Colposcopy examination

DR. R. ARCHANA AND DR. POOJA
FINAL YEAR , MBBS
LHMC

HISTORY;
 First described by HANS HINSELMAN
of germany in 1925 as a screening tool for
cervical cancer.

WHAT IS COLPOSCOPY?
 Colposcopy is a
gynecological
procedure that
illuminates and
magnifies thevulva,
vaginal walls, and
uterine cervix in
order to detect and
examine
abnormalities of
these structures

WHY IS COLPOSCOPY DONE?
 Colposcopy is usually done if:
 Pap smear is abnormal, or
 When the cervix looks abnormal during the
collection of a Pap smear.
 Even if a Pap smear result is normal,
colposcopy is ordered when the cervix appears
visibly abnormal
 patient who presents with postcoital vaginal
bleeding.
 . The purpose of the colposcopy is to determine
what is causing the abnormal looking cervix or
the abnormal Pap smear so that appropriate
treatment can be given

.


Preparation
Patients should not douche, use tampons, or have
sexual intercourse for 24 hours before colposcopy.
•Patients should empty their bladder and bowels
before colposcopy for comfort.
•For mild cramps or a sharp pinching when the
tissue is removed ibuprofen can be taken the night
before and the morning of the procedure (no later
than 30 minutes before the appointment).
•Patients who are pregnant or allergic to aspirin or
ibuprofen can instead take pcm

Pregnant women may undergo colposcopy if
they have an abnormal Pap test; special
precautions, however, must be taken during
biopsy of the cervix.

HOW IS COLPOSCOPY DONE?
 A colposcope is a
microscope. The
instrument has a range
of magnification lenses.
 color filters :detect
tiny abnormal blood
vessels on the cervix.
 The colposcope is used
to examine through
thevaginal opening

Typical Mayo tray set-up for colposcopy. From left to right: cotton balls, Monsel's
solution, saline, vinegar, Lougal's iodine, cotton-tipped applicators, rectal swabs
(Texas Q-tips), Ring forceps, vaginal speculum, biopsy forceps, ECC curette,
endocervical speculum. Additional possible items not shown include benzocaine
solution, side-wall retractors, and cervix brush

 The first step of the procedure is
examining the vulva and vagina for signs
of genital warts or other growths.
 A Pap smear is then taken.
 Examine at the squamocolumnar
junction

WHAT SPECIAL TESTS ARE DONE
DURING COLPOSCOPY?
 Three special tests are done during
colposcopy:
 Acetic acid wash,
 Use of color filters, and
 Sampling (biopsy) of tissues of the
cervix.
.

•acetic acid, diluted 3% to 5%.
• It washes awaymucus and allows
abnormal areas to be seen more easily
•stains the abnormal areas white. called
"acetowhite lesions.“
• Sometimes, however, normal areas can
also stain white, but these areas have
vague or faint borders
Lugol's solution or Schiller's solution :Normal
cells will generally take up the iodine stain (and turn
brown) in a uniform manner, whereas severe
precancers and cancerous areas will not.

 .
 Helps in examining capillaries in the area of the
squamocolumnar junction.
 Blue or green filtered light can cause abnormal
capillaries to become more obvious, usually inside
an acetowhite area.
 Normal capillaries are slender and spaced out
evenly. In contrast, abnormal capillaries can appear
as red spots (thickened capillaries seen on end) or
can produce a pattern resembling hexagonal floor
tiles.
 The worse the cervical disease, the thicker and
more widely spaced out are the capillaries.. Thus,
when cancer eventually develops, capillaries take
on odd shapes, like punctuation marks.

 The biopsy of abnormal areas is a critical part of
colposcopy because treatment will depend on
how severe the abnormality is on the biopsy
sample.
 As part of the biopsy procedure, endocervical
curettage(sampling of the tissues within the
endocervical canal, or the opening of the cervix
to the uterine cavity) is often performed.

Tischler cervical biopsy forceps: A. Standard surgical instrument grips, B. "Pistol grip"
Kogan endocervical
speculum. Blades typically
come in 2mm, 4mm (shown
here) or 6mm sizes. The
blades may be inserted into
the cervical os and gently
opened to allow better
visualization

AFTERCARE
 If a biopsy was done, there may be a dark vaginal
discharge afterwards. After the sample is removed,
Monsel's solution applied to the area to stop the
bleeding. When this mixes with blood, it creates a black
fluid that looks like coffee grounds. This fluid may be
present for a couple of days after the procedure. It is
also normal to have some spotting after colposcopy.
 Pain-relieving medication can be taken to lessen any
postprocedural cramping.
 Patients should not use tampons, douche, or have sex
for at least a week after the procedure (or until the
doctor says it is safe) because of the risk of infection.


RISKS
 Patients may have bleeding or infection after
biopsy. Bleeding is usually controlled with a topical
medication. If colposcopy is performed on a
pregnant patient, there is a risk of premature labor.
 A patient should call her doctor right away if she
notices any of the following symptoms:
 heavy vaginal bleeding (more than one sanitary pad
an hour)
 fever, chills, or an unpleasant vaginal odor
 lower abdominal pain

 Colposcopic diagnosis of cervical neoplasia
depends on mainly 4 features
 ACETOWHITINING MARGIN AND SURFEACE
 CONTOUR OF ACETOWHITE AREA
 VASCULAR FEATURE &
 COLOUR CHANGE AFTER APPLICATION OF
IODINE SOLUTION

 SENSTIVITY-87% TO 99% to diagnose cervical
neoplasia
 SPECIFICITY-23% TO 87%

COLPOSCOPIC VIEW
VASCULATURE-best seen before application of
acetic acid
ABNORMALITIES ARE
Punctuation
Mosaic pattern &
Atypical vessels

CONT…….
 Normally afferent & efferent capillaries within the
villi of columnar epithilium become compressed
during metaplastic process & not incorporated
within the newly form epithiliumr
 Instead they form a fine network below the
basement membrane
 When CIN develop as a result of of HPV infection
afferent and efferent capillary system incorporate in
to the diseased dysplastic epithelium..
 This form the basis of punctate mosaic blood
vessels

CONT…….
 PUNCTATE PATTERN-terminating vessels in
stromal papillae underlying the thin epithelium
appear as black point in a stippling pattern on
colposcopy called PUNCTATE AREAS
 MOSAIC PATTERN-epithilium appear as
individually small large round ,polygonal,regular or
irregular blocks.
 This pattern appear cause of interconnecting blood
vessel in stromal papilla which is observed as
cobbled area.

FINE PUNCTATION
 fine punctuation refer to
looped capillaries viewed
end on that appear to be
of fine calibre and located
close to one another,
producing a delicate
stippling effect
 Fine mosaics are a
network of fine-calibre
blood vessels .
 found in low-grade (CIN
1) lesions.

COARSE PUNCTATION
 Coarse punctation coarse
mosaic are formed by vessels
having larger calibre and larger
intercapillary distances,
 occur in more severe
neoplastic lesions CIN 2, CIN
3 lesions and early preclinical
invasive cancer.
 Sometimes, the two patterns
are superimposed in an area so
that the capillary loops occur in
the centre of each mosaic ‘tile’.
This appearance is called
umbilication

LEUKOPLAKIA
 Leukoplakia or hyperkeratosis is
a white well demarcated area on
the cervix
 The white colour is due to the
presence of keratin .
 Usually leukoplakia is idiopathic,
 but it may also be caused by
chronic foreign body irritation,
HPV infection or squamous
neoplasia.
 it should be biopsied to rule out
high-grade CIN or malignancy

CONDYLOMA
 Condylomata are multiple, exophytic lesions, that are infrequently
found on the cervix, but more commonly in the vagina or on the vulva
 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, each element of
which contains a central capillary.
 the surface of a condyloma may have a whorled, heaped-up
appearance with a brain-like texture, known as an encephaloid
pattern
 densely hyperplastic.
 These lesions may be located within, but are more often found
outside the transformation zone
 condyloma is whiter. .
 Condylomatous lesions may not take up iodine stain or may stain
only partially brown.

CONDYLOMATA-.. FIG SHOWING
GEOGRAPHICAL SATELLITE LESION FAR AWAY
FROM SQUAMOCOLUMNAR JUNCTION
FIG2 SHOWING EXOPHYTIC CONDYLOMA IN THE
CERVIX AFTER APPLICATION OF ACETIC ACID

COLPOSCOPIC VIEV AFTER APPLICATION OF
5% ACETIC ACID SOLUTION
 Degree to which the epithelium takes up acetic acid correlated with
the color tone or intensity the surfacre shine and the duration of
the effect and in turn with the degree of neoplastic change in
lesion
 LOW GRADE LESION-appears less dense
 less extensive thin and
 irregular margin or of angular margin with fine punctatin /mosaic
 HIGH GRADE LESION-appears dense poaque
 grey white aceto white areas with coarse punctationor mosaic
 and wid regular and well demarcated borders.
 These lesion often involve both lips and harbour atypical vessels

IT IS A GEOGRAPHICAL SATELLITE LESION
AFTER APPLICATION OF 5% ACETIC ACID FAR
AWAY FROM SQUAMOCOLUMNAR JUNCTION
SUGGESTIVE OF LOW GRADE LESION

FIG-1.. SHOWING A CIRCUMORIFICIAL
ACETOWHITE CIN-1 LESION WITH IRREGULAR
MARGIN AND FINE MOSAIC
FIG-2..INVOLVES BITH ANT. AND POST.
LIP,MODERATLY DENSE
FIG-3..MILD DENSE ACETOWHITE LESION
WITH FINE MOSAIC

CIN -2 LESION
FIG1 SHOW..MODERATELY DENSE ACETOWHITE LESION
WITH WELL DEFINED MARGIN AND COARSE PUNCTATION IN
THE ANT. LIP AND 3 ‘O CLOCK POSITION
FIG2 DENSE WELL DEFINED ACETOWHITE ARE WITH
REGULAR MARGIN AND COARSE MOSAIC
FIG3 ACETOWHITE LESION WITH COARSE PUNCTATION

CIN3 LESION
FIG1..SHOWS A CIRCUMORIFICIAL DENSE OPAQUE
ACETOWHITE AREA WITH COARSE MOSAIC
FIG2..SHOWS DENSE ACETOWHITE LESION WITH
REGULAR MARGIN AND COARSE IRREGULAR
PUNCTATION
FIG3..DENSE ACETOWHITE LESION WITH RAISED
AND ROLLED OUT MARGIN

CERVICITIS- INFLAMED WITH A REDDISH
APPEARANCE
BLEEDING ON TOUCH
THERE ARE ILL DEFINED PATCHY ACETO WHITE
AREAS

AFTER APPLICATION OF IODINE
 Normal vaginal and cervical squamous epithilium
and mature metaplastic epithilium contain glycogen
rich and thus take up iodine stain turns black or
brown but
 Dysplastic epithilium contains little or glycogen thus
does not stain with iodine remains mustard saffron
yellow
 Immature metapplasia partially stains cause
columnar epithilium does not take iodine.
 Condylomatous lesion does not take iodine

CIN1
 MUSTARD YELLOW
IODINE NEGATIVE
AREA WITH
IRREGULAR MARGIN

CIN2
 MUSTARD YELLOW
IODINE NEGATIVE
AREA IN ANTERIOR
LIP

•CIN 3
 (A)DENSE SAFFRON
YELLOW IODINE
NEGATIVE AREA
 (B) DENSE MUSTRD
YELLOW IODINE
NEGATIVE AREA IN
THE UPPER LIP

CONDYLOMA
 Fig. showng
 Lesion doesnot takes
iodine

MODIFIED REID COLPOSCOPIC INDEX

Colposcopy examination

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