2. • Examination of cervix, vagina ,
vulva with a binocular
microscope.
PRINCIPLE
• Pre-malignant and malignant
cervical conditions produce
colposcopically identifiable
epithelial changes that
generally occur within the
transformation zone
3. • Focal distance usually between 250 – 300mm.
• Low magnifications of 5x give birds eye view ,
and are best for localizing an area of interest.
• For detailed exam usually 15x used, best for
angioarchitecture.
• Magnifications higher than 20x cause loss of
orientarion.
4. Goals of Colposcopy
To detect abnormal epithelium,
To identify the area of epithelium with the
highest degree of disease
To direct biopsies to that area
4
6. ECTOCERVIX – squamos epi
stratified, non-keratinizing, glycogen-containing
squamous epithelium. It is opaque, has multiple
(15-20) layers of cells and is pale pink in colour
7. ECTOCERVIX – squamos epi
The intermediate and superficial layer cells contain abundant
glycogen in their cytoplasm.
As cells mature they move upwards, increasing in size &
radually losing their nuclear content.
Immature cells & Neoplastic cells –
• lack of normal glycogenation
• High nuclear content
8. ENDOCERVIX
• lined by the columnar epithelium (sometimes referred to as
glandular epithelium).
• composed of a single layer of tall cells with dark-staining nuclei
close to the basement Membrane.
• thin single cell layer allows the coloration of the underlying
vasculature in the stroma to be seen more easily
• The columnar epithelium forms several crypts into the substance
of the cervical stroma.
11. SCJ
The ECTOcervix is covered by
both stratified nonkeratinizing squamous and
ENDOcervix columnar
epithelium.
These two types of
epithelium meet at the
squamocolumnar junction =.
2 TYPES
ORIGINAL / NATIVE.
NEW
12. Formation of NEW SCJ
•
SQUAMOUS
METAPLASIA
• Physiological
replacement of
the columnar
epithelium with
squamous
epithelium
• Metaplasia is
most active
during
peripubertal and
pregnancy years;
the reserve cells
also being most
vulnerable in
them
13.
14. Transformation Zone
• This is the most
mitotically active area.
• Cells most prone to
oncogenic stimuli.
• IMPORTANT because
almost most cervical
cancer occur in this
zone
17. COLPOSCOPY & HISTOLOGY OF TZ
• As reserve cell hyperplasia progresses to several layer
thickness, columnar epithelium is pushed off and replaced,
with flattening of columnar villi.
When the crypts of columnar epithelium are blocked by the growing sq epi,
nabothian cysts are formed. The outer extent being the limit of met epi n
hence the outer limit of TZ ,ie, OLD SCJ.
20. COLPOSCOPIC & NEOPLASTIC
SIGNIFICANCE OF TZ
• The older metaplastic epi will move outwards towards
old SCJ, and will finally become indistinguishable from
original sq epi in thickness & glycogenation.
• The metaplastic epi closest to the new SCJ is the
newest sq epi on the cervix.
• Most cervical neoplasia occur in TZ
• Within the TZ, More severe disease tends to be
more cephalad where met epi most immature.
21. • For a colposcopic examination to be deemed
‘satisfactory’, the TZ must be viewed entirely,
all the way upto col epi and 360⁰ around.
22.
23. • There is a gradient of maturity in TZ .
• The most mature metaplasia at periphery is
acetic acid & iodine neg (like original sq epi)
• Immature metaplasia is frosty acetowhite with
some of the underying bv seen through at
times resembling fine punctuation of Lg
lesion.
• The vessls overling nabothian cysts cabn be
large & alarming, but will have a benign
arborizing nature
25. INDICATIONS FOR COLPOSCOPY
•
•
•
•
•
•
•
•
Abnormal Pap smear, with no gross lesion on cervix
Women with PCB, metrorrhagia
Persistence of inflammatory cels despite adequate treatment
Grossly abnormal / unhealthy cx or vagina
Women with positive high risk HPV DNA test, even if Pap neg.
Trearment of women with CIN
Monitoring of women treated for CIN
Preop evaluation of women diagnosed with Stage Ia or b
cervcal cs on cl ex & bx – to rule out vag involvement
• Evaluation of women with anogenital condylomas
26. WHEN TO PERFORM COLPOSCOPY
Ideally colp ex should be done under optimal
hormOnal conditions, but no pt should be denied the test
bcos she is not in the right phase nor bcos she has not
received estrogen prior.
Menstrual cycle : day8 – day 12 as cervical mucus abundant &
clear, and ext os open.
Postmenopausal women should ideally receive estrogen for 7
days, n colpo performed on last day of estr. Not after stopping as
mucosa reverts rapidly.
Colpo under adequate estr reduces chances of unsatisfactory
colpo, need for ECC.
29. APPLY NS
HOW
Swab off mucus with saline soaked swab
Thoroughly moist cervix & vagina with NS
GOAL
To remove mucus
to conduct a preliminary inspection for surface
abnormalities (e.g., leukoplakia, condylomata)
to identify the distal and proximal borders of the
TRANSFORMATION ZONE
the best way to examine THE VASCULATURE
31. Columnar epi = dark red grape
like / villous
Squamos epi = pink
Metaplastic squamos = paler
than original
NEW SCJ based on colour
difference – 360 deg
Native / OLD SCJ – imaginary
line through most distal crypts.
Occasionally subtle color
difference
The entire TZ, including new SCJ, and borders of all
lesions must be visualized 360oin order for
colposcopy to be satisfactory
32. Viewing the TZ in
difficult cases
• Using a dry cotton swab, put
pressure backwards on post
lip to permit examn of post
part of cervical canal.
Similarly, ant. But lat lips not
always seen.
• Use endocervical speculum if
needed to view entire
transformation zone
36. Normal vasculature - Squamos
• Two types of capillaries are colposcopically apparent in the native or original
squamous epithelium: reticular (network) or hairpin-shaped capillaries
• Usually appears as dots with only a slight, if any, appearance
of a loop at each. Inflammation of the cervix (e.g., trichomoniasis) often causes
hairpin vessels to form staghorn-like shapes, so that the vessels become
more
prominent and the loop appearance is more apparent
• Often no vascular pattern is seen on the original squamous epithelium .
37. Normal vasculature – Metaplastic
Squamos
3patterns
•a tree branching
•commonly seen overlying nabothian cysts
•when healing has taken place after therapy
for CIN the vessels are long and run parallel
to one another
38. Normal vasculature
- Columnar
Terminal networks confined to
the stromal core of each
grape-like villus, which
projects up to the epithelial
surface.
With the colposcope, the
rounded tips of the individual
villi are the main features seen
and the top of the vessel
network in each villus appears
as a dot.
Large, deep branching vessels
may be seen in some cases.
39. ECTOCERVIX – squamos epi
After menopause, the
cells do not mature
beyond the parabasal
layer. Consequently, the
epithelium becomes
thin and atrophic. On
visual examination, it
appears pale, with
subepithelial petechial
haemorrhagic spots, as
it is easily prone to
trauma
43. APPLY ACETIC ACID
HOW
Swab liberally with AA soaked swab for 45sec to 1 mte..
Donot rub as it abrades the epi
3 – 5%. 5% preferred for all except PMW (3%).
5% causes burning in some esply if inflamed.
3% takes longer to elicit response.
Action transient n disappears in 1 – 3mts, so reapply
ACTION
coagulates and cleares the mucus.
Dehydrates the cell
It causes a reversible coagulation or precipitation of the
nuclear proteins and cytokeratins.
47. Normal TZ findings - AA
Nabothian follicle
Immature sq
metaplasi
Mature sq
metaplasi
The new SCJ
appears like a
white step due to
adjoining
immature
metaplastic epi
48. FINDINGS OF TZ FOLL AA
• Grossly, the metaplastic
islands appear as glassy
islands over col epi and
translucent tongues
from original sq. epi
• Acetowhitening around
gland openings.
49. AWA
• immature squamous metaplasia
• congenital transformation zone
• in healing and regenerating epithelium
(associated with inflammation)
• leukoplakia (hyperkeratosis)
• condyloma.
50. LUGOL’S IODINE
• Role debatabe.
• Some say it adds little to the colposcopic evaluation.
• Some argue that it helps in doubtful situations, esply
in assessment of grade2 lesions. They say that a large
number of grade 2 lesions are of mature metaplasia:
when theses stain dark brown, there is no suspicion
of abn , and biopsy avoided.
• It may also pick up LGL which may be too subtle on
AA
• Lugol’s iodine solution to aid in delineating potential
biopsy site
51. BASIS OF SCHILLER’S TEST
Iodine is glycophilic and hence the application of
iodine solution results in uptake of iodine in glycogencontaining epithelium.
original and newly formed mature squamous metaplastic epithelium is
glycogenated = I positive mahogony brown
CIN and invasive cancer contain little or no glycogen = i neg mustard to
golden yellow
Columnar epithelium doesnot contain glycogen I neg
Immature squamous metaplastic epithelium usually lacks glycogen or,
occasionally, may be partially glycogenated = partial uptake +/_
53. Col epi – I neg yellow
Squamos native & mature
met – I positive
mahogony / dark brown
Immature metaplasia –
Ineg / partial uptake if
partially glycogenated
Endocervical polyps – I
neg as covered by col epi /
immature met epi
After application of Lugol’s iodine
solution, the endocervical polyp and
the immature squamous metaplasia
surrounding the os partially take up
iodine
54. COLPOSCOPIC FINDINGS IN
CIN
Colposcopy has a reported sensitivity
ranging from 87%
to 99% to diagnose cervical
neoplasia, but its specificity
is lower, between 23% and 87%
56. ABNORMAL VASCULATURE
Normal vessels of of columnar epithelium
become compressed during the normal metaplastic
process and are not incorporated within the newly
formed squamous epithelium.
In HPV infection and arypia, capillary system
may be trapped (incorporated) into the diseased
dysplastic epithelium through several elongated
stromal papillae and a thin layer of epithelium may
remain on top of these vessels.
57.
58. Abnormal vasculature in CIN
• Terminal vessels in the
papillae viewed end –
on = punctuation
• Interconnecting vessels
running parallel to
surface = mosaic
• Both when seen =
umbilication
63. AA CHANGES GRADIENT
With low-grade CIN, the acetic acid must penetrate into the lower onethird of the epithelium (where most of the abnormal cells with high
nuclear density are located). Hence, the appearance of the whiteness is
delayed and less intense .
Areas of high-grade CIN and invasive cancer turn densely white and
opaque immediately after application of acetic acid, due to their higher
Concentration of abnormal nuclear protein and the presence of large
numbers of dysplastic cells in the superficial layers of the epithelium.
64. AA CHANGES GRADIENT
The grade of lesion correlates with intensity of whiteness,
surface shine, rapidity of appearance and duration of whiteness.
LOW-GRADE LESIONS
less dense, less extensive and less
complex acetowhite areas close to or abutting the
squamocolumnar junction with well demarcated, but
irregular, feathery or digitating margins
satellite acetowhite lesions detached
(far away) from the squamocolumnar junction
geographical patterns (resembling geographical
regions).
66. High Grade Lesions
dense, opaque, grey white acetowhite areas
coarse punctation and/or mosaic
regular and well demarcated borders
Raised / rolled edge;
extensive and often involve both lips and may occasionally
harbour atypical vessels
69. HIGH GRADE LESION ctd
Visualization of one or more
borders within an acetowhite
lesion (‘lesion within lesion’) or a
lesion with differing colour
intensity.
The crypt openings may have
thick, dense and wide acetowhite
rims called cuffed crypt openings .
These are whiter and wider than
the mild, line-like acetowhite rings
that are sometimes seen around
normal crypt openings.
76. FEATURES S/O INVASIVE CA
• lesions with irregular and exophytic surface contour,
strikingly thick chalky white lesions with raised and rolled out
margins,
• Strikingly excessive atypical vessels, bleeding on touch or the
presence of symptoms such as vaginal bleeding
• Large high-grade lesions, involving more than three
quadrants of the cervix
• the presence of a wide abnormal transformation zone
(greater than 40 mm ),
• Complex acetowhite lesions involving both lips of the cervix,
• lesions obliterating the os,
•
77. ATYPICAL BV’s – sign of invasive
cancer
One of the earliest colposcopic signs of possible invasion is blood
vessels breaking out from the mosaic formations and producing
irregular longitudinal vessels.
. As the neoplastic process closely approaches the stage of
invasive cancer, the blood vessels can take on increasingly
irregular, bizarre patterns , as a result of horizontal pressure of
the expanding neoplastic epithelium on the vascular spaces,
. Appearance of atypical vessels usually indicates the first signs
of invasion
88. COLPOSCOPY IN GLANDULAR
NEOPLASIA
• There are no obvious colposcopic features that allow definite
diagnosis of adenocarcinoma in situ (AIS) and
adenocarcinoma.
• Most cervical AIS or early adenocarcinomas are discovered
incidentally after biopsy for squamous intraepithelial
neoplasia
• SUSPICIOUS
Dense acetowhite area in col epi
More acetowhite nature of some villous tips compared to others
Abnormal vessels in col ep esply root and writing like
Multiple cuffed crypt openings in dense AWA
90. BIOPSY – THE GOAL
• The main objective of colposcopist is to
distinguish between lesions that are
“insignificant” not requiring biopsy and those
that are “suspicious” requiring biopsy.
91. BIOPSY – THE GOAL
•
Mentally map abnormal areas.
•
Remember that colposcopic observation's main goal is to
highlight areas for biopsy.
•
Use the following parameters to grade severity of lesions:
–
–
–
–
–
–
Mild acetowhite epithelium < Intensely acetowhite
Diffuse vague borders < Sharply demarcated borders
Follows normal contours of the cervix < "humped up"
No blood vessel pattern < Punctation < Mosaic
Atypical vessels - usually cancer
Normal iodine reaction (dark) < Iodine-negative epithelium (yellow)
– Leukoplakia - usually a very good (condylomata) or a very bad sign
92. BIOPSY - WHEN
• All areas of keratoses even smear neg.
Prolapse pts may be exempted esply if smear
neg n lesion outside TZ.
• All colposcopically abnormal lesions
• All unusual lesions difficult to interpret at
colpo.
• Any doubt (overtreatment better)
93. BIOPSY - WHERE
• Homogenous Abnormal area – closest to new
SCJ
• Heterogenous – most suspicious looking area
• Always include the area with vessel atypism
• In case of doubt n large lesion, multiple
biopsies
• Biopsy of posterior lesion first
• In the endo cervix only if os wide open and
lesion in lower part of cervical canal with its
upper limit seen. ( in all other cases, ECC)
95. BIOPSY- TECHNIQUE
• When biopsy site at margin of the ext os, the fixed part of
forceps introduced into cervical canal, whilst the mobile part
remains on ectocervix.
• After each bite, cervix is swabbed with AA soaked swab to
confirm bx has been taken from correct site.
• Ideally, when multiple biopsies, place in separately labelled
containers, n write corresponding nos on colposcopic diagram
to be sent to pathologist.
96. BIOPSY WHEN TO AVOID
• AWA in TZ extending into cervical canal , and upper
extent n new SCJ not visible.
BX of lower part of lesion will be of no value unless
nature of upper part determined
• Also may unnecessarily cause confusion after a
cone / HE due to reepithelialization as changes
mimicking inv.
97. ECC
– Glandular lesion (irrespective of
findings of colposcopy )
– Unsatisfactory colposcopy
(whether or not a cervical lesion
identified on colposcopy)
– Normal colpoposcopy of
ectocervix, yet abnormal
cytology
– CONTRAINDICATED in
pregnancy or active cervicitis
98. • Before ECC is performed, the posterior fornix must be dry to
avoid the loss of curetted tissue in the acetic acid solution
which accumulated during its application on the cervix.
• In order to avoid the potential confusion of inadvertently
sampling a visible lesion on the ectocervix or including
residual tissue from an ectocervical biopsy in the
neighbourhood of the external os in the endocervical curette
specimen, ECC may be performed under colposcopic control,
before obtaining a cervical biopsy.
• The yield of an ECC is very low in inexperienced hands, as it is
frequently associated with inadequate tissue sampling. Thus,
in such situations, a negative ECC should not be taken as
unequivocal evidence of the absence of neoplasia in the
endocervical canal.
99. Examination of the Vagina
• Very imp, esply in women with abnormal pap
but no cervical abn on colpo
• Cervix mobilized with swab, to visualise
fornices.
• Lat walls swabbed with acetic acid
• Speculum progressively withdrawn open to
examine ant & post walls.
101. P/V/R
f it is performed before colposcopy, only water should be used
as a lubricant.
102. EX OF VUVLA, PERINEUM
As the speculum is withdrawn, the vaginal walls and,
subsequently, the vulvar, perineal, and perianal epithelium
should be inspected. The surfaces are bathed with acetic acid
and after one or two minutes the acetowhite areas are noted
and evaluated.
no general agreement on whether these areas should be
routinely examined in this fashion
103. Complications
• Bleeding
– Saturate the end of a tampon with Monsel’s and insert
to provide pressure and astringent action for persistent
oozing
– Cauterize the biopsy site
– Inject 1-2 cc of 2% lidocaine with epinephrine into the
bleeding site
– Rarely, a cervical stitch of 4-0 absorbable suture across a
deep biopsy site
104. Complications
• Infection is rare but typically occurs on the 3rd or 4th day after
biopsy
• Avoid biopsy with active cervicitis
• Pain can be minimized by caring and careful explanation of
procedure, a warm room, NSAIDs given the night before and
morning of procedure (Avoid Aspirin)
105. ERRORS IN COLPOSCOPY
• Gr.2 AWA lesions interpreted as LGL/HGL by colposcopist may
be reported by pathologist as met epi.
• Microconvoluted and exophytic condyloma misinterpreted as
inv. Ca
• Acetowhite strands of immat met epi over col epi of endocx
may be misinterpreted as AIS.( n vice versa)
• When keratosis in the TZ is light, it may become dense white
after AA n resemble HGL
• Severe candidiasis may be misinterpreted as keratosis
• Coarse punctuations and vascular patterns of inflammation
may be misinterpreted as inv ca.
112. Leukoplakia
•
Well demarcated white area before AA
application.
• Usually leukoplakia is idiopathic, but it may
also be caused by chronic foreign body
irritation, HPV infection or squamous
neoplasia.
• It is not usually possible to colposcopically
evaluate the vasculature beneath such an area
•
No matter where the area of leukoplakia is
located on the cervix, it should be biopsied to
rule out high-grade CIN or malignancy.
113. Condylomata
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,
It is always prudent to obtain
a biopsy to confirm the
diagnosis of any exophytic
lesion
and to rule out malignancy
118. SUMMARY
• The main goal of colposcopist is to identify the
site to biopsy
• Of value in colposcopic interpretation
Response to AA
Surface cintour & margins
Puntuation, mosaicism &ICD
Atypical bv
Appearance of gland openings
I uptake
119. SUMMARY
• Mild flat AWA = immat met / LGL
• Dense AWA = HGL
• Dense AWA in col epi = glandular disease
• I neg could be immat met , col epi, atrophy,
inflammation, HPV , CIN, Ca
• I partial pos = immat met / LSIL, HPV
subclinical inf
120. SUMMARY
• Fine mosaic = LSIL
• Coarse mosaic = HGL
• Atypical vessels ( parallel, abn calibre, comma ,
cockscrew, spaghetti ) = INV CA
• S/O INV CA
–
–
–
–
–
Irregular surface contour ( mountain range)
Denses AWA
Wide , irregular coarse punctuation & mosaic
Atypical vessels in sharply demarcated raised dense AWA.
In flattish lesions microinv ca
121. SUMMARY
• Metaplastic epi, hpv infection, inflammation,
condyloma, keratosis can mimic neoplasia.
• Can be differentiated by the experienced
colposcopist; else better to biopsy
