnar epithelium becomes prominent after application of acetic
acid and has a velvety, grainy surface appearance. The finger-like villi
protruding into the endocervical canal and the multiple longitudinal folds
(fissures) are characteristics of the epithelium but may not always be
visible.

30. Columnar epithelium
 The columnar epithelium may become temporarily white after application of acetic acid but regains its red colour
within a few seconds. The junction between the squamous epithelium and the columnar epithelium becomes very
distinct after application of acetic acid. The columnar epithelium retains its red colour after application of Lugol’s
iodine.
 Prominent normal branching blood vessels are often seen on the columnar epithelium, because the epithelium is
thin and transparent.

31. Location of squamocolumnar junction (SCJ)
(a) early reproductive age group. The SCJ is located far away from the external os. Note the presence of everted columnar epithelium occupying a large portion of the ectocervix producing
ectropion
(b) The new SCJ has moved much closer to the external os in a woman in her 30s. The SCJ is visible as a distinct white line after the application of 5% acetic acid due to the presence of immature
squamous metaplastic epithelium adjacent to the new SCJ
(c) The new SCJ is at the external os in a perimenopausal woman
(d) The new SCJ is not visible and has receded into the endocervix in a postmenopausal woman. Mature metaplastic squamous epithelium occupies most of the ectocervix

33. Normal blood vessels
 Normal branching capillaries or hairpin like blood vessels are often seen
over the original squamous epithelium.

34.  Tongue-like projections of the epithelium towards the external os (centripetal extensions) signify that the metaplastic process
is still active. These tongue-like projections may be faintly white after application of acetic acid.
 Nabothian cysts (or follicles) are retention cysts formed because of blockage of the crypt openings by the metaplastic
epithelium. Nabothian cysts look like white pimples or blisters on the cervix, with fine capillaries of blood vessels stretched
them.
 Sometimes the blood vessels are visible as a network of fine capillaries of uniform calibre on the surface. They look like the
mosaic tiles on a floor. The mosaic pattern of vessels seen in metaplastic epithelium is known as fine mosaic because of the
uniform distribution of the fine capillaries. They are better visualized on an acetowhite background.
Squamous Metaplasia

35.  Metaplastic epithelium may turn white after application of acetic acid (acetowhite). The white area is
usually thin, patchy, or transparent. The margin of the white patch is often indistinct, irregular, or “fluffy
 Uptake of Lugol’s iodine in the metaplastic epithelium depends on the degree of maturation. In
metaplastic epithelium there is usually partial or patchy iodine uptake.
Squamous metaplasia

36.  The transformation zone may have any of the features of metaplasia: crypt openings,
nabothian cysts, islands of columnar epithelium, fine mosaics or punctations, and acetowhite
epithelium

37. Normal vessel appearance

38. Transformation Zone
Transformation Zone Classification
Type 1
Is completely ectocervical
Is fully visible
May be small or large

39. Transformation zone
Type 2
Has endocervical component
Is fully visible
May have ectocervical component, which may be small or large

40. The Colposcopy examination

41. Indication
 The best time to schedule colposcopy is during the first half of the menstrual cycle (the follicular phase), when cervical mucus is
clear.
 The most common indication for colposcopy is an abnormal cervical cancer screening test.
 Visual inspection with acetic acid (VIA)-positive women may have colposcopy or direct treatment
 Women positive on an HPV test can have triaging with cytology or VIA or may be directly referred for colposcopy.
 Symptoms suggestive of cervical cancer, e.g. profuse foul-smelling vaginal discharge, abnormal or contact vaginal bleeding, post
menopausal bleeding (along with endometrial assessment)
 Cervical cancer suspected on naked-eye examination of the cervix
 Follow-up after treatment of cervical precancer
 Evaluation of other lower genital tract abnormalities (e.g. genital warts, vulvar lesions)
 Colposcopy should be postponed if there is severe cervico-vaginal inflammation, making satisfactory visualization of the cervix
difficult. However, if cervicovaginal inflammation is accompanied by a growth or an ulcer on the cervix, a biopsy of the growth or
ulcer should be obtained without further delay.

43. Instruments and consumables for
Colposcopy
 Gloves (disposable or sterile reusable)
 cotton swabs, cotton swab sticks
 normal saline
 dilute acetic acid (3–5%) solution (freshly prepared)
 5% Lugol’s iodine solution
 Monsel’s solution/paste or silver nitrate
 10% formaldehyde solution
 lubricant jelly.

44. Instruments and consumables for
Colposcopy

45. How does acetic acid help to detect abnormalities on
colposcopy?
 Acetic acid causes reversible coagulation and precipitation of proteins in the epithelial cells. It also draws water out of the cells,
causing the cell membrane to collapse around the large abnormal nucleus (if any).
 Because of these changes, the epithelium, which is normally a transparent filter, becomes opaque and does not allow passage of
light through it.
 The reflected light from the opaque epithelium gives a white colour to the epithelium.
 In normal squamous epithelium, the cells have very low protein levels, because the cytoplasm is replaced by glycogen and the
nuclei are very small or absent. Acetic acid does not have any effect, because there is no protein to coagulate.
 In neoplastic epithelium, there are many cells with a high protein content because of large nuclei, extra chromatin, and intact
cytoplasm. The excess protein gets coagulated with acetic acid and acts as an opaque barrier to the light. The reflected light gives
the white appearance.
 The higher is the grade of neoplasia, the greater is the protein content and the greater is the density of acetowhitening.

46. How does acetic acid help to detect abnormalities on
colposcopy?

47. Steps of Colposcopy
 Inspect the external genitalia and the perianal area for any warts, white or red patches, ulcers,
or growths.
 Insert the speculum and adjust it so that the entire cervix is exposed and the woman is
comfortable.
 Note the characteristics of the vaginal discharge, if any.
 Use just enough magnification to have a complete panoramic view of the cervix. Usually, 6× to
8× magnification is adequate.
 Examine the cervix for cervicitis, growths, ulcers, or contact bleeding.

48. Steps of Colposcopy
 Apply normal saline to the cervix with cotton swabs and gently remove the mucus and
discharge.
 Identify the external os and the squamocolumnar junction (SCJ).
 Examine blood vessels with the green filter. Increase the magnification if required.
 Soak a swab in 3–5% acetic acid and apply to the cervix for 1 minute. Remove the swab from
time to time to see if any white patch is appearing. Use copious amounts of acetic acid to soak
the entire cervix.
 Locate the SCJ and try to trace the SCJ in its entirely. Determine the type of transformation
zone (TZ).
 Determine the extent of the TZ by locating the most distal crypt opening or nabothian cyst or
the outer extent of any lesion present.

49. Steps of Colposcopy
 Look for any acetowhite areas inside and outside the TZ.
 Apply Lugol’s iodine and inspect for iodine staining.
 Decide whether to take a biopsy or perform endocervical curettage, and plan the
management.
 Remember to take the biopsy from the colposcopically most abnormal area.
 Document the findings appropriately after completion of the procedure.

50. Endocervical curettage
 Indications
 the transformation zone is of type 3 and no lesion is visible on the ectocervix, although the
screening test is positive
 glandular abnormalities are suspected on cytology.
 It is better to avoid curettage as a routine procedure, because the yield of tissue is low, the
procedure causes pain to the woman, and the benefit is doubtful.
 Endocervical curettage should be performed as the last procedure of colposcopy.
 The curette should be introduced about 2 cm inside the endocervical canal.
 The endocervix should be scraped from the inside out.
 All four walls should be scraped systematically.
 The tissues collected should be put into formaldehyde solution for histology.
 Gentle pressure on the cervix with a swab for a minute will stop the bleeding, if any.

51. Documentation

52. • Draw two concentric circles.
• The outer circle represents the boundary of the cervix, and the inner circle represents the external os.
• The circle is divided into four quadrants by two perpendicular lines.
• Draw the lesion, showing its position in relation to the quadrants and the external os.
• The following legends are used as applicable: AW, acetowhite; P, punctation; M, mosaic; AV, abnormal vessels; I, iodine-
negative.
• The site of biopsy is marked by an “x”.
•

53. •Swede score (minimum, 0; maximum, 10):
Total score 0–4: normal/CIN1
•Total score 5–6: CIN2/CIN3
•Total score 7–10: CIN3/cancer.

54. Finally, a provisional diagnosis should be made from any
of the following categories:
 Normal
 condyloma/subclinical papillomavirus infection (SPI)
 low-grade squamous intraepithelial lesion (LSIL)
 high-grade squamous intraepithelial lesion (HSIL)
 adenocarcinoma in situ
 squamous cell cancer
 adenocarcinoma
 other.

