Introduction to

Colposcopy
 Indication for Colposcopy

 Epithelial cell abnormalities Sexual partner of patients with genital tract

detected by cervical cytology neoplasia

 Positive high risk HPV DNA in Oncogenic Human Papillomavirus in

ASC-US triage appropriate guideline algorithms

 Suspicious cervical lesions Unexplained vaginal bleeding

 Vulvar or vaginal neoplasia Post–coital bleeding

Positive screening test by Cervicography

 History of in-utero DES exposure
or Speculoscopy
 Basic Satisfactory Requirements of
Colposcopic Exam
 Adequate Visualization
 Entire TZ Zone seen
 Abnormal areas seen in entirety
 Endocervical Canal free of Dysplasia
 No Evidence of Invasive Cancer
 Abnormal Areas Biopsied
 ECC Completed (Non-Pregnant patients)
 Colposcopy - Objectives

 Determines the presence of invasive cancer

 Localizes the squamocolumnar junction
 Identifies the most severe disease for biopsy
 Evaluates the extent of disease
Instrumentation Procedure
 Colposcope
 Vaginal speculum
 Endocervical speculum
 Large & small swabs
 Endocervical curette
 Cervical biopsy forceps
 Solutions:
 Normal saline
 Acetic Acid
 Monsel’s
Instrumentation
Collin’s bivalve specula of different sizes Vaginal side wall retractor

Endocervical speculum Cervical punch biopsy forceps

with sharp cutting edges
 A method of identifying
outer & inner borders of the transformation zone
Colposcopic Examination
 Obtain Pap, cultures, KOH as Needed

 Perform Cervical Colposcopic Exam

 Use Green Filter, if needed

 Mentally Map Cervical Landmarks and abnormal areas

 Colposcopic magnification of 10X – 15X

 Is Exam Satisfactory?
Look for
 Satisfactory Colposcopy:
 360 degree view of the T-zone
 Proximal and distal extent of cervical lesions seen

 Gross lesions or Pathology

 Tumors
 Infections

 Don’t forget to check for vaginal and vulvar lesions

Collection of Target Biopsy
 Select the most severe lesion
 Sharp instruments
 2-3 mm biopsy
 Colposcopically assisted always!
 Biopsy at the SCJ
 Monsel's solution /cauterisation for
hemostasis
Satisfactory Colposcopy exam
 360 degrees of squamocolumnar junction visualized

 Proximal and distal extent of cervical lesions identified

 Cytology, colposcopic impression and histology correlate

SCJ
Multiple nabothian cysts in the mature squamous Nabothian cyst with
metaplastic epithelium occupying the ectocervix regularly branching tree like
vessels
Normal vascular pattern
 Punctation
Definition
 Vertical single loop intraepithelial capillaries
viewed end on in a demarcated area

 Etiology

 Normal vascular pattern

 Abnormal modification of existing vascular

architecture

 Arises from the normal original columnar

epithelial angioarchitecture
Colposcopic Appearance
 Red dots usually seen within
an area of acetowhite
epithelium

 Variable with increasing

severity of disease

 Increasing caliber of dot from

fine to coarse

 Increasing intercapillary
distance
 Coarse punctation

Coarse punctation before & after application of acetic acid

Differential and Significance
 May result from inflammation, repair, viral effects,
neoplasia or the variant of fetal metaplasia (congenital
t-zone)

 May represent normal to neoplasia

 Vessel caliber and intercapillary distance predict the

severity

 Average intercapillary distance is 100 microns

 Increases with progressive neoplasia

 Mosaic
 Intra epithelial capillaries
encompassing blocks or buds forming
a mosaic, tile or “chicken wire” pattern

 May be normal or abnormal

modification of existing vascular
architecture

 Red, tile-like grid usually viewed within

acetowhite epithelium

 Fine or coarse caliber

 Variable intercapillary distance with

increasing severity of neoplasia
Mosaic: Differential and Significance
 May be seen in the normal variant of fetal metaplasia
(congenital t-zone)

 Represented in any level of neoplasia

 May be observed in benign tissue (not aceto-white)

 Caliber and intercapillary distance predict the severity of

disease
 Atypical
vessels patternِ
 Superficial blood vessels exhibiting bizarre
Atypical Vessels variation in caliber, course and branching
pattern

 Develop in response to tumor angiogenesis

factor (TAF)

 Result in chaotic, rapidly proliferating vessels

attempting to nourish rapidly in neoplastic
tissue

 Lack systematic, uniform branching

Atypical Vessels:
Differential and Significance
 ASSOCIATED WITH CANCER UNTIL PROVEN OTHERWISE

 May be observed in areas of immature metaplasia

 Colposcopically directed biopsy is mandatory

 Post Menopausal Cervix:
The entire new SCJ is visible Epithelium is pale, brittle, lacks lusture,
colposcopic examination is satisfactory. shows sub-epithelial petichiae, SCJ not
the TZ is fully visualized. The metaplastic
visualized
squamous epithelium is pinkish-white
compared to the pink original squamous
epithelium
 Squamous metaplasia

Earliest colposcopic changes in

immature squamous metaplasia
(after 5% AA) in which tips of
columnar villi stain white &
adjacent villi start fusing together

Prominent white line corresponds to

the new SCJ & tongues of immature
Squamous metaplasia a) with crypt
openings at 4-8 o’clock positions
b) after application of AA
 The endocervical polyp &
Immature squamous metaplastic epithelium (narrow arrow) the immature squamous metaplasia
on the polyp with intervening areas of columnar epithelium surrounding the os partially take up
a) after application of AA iodine.
Leukoplakia
 Usually benign

 May obscure an underlying

neoplasia

 Therefore, all patches

observed before application of
acetic acid must be biopsied

Hyperkeratosis ( Leukoplakia)
 Geographic satellite lesion

condyloma low-grade lesion

Thin acetowhite lesion with Moderately dense acetowhite
geographic margins in the upper lesions with irregular margins in
lip. Histology indicated CIN 1 the anterior & posterior lips ( CIN
1)
 circumorificial acetowhite CIN 1
lesion with irregular margin & fine mosaics
Moderately dense acetowhite lesions with well Dense well defined acetowhite
defined margins & coarse punctations in the area with regular margins &
anterior lip & in 3 o’clock position (CIN 2 lesion coarse mosaic ( CIN 2 lesion )
A dense acetowhite lesion with varying colour Acetowhite lesions with coarse punctation
intensity & (a) & mosaics (b) in a CIN 2 lesion
coarse mosaics (a) in a CIN 2 lesion
 A dense acetowhite lesion with regular
A circumoral dense opaque acetowhite area with margin & coarse,
coarse mosaics ( CIN 3 lesion) irregular punctation in a CIN 3 lesion.
Modified
Reid
Score
 Preclinical invasive
Carcinoma

Early invasive cancer: note the raised irregular mosaics with umbilication (a), breaking
mosaics (b), surface irregularity & the atypical vessels after the application of 5% AA
 Invasive cervical cancer
Atypical
Vessels
patternِ

Note the irregular surface contour with

mountains & valleys appearance with
atypical blood vessels in the dense
acetowhite area
 Glandular lesions

A dense acetowhite lesion in the endocervical canal visible after stretching

the os with a long dissection forceps (adenocarcinoma in situ)
Adenocarcinoma in situ: The tips of some of the columnar villi turn densely
white compared to the surrounding columnar villi after the application of acetic
acid (arrow). The nabothian cysts turn white after the application of AA
 Adenocarcinoma:

the greyish white dense acetowhite lesion with The elongated, dense acetowhite lesion with
character writning-like atypical blood vessels(a) irregular surface in the columnar epithelium
with atypical blood vessels (a)
 Inflammatory lesions of the
Uterine Cervix

Chronic cervicitis: This cervix is

Reddish “angry-looking”, inflamed columnar
epithelium with loss of the
villous structure & with inflammatory exudate
(before application of 5% AA)
extensively inflammed with a reddish
appearance &
bleeding on touch, there are ill-
defined, patchy acetowhite areas
scattered all over the cervix after the
application of AA
 TV after Acetic acid
Multiple red spots (a) suggestive of Trichomonas
vaginalis colpitis ( strawberry appearance), after
application of 5% AA

T.V. After Lugol’s

Trichomonas vaginalis colpitis

after application of Lugol’s iodine
(leopard-skin appearance)
Lines of treatment
 No treatment
 Follow up
 LEEP
 Cryotherapy
 Laser
 Cone biopsy
 Hysterectomy