Colposcopy is a procedure that uses magnification and acetic acid/Lugol's iodine to examine the cervix. It can detect precancerous lesions and cancers. The key steps are applying acetic acid and iodine to visualize lesions, which appear white or yellow. Biopsies are taken from abnormal areas. For pregnant patients, extra care must be taken to avoid bleeding and injury during the procedure. Lesions suspicious for cancer must still be biopsied.

1. COLPOSCOPY
CLINICAL DISCUSSION AND
TRAINING SESSION

2. WHAT IS COLPOSCOPY?
• Inroduced by Hinselman in late 1925
• Magnification and illumination of female lower
genital tract with various stains
Lugol’s iodine and Acetic acid(3% or 5%)
Except illumination, magnification and Green filter
to enhance visualization of vascularity, no much
advanced over the last century

3. Old Versus New

4. INDICATIONS
1)one cervical sample with borderline changes in high risk HPV+
2)one sample with mild dyskaryosis in high risk HPV+
3)One sample with mild dyskaryosis with inadequate HPV test
4)one sample with borderline changes involving endocervix
5)one sample with moderate – severe dyskaryosis
6)One sample with possible invasive disease
7)One sample with glandular neoplasia

5. Cont.
8)One sample with glandular neoplasia
9) Three consecutive inadequate samples
10)Any grade of dyskaryosis after CIN treatment prior next recall
11)Three abnormal sample of any grade over 10 years period
12)Suspicious symptoms and abnormal cervix
If there is no HPV DNA test facilities, consider colposcopy if,
13)Three samples with borderline changes in squamous cells
14)One sample with mild dyskaryosis

6. • Accuracy of colposcopy improved if entire
squamo-columnar junction is seen and upper
limit of any lesion is seen
• Size and topography of lesion are taken
seriously when extend into cervical canal or
vagina
• This is a subjective assessment with intra
observer variability and commonly produce
inconclusive findings
• Inter observer variability affect low grade
lesions more often than high grade lesions

7. BJOG 2012-AUGEST/13-VOL119/ISSUE11
• Accuracy of colposcopy targeted biopsies in
systematic review and Metanalysis
TYPE SENSITIVITY SPECIFICITY
CIN 1 92% 25%
CIN 2 80% 64%
CIN 3 83% 44%

8. Colposcopy rather than the biopsy itself limit the
detection, because we can not take targeted
biopsy from place which is not visible

9. Lets see the STEPS !!!
1. Explain the procedure and get consent-some
times cryotherapy or Loop excision can do
simultaneously to reduce re-visits.
2. Put on modified lithotomy position and use
medium sized warm clean water lubricated
Cusco speculum insert gently.
3. Note the changes seen in cervix and gently
wipe secretion on cervix using saline soaked
cotton balls without eroding cervix

10. 4.Avoid rough traumatic handling of cervix
5.If colposcopist is interested in assessing repeat
smear, it can be taken with spatula prior to
apply any solution. This is a debatable step and
yet people practice.
Smears induced bleeding settles once acetic acid
apply
6)Cervical cells for HPV DNA, and bacteriological
studies also can take before apply acid-iodine

11. 7)Apply green filter and 15 power magnification to
see vascularity before acid-iodine apply as they
cause swelling of vessels themselves
Other value of this pre assessment is to see whole
transformation zone. If inner border of
transformation zone as S-C junction was failed to
recognize in entire 360’ view-procedure is
inadequate or unsatisfactory
Distal limit or original S-C junction is demarcated at
imaginary line along most distal glandular crypts or
nabothian follicles

14. 8) Apply 5% acetic acid as it is more faster and
obviously stains. Confirm strength of solution.
Liberally apply even on ectocervix.
This enables to find entire new SC junction and
detect abnormal transformation zones
Aceto white areas forms over 1 min and
thereafter dissapear.Hence need repetitive
application.