56. Abnormal colposcopy

57. Abnormal colposcopy – General principles
 To describe any abnormality, as a general principle the following should be noted:
 the location of the abnormality: inside and/or outside the transformation zone
 the location of the abnormality by the “clock position”
 the size of the abnormality by the number of cervical quadrants it covers
 the size of the abnormality by the percentage of the area of the cervix involved (< 25%, 25–50%, 50–75%, > 75%).
 All high-grade CIN lesions are situated in the TZ and arise from or are close to the SCJ. In a type
2 or type 3 TZ, the lesion extends inside the endocervix.
 Lesions outside the TZ or away from the SCJ are usually due to sub clinical papillomavirus
infection (SPI), condyloma, or CIN1.

58. Grade 1 changes
 Thin acetowhite epithelium
 Irregular, geographical border
 Normal blood vessels
 Fine mosaic
 Fine punctation

59. Abnormal colposcopic findings – Grade 2 (major) changes
 Dense acetowhite epithelium
 Rapid appearance of acetowhitening
 Cuffed crypt (gland) opening
 Coarse mosaic
 Coarse punctation

60.  Sharp border
 Ridge sign
 Rag sign: In high-grade lesions and invasive cancers, the epithelium tends
to peel off easily.
Abnormal colposcopic findings – Grade 2 (major) changes

61.  Lugol’s iodine staining: CIN lesions, especially CIN2 or CIN3, are uniformly iodine-negative and are visible as bright yellow
(“canary yellow” or “mustard yellow”) iodine-negative areas on the background of dark brown iodine-stained normal
epithelium. The detection of iodine-negative areas indicates a positive Schiller test.
 Iodine-negative areas in the absence of background acetowhitening do not have any significance, because they may be
due to inflammation, atrophy, or dystrophy (loss of the normal epithelial cell function of accumulating glycogen). The
utility of applying iodine is to delineate the lesion before treatment.

62. Changes suspicious of invasion
 Atypical vessels
 Fragile vessels
 Irregular surface
 Exophytic lesion: A thick, raised acetowhite area with an irregular surface
suggests invasive cancer.
 Necrosis or ulceration

63. Calculating the Swede score

64. Margin and surface of the lesion

66. Size of the lesion

68. The basic principles of treatment of cervical
intraepithelial neoplasia
 The entire transformation zone undergoes HPV-induced clonal change and is at risk of
developing CIN. Therefore, the whole transformation zone should be treated (ablated or
excised), irrespective of the size of the lesion.
 High-grade CIN lesions often extend into the crypts present in the transformation zone. The
depth of the crypts can be up to 5 mm. During ablative treatment, the tissue destruction
must extend up to 7–8 mm to ensure complete clearance of disease.
 CIN2 and CIN3 lesions should always be treated except in very young women (younger than
25 years).
 The decision to treat a CIN lesion may be based on colposcopic findings (“see and treat”)
without waiting for histological verification.
 Ablative or excisional treatment can be performed for VIA- or HPV -positive women without
colposcopic or histological verification (“screen and treat”) in situations where these
diagnostic services are not available.

69. Role of hysterectomy to treat CIN/AIS
 Hysterectomy should not be performed as initial treatment for CIN/AIS lesions.
Hysterectomy is indicated if the endocervical margin of the excised cone after LLETZ or
cold-knife conization is positive for CIN2/CIN3/AIS and a repeat excision is not technically
possible. Hysterectomy may be performed for benign indications coexisting with CIN
lesions only if the upper limit of the lesion is visible and there is no suspicion of invasive
cancer.

70. Principle of cryotherapy
 The technique of cryotherapy depends on the destructive power of cold injury to the
normal and neoplastic epithelial cells. Nitrous oxide (N2O) or carbon dioxide (CO2) gases are
used to induce the freezing effect on the cervix.
 he temperature of either of the gases, when released to atmospheric pressure from a
compressed state, drops to -60 to -80 °C. When the gas is applied to the cervix, the tissue
temperature is reduced to -20 °C, causing permanent damage to the epithelial cells.
 The ectocervix has sparse sensory nerve endings. As a result, an ectocervical procedure like
cryotherapy does not require any anaesthesia.

71. Cryotherapy criterioa
 The lesion should be on the ectocervix without any extension to the endocervix or to the
vagina.
 The SCJ should be at the external os or on the ectocervix (type 1 transformation zone).
 The lesion should not occupy more than 75% of the cervix.
 The size of the lesion should be such that it can be covered by the tip of the largest
cryotherapy probe.
 There should not be any suspicion of invasive cancer on colposcopy or cytology.
 No glandular abnormality should be suspected on cytology.
 Ideally, a punch biopsy should be obtained from the lesion before cryotherapy, although it is
not necessary to wait for the biopsy report to perform the procedure.

72. Steps
 The pressure of the gas cylinder should be 40–70 kg/cm2 when the gas is flowing (indicator in
the green zone).
 Wipe the cryotip with saline or lubricant, to ensure adequate thermal contact. Apply the probe
tip firmly to the cervix with the centre of the tip on the external os.
 Check that the vaginal walls are not touching the probe tip. Press the trigger on the handgrip
so that gas starts flowing, and start the timer.
 Check for the formation of ice at the tip of the probe. Release the trigger after 3 minutes, when
you will see an ice ball formed over the cervix extending 4–5 mm beyond the edge of the tip.
 If the ice ball has formed adequately, the probe tip will remain stuck to the cervix.
 Wait for 5 minutes for thawing, when the ice will melt and the probe may detach from the
cervix. Reapply the probe at the same place as before, and freeze the cervix for another 3
minutes. Release the trigger and wait until the ice melts and the probe detaches from the cervix
on its own.
 The cervix will have a white crater, which indicates that the cervix is properly frozen.
 Ask the woman to continue lying down for 5 minutes before letting her getting up.

73. Complication
 Cryotherapy is a safe procedure with no significant operative morbidity. The possible side
-effects and complications are:A little discomfort or cramping in the lower abdomen
during and after the procedure
 Watery vaginal discharge for 2–3 weeks
 Pelvic infection, requiring antibiotics and supportive treatment – rare
 Excessive bleeding, requiring hospital admission or blood transfusion – extremely rare
 Stenosis of the cervix (late complication) – extremely rare
 Vaginal pain if the probe with the ice ball touches the vaginal walls.

74. Post-treatment advice
 The woman should be counselled that she will have a clear or slightly bloodstained watery vaginal discharge
that can persist for up to 2–4 weeks, and she will have to use sanitary towels.
 The woman should be informed of the following warning signs:
 foul-smelling, purulent discharge
 fever for more than 2 days
 severe lower abdominal pain, especially if accompanied by fever
 excessive vaginal bleeding (other than the blood loss during normal menstruation)
 bleeding with clots.
 The woman should be advised not to have sexual intercourse for 4–6 weeks, or until the watery discharge
disappear completely.
 Follow-up after cryotherapy:The woman may be advised to come back for a check-up after 1 month to
exclude infection or other complications. No screening or speculum examination or colposcopy should be
done. The biopsy report, if available, should be reviewed. In a screen-and-treat programme, this follow-up
visit is often omitted.
 The next check-up should be done after 8–12 months, when the woman may have the screening test
originally performed or a direct colposcopic examination.
 If there is a persistent lesion at follow-up, it is preferable to excise the lesion, although cryotherapy may be
repeated if the usual criteria for cryotherapy are fulfilled.


75. Indications for LLETZA
 CIN1 lesion that is persistent beyond 2 years
 CIN2 or CIN3 lesions
 CIN lesions that can not be treated by cryotherapy
 Cervical glandular intraepithelial neoplasia (CGIN) (adenocarcinoma in situ) (cold-knife conization
preferred)
 Microinvasive cancer (cold-knife conization preferred)
 Cytology ASC-H or HSIL with a type 3 transformation zone and no visible lesion on colposcopy
 Persistently abnormal cytology in the absence of any lesion visible on colposcopy
 VIA- or HPV-positive lesions that cannot be treated by cryotherapy (only in settings where the
screen-and-treat algorithm is practised)
 Cytology and/or endocervical curettage shows glandular abnormalities

76.  Repeat the colposcopic assessment.
 Apply Lugol’s iodine to delineate the margin of the lesion. The entire procedure should be
performed under colposcopic guidance.
 Inject a local anaesthetic agent (5–7 mL of 1% lignocaine with adrenaline) into the stroma of the
ectocervix (just beneath the epithelium) in a ring pattern at the periphery of the lesion. Avoid the 3
o’clock and 9 o’clock positions, because you may encounter a branch of the descending cervical
artery.
 Set the power setting of the ESU to a blend of 40 W of coagulation and 40 W of cutting current
 Select a loop of appropriate size depending on the size of the lesion and the type of excision to be
done.
 If the diameter of a lesion exceeds the width of the largest loop, multiple passes will be necessary
to remove the whole lesion. Always start by excising the central part of the TZ.
Steps LLETZ

77.  Introduce the loop into the tissue 2–3 mm outside the outer margin of the lesion (the left or right or lower
margin, but not the upper margin) and activate the ESU by pressing the cutting button.
 The direction of cutting (from one side to the other, or from below upwards) should follow the long axis of the
lesion.
 Guide the loop parallel to the surface of the cervix across the endocervical canal until the opposite outer margin of
the lesion is reached.
 Gradually withdraw the loop, and as soon as it is out of the tissue, release the cutting button to inactivate the ESU.
 Use a pair of forceps to remove the excised tissue.
 Carefully fulgurate the defect on the cervix with a ball electrode using the pure coagulation current to control all the
bleeding spots (use the spray mode of the ESU, if available).
 Carefully evaluate colposcopically to plan whether further excision will be necessary. If so, excise the residual lesion
in the posterior lip first, and then move to the anterior lip.
 Secure haemostasis carefully.
 Cauterize the margin of the defect.
 Put the excised tissue in formalin, and mark the 12 o’clock position with a stitch or by stapling, so that the
pathologist can orient the specimen.

78. Type 1 excision with LLETZ/ LEEP. Type 2 excision with LLETZ/ LEEP.
Type 3 excision using a large loop (LLETZ/LEEP). Type 3
excision using a straight wire (SWETZ).

80. Indications for cold-knife conization
 Glandular lesions suspected on cytology and/or detected on histology
 Evidence of microinvasive carcinoma
 High-grade squamous lesions in which the upper limit of the lesion is not visible
 Disparity between diagnostic modalities
 Treating high-grade lesions not suitable for ablation in settings where LLETZ facilities
are not available

81. Steps
 The patient should have either regional (spinal or epidural) or general anaesthesia.
 Apply Lugol’s iodine to the cervix to delineate the lesion.
 Grasp the anterior lip of the cervix with a tenaculum beyond the ectocervical margin of the
lesion.
 Insert stitches lateral to the cervix (at the 3 o’clock and 9 o’clock positions) just below the
cervicovaginal junction. Retraction of the lateral vaginal walls with a retractor by the
assistant will facilitate this step.
 Place a stitch at the 12 o’clock position close to the external os; this will help the
pathologist to orient the specimen after surgery.

82. Steps
 Inject 5–10 mL of premixed solution of 2% lignocaine and epinephrine at a concentration of
1:100 000 into the stroma of the ectocervix (just beneath the epithelium) at the periphery of
the lesion, avoiding the 3 o’clock and 9 o’clock positions.
 Make a circular incision starting at the 9 o’clock position on the face of the cervix beyond the
limit of the lesion using a scalpel. Complete the incision on the posterior lip before moving to
the anterior lip.
 Gradually angle the tip of the blade towards the endocervical canal until about 15–20 mm of
the endocervix is resected.
 Remove the specimen, to be placed in the biopsy vial containing 10% formaldehyde.
 Fulgurate the bleeding points on the cervix with a ball electrode using the pure coagulation
current from the ESU. Use the spray mode of the ESU if possible.
 Perform endocervical curettage and send the curetting

84. Cases
HTTPS://SCREENING.IARC.FR/ATLASCOLPODIAG_LIST.PHP?FINALDIAG=17&E=,0,
1,2,3,8,10,15,19,30,31,43,46,47,60,61,68,73,83,88,89,93,96,102,105,111#0

91. References
 Colposcopy and Treatment of Cervical Precancer Prendiville W and Sankaranarayanan R (2017).
Colposcopy and Treatment of Cervical Precancer. Lyon: International Agency for Research on
Cancer. IARC Technical Publications; 45.
 Atlas of colposcopy – principles and practice https://screening.iarc.fr/atlascolpo.phpBasu P and
Sankaranarayanan R (2017). Atlas of colposcopy – principles and practice. Lyon: International
Agency for Research on Cancer. IARC CancerBase No. 13.
 Colposcopy and treatment of cervical intraepithelial neoplasia: a beginners’ manual. Sellors JW,
Sankaranarayanan R (2003). Colposcopy and treatment of cervical intraepithelial neoplasia: a
beginners’ manual. Lyon: International Agency for Research on Cancer.
 A practical manual on visual screening for cervical neoplasia Sankaranarayanan R, Wesley RS
(2003). A practical manual on visual screening for cervical neoplasia. Lyon: International Agency
for Research on Cancer. IARC Technical Publication No. 41.
 https://screening.iarc.fr/iarcpublications.php SCR publication books

92. Thank You