• INTRODUCTION

• Introduced by Hinselmann in 1927

• Colposcopy refers to vaginal inspection ( from the greek

colpos, vagina and skopein, to see)

• Main object of the examination is the cervix

COLPOSCOPE

A colposcope is a low-power, stereoscopic, binocular,

field microscope with a powerful variable-intensity
light source that illuminates the area being examined
• Magnification colposcope is 10-20 times

• Working focal length of about 300 mm

• Powerful co-axial light source allowing stereoscopic

inspection of cervix under magnification 5x to 40x

• Green filters helps to study the vascular patterns by giving

red colours a black colour against a pale green background
• INDICATIONS

• Diagnostic screening procedures are-

Abnormal pap smear of the cervix

Abnormal areas on the vagina and pre-operative assessment

in early stages of cancer cervix

Abnormal vulval area

Locate the abnormal areas and biopsy

• Therapeutic indications

Precise conservative treatment with laser and cone biopsy can

be performed in CIN lesions using micromanipulator

 Delineates the area and destroys the entire lesion

 Depth of destruction of 4-5 mm is adequate in CIN lesions

 Depth upto 1 cm may sometimes be required

Lifelong follow-up of conservative treatment

• Colposcopy of the vagina

To evaluate vagina with abnormal pap smear but normal

colposcopic findings of the cervix

Rule out extension of CIN

Women with HPV viral infection

Gross lesion present

Follow up hysterectomy or conservative therapy performed for

CIN disease
• Technique

• Patient is placed in lithotomy position

• Cervix is visualized using a cusco’s speculum

• Colposcopic examination of the cervix and vagina is done

using low power magnification

• Cervix is gently swabbed and cleaned with saline

• Green filter and high magnification can be used now

• Cervix is wiped with 3%acetic acid and examination repeated

• In post-menopausal women

• Administer estrogen daily for 1-2 weeks to improve

colposcopic findings and allow squamocolumnar junction to
pout out of external os

• Vaginal misoprostol (prostaglandin) 3 hours before colposcopy

can dilate the cervix and allow endocervical visualization
• Colposcopic terminology

• Normal colposcopic findings

A. Normal squamous epithelium

B. Columnar epithelium

C. Transformation zone
• Abnormal colposcopic findings

A. Atypical transformation zone

Mosaic
Punctuation
Acetowhite epithelium
Keratosis
Atypical vessels
Iodine negative

B. Suspected frank invasive cancer

• Unsatisfactory –

transformation zone not seen

• Other findings-

Condyloma, ectopy and papilloma are of importance

• