The document discusses colposcopy, which uses a low-power microscope to examine the cervix. It describes cervical intraepithelial neoplasia (CIN) grades 1-3 and squamous intraepithelial lesions. The colposcope allows inspection of the cervix before and after acetic acid application using criteria like vascular patterns, whiteness, and iodine negativity to evaluate lesions. Colposcopy is used to screen for cervical cancer, evaluate abnormal pap smears, and follow up on CIN treatment. Steps involve inspection, biopsies if needed, and documentation. Advantages include aiding diagnosis and follow up while disadvantages include inadequacy for endocervical lesions.

1. Benha Univesity Hospital, EGYPT
Colposcopy
Aboubakr Elnashar

2. Aboubakr Elnashar

3. Aboubakr Elnashar

4. Cervical intraepithelial neoplasia (CIN):
It includes Dysplasia & CIS
CIN 1 =Mild D.
CIN 2=moderate D.
CIN 3=Severe D or CIS.
Low grade CIN=CIN 1 or HPV.
High grade CIN=CIN 2 or 3
Aboubakr Elnashar

5. CINI
CINII
CINIIIAboubakr Elnashar

6. HPV
Microinvasion
Aboubakr Elnashar

7. Squamous intraepithelial lesion (SIL): includes
HPV & CIN.
Low grade SIL =CIN 1 or HPV.
High grade SIL= CIN 2 or 3
Aboubakr Elnashar

8. Aboubakr Elnashar

9. History
Hinselmanin (1925)
Aboubakr Elnashar

10. 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)
1960: Cryosurgery
1980: Laser surgery
1988: Computer-aided colposcope
1989: LLETZ (Prendiville & Cullimore)
1991: Pap Net
2000: Telecolposcopy (Harper et al)Aboubakr Elnashar

11. Instrument
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
halogen lamp)
3. A mounting device that permits easy
movements of the apparatus.
Aboubakr Elnashar

12. It is fitted with 3:
1.Green filter for easier observation of the vessels
2.Camera for photography
3.Monocular teaching arm.
Aboubakr Elnashar

13. Aboubakr Elnashar

14. Aboubakr Elnashar

15. Aboubakr Elnashar

16. Equipments needed
1.Examination table.
2.Instruments:
a.Self-retaining vaginal speculum
b. Endocervical speculum
c. Dressing forceps
d. Equipments for biopsy:
punch biopsy forceps,
endocervical curette,
Iris hooks,
single toothed tenaculum,
solutions to stop the bleeding,
formalin
e. Equipments for cytology:
spatula,
fixatives Aboubakr Elnashar

17. Aboubakr Elnashar

18. 3. Solutions:
a. Saline
b. Acetic acid (3-5%)
c. Lugol, s iodine solution
4. Cotton swabs or dry gauze.
5.Documentation facilities:
special form
cervicogram
Aboubakr Elnashar

19. Aboubakr Elnashar

20. Modern colposcopes
New optical lenses,
fiberoptic light sources &
Videocameras, digital
computer
Enhancement
Manipulation according to physician,s preference.
Telecolposcopy (Harper et al,2000)
Aboubakr Elnashar

21. Aboubakr Elnashar

22. 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.
Aboubakr Elnashar

23. •Screening colposcopy
More sensitive & more cost effective than
cytological screening.
When access to cytopathology is difficult
(Cecchini et al,1997).
•Portable colposcopy in rural areas is cost
effective & highly acceptable (Martin et al,1998).
Aboubakr Elnashar

24. Recent recommendations of FIGO for management of abnormal
smear (Benedet,2000)
Persistent inflam., persistent ASCUS, LSIL, HSIL, AGCUS,Invasive
Colposcopy±biopsy
Normal or LSIL HGSIL Invasive
6 mo smear x 2 LEEP Appropriate TT
Normal Persistent
Annual screening
Aboubakr Elnashar

25. Steps
1.Inspection of unprepared cervix
2.Inspection of the cervix after application of
saline
3.Inspection with green filter
4.Inspection after application of acetic acid
5.Inspection after application of Lugol s
iodine
Aboubakr Elnashar

26. .± Exposure of the lower cervical canal (endocervical
speculum)
.± Biopsy: from that part with greatest degree of
abnormality
1. Punch. False negative rate up to 54% (Buxton et
al,1991) Multiple biopsies
Excisional techniques are superior to destructive
techniques
2. Loop excision
3.Endocervical curette: ECB has replaced ECC
4. Cone.
Aboubakr Elnashar