16. 9)Apply Lugol’s iodine
Normal squamous cells contain glycogen that
stain brown with iodine. But not the columnar
cells as they have minimal or no glycogen.
Similarly immature squamous metaplasia,
inflammatory and regenerating epithelium and
congenital transformation zone contain very
little or no glycogen and either do not or only
partially stain with iodine.

17. cont.
Abnormal transformation zones, such as those with CIN
or invasive cancer, contain very little or no glycogen. The
degree of differentiation of the cells in a preneoplastic
squamous lesion determines the amount of intracellular
glycogen and thus the degree of staining observed.
Therefore, one would expect to see a range of staining
from partially brown to mustard yellow across the
spectrum from low- to high-grade CIN. Usually high-grade
CIN takes up less of the stain, appearing as mustard or
saffron yellow areas. In the case of high-grade CIN,
vigorous or repeated application of iodine may
occasionally peel off the abnormal epithelium and the
underlying tissue stroma may appear pale, as it lacks
glycogen.

19. 10)If necessary, perform biopsy from site with
worst features and multiple biopsies to be taken
while observing under scope
Bleeding sites cover by Monsel paste (ferric
subsulfate) or silver nitrate
Better apply them before see the bleeding

20. 11)Consider endocervical curate if ectocervix
shows no abnormality but abnormal cytology,
glandular lesions evidenced in cytology or
colposcopy examination is unsatisfactory
ECC is frequently associated with inadequate
sampling so that negative ECC do not rule out
ABSENCE OF ENDOCERVICAL NEOPLASIA
Before ECC,posterior fornix should not have
acetic acid to protect sample

21. 12) Before end, as speculum withdraws, inspect
rest of genital tract and do bimanual& digital
rectal examination to complete clinical
assessment.
Thank patient, admire for enthusiasm, notes
complete and arrange follow-up with histology
report

22. If the woman is pregnant!!!
• The steps in the colposcopic procedure for a pregnant
woman are similar to those for a non-pregnant woman,
but extra care must be taken not to injure any tissues
when a digital examination or speculum insertion is
performed. If a repeat cytology smear is needed, this
may be performed using a spatula, by applying gentle
pressure to avoid bleeding. Some may prefer to obtain
a cytology sample at the end of the colposcopic
procedure, in order to avoid inducing bleeding that
may obscure the colposcopic field, but this may result
in a poor hypocellular sample, as cells might have been
washed away during the different steps of the
colposcopic procedure.

23. • increased vascularity leads to easily induced
bleeding; the blood vessel pattern in cervical
pseudo-decidual tissue tends to mimic
invasive cancer; and CIN tends to appear as a
more severe grade than it actually is (due to
increased size, increased oedema and
vasculature pattern). Thus considerable
experience is required for colposcopy in
pregnancy.

24. • As pregnancy progresses, cervical biopsy is associated with an
increased probability and degree of bleeding, which may often be
difficult to control. The risk of biopsy should always be weighed
against the risk of missing an early invasive cancer. All lesions
suspicious of invasive cancer must be biopsied or wedge excised.
Sharp biopsy forceps should be used, as they will produce less
tearing of tissue. Biopsy should always be carried out under
colposcopic vision to control depth. The prompt application of
Monsel’s paste or silver nitrate to the biopsy site, immediate bed
rest for 15 to 30 minutes, and the use of a tampon or other
haemostatic packing to put pressure on the biopsy site are helpful
to minimize bleeding. Some women may need an injection of
pitressin into the cervix or suturing for haemostasis. To avoid a large
amount of tissue slough, due to the effect of Monsel’s paste,
haemostatic packs should not be left in place for more than a few
hours after the paste has been applied. Alternatively, cervical biopsy
in a pregnant woman may be performed with diathermy loop. If
colposcopy is inadequate, and cytology suggests invasive cancer, a
conization must be performed, ideally in the second trimester. Non-
invasive lesions may be evaluated post-partum