27. Aboubakr Elnashar

28. .To stop bleeding after biopsy:
compression with gauze,
ferric sulphate (Monsel s) soln.,
silver nitrate,
Albothyl concentrate,
vaginal gauze pack,
stitches
.Documentation:
1. Colposcopy record form
2. Longhand drawing
3. Colpophotography
4. Video-camera
Aboubakr Elnashar

29. Aboubakr Elnashar

30. Colposcopy evaluates changes in the: terminal
vascular network
surface epithelium after application of acetic acid.
Colposcopy is based on evaluation of the
transformation zone (T.Z).
Colposcopy:
Cervix
Vulva
Vagina.
Aboubakr Elnashar

31. Diagnostic criteria
.Vascular pattern:
1.Normal & benign: branched, hairpin &
network. It is tree like branching
2.Preinvasive & invasive: Mosaic, punctation &
atypical vessels
Matue-Aragones classification:
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.
Aboubakr Elnashar

32. .Inter-capillary distance (ICD):
Increased in preinvasive & invasive lesions.
Decreased in inflammatory lesions
Measured by comparing with that of adjacent
normal epithelium or colpophtograph.
Aboubakr Elnashar

33. .Contour:
1.Smooth (original sq. epi.)
2. Grape like (col. Epi. & ectopy)
3. Slightly elevated (preinvasive lesions)
4. Nodular, polypoidal or ulcerated (invasive
lesions)
.
Aboubakr Elnashar

34. .Color:
Contrast is more important.
CIS is darker than dysplasia & much darker than
normal epi.
Invasive cancer is whitish with glazed gelatinous
appearance.
Aboubakr Elnashar

35. .Clarity of demarcation:
1.Sharp: CIN 3
2. Diffuse: CIN 1 & inflammatory lesions
.
Aboubakr Elnashar

36. .Whiteness after acetic acid:
.Density of whiteness
.Time needed for whiteness to appear &
disappear
.Sharpness of demarcation
.Presence of punctation or mosaic
Aboubakr Elnashar

37. .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
Aboubakr Elnashar

38. Advantages
1.Can be applied at each gynecologic
examination
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.
Aboubakr Elnashar

39. 6.Differentiate between inflammatory atypia &
neoplasia, between invasive & non-invasive
lesions.
7.HPV are best detected by colposcopy.
8.Helps to avoid unnecessary smear, biopsy,
conization, hystrectomy
9.Cytologic smears may be obtained under
colposcopic direction
10.Good for follow-up.
Aboubakr Elnashar

40. Disadvantages
Inadequate for detection of
endocervical lesions.
Aboubakr Elnashar

41. International Federation of Cervical Pathology & Colposcopy
(1991)
Normal: Original squamous epithelium
Columnar epithelium
Normal transformation zone
Abnormal: Acetowhite epithelium Punctation
Mosaicism Leukoplakia
Iodine negative Atypical vessels
Suspect invasive cancer:
Unsatisfactory:
SCJ not visible, severe inflam or atrophy, invisible cervix
Miscellaneous:
Nonacetowhite micropapillary surface, exophytic condyloma,
inflammation, atrophy, ulcer
Aboubakr Elnashar

42. Normal
Aboubakr Elnashar

43. Aboubakr Elnashar

44. Aboubakr Elnashar

45. Aboubakr Elnashar

46. Aboubakr Elnashar

47. Aboubakr Elnashar

48. Abnormal
Aboubakr Elnashar

49. Aboubakr Elnashar

50. Aboubakr Elnashar

51. Aboubakr Elnashar

52. Aboubakr Elnashar

53. Aboubakr Elnashar

54. Aboubakr Elnashar

55. Aboubakr Elnashar

56. Aboubakr Elnashar

57. Suspect invasive cancer
Aboubakr Elnashar

58. Aboubakr Elnashar

59. Aboubakr Elnashar

60. Unsatisfactory
Aboubakr Elnashar

61. Aboubakr Elnashar

62. Miscellaneous
Aboubakr Elnashar

63. Aboubakr Elnashar

64. Aboubakr Elnashar

65. Aboubakr Elnashar

66. Aboubakr Elnashar

67. Colposcopy of the vulva
*Steps:
1.Examination after smearing with a water soluble
lubricant.
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
acetowhite,leukoplakia,micropapillae, papules.
Aboubakr Elnashar

68. Aboubakr Elnashar

69. Aboubakr Elnashar

70. Thank You
Aboubakr Elnashar
Aboubakr Elnashar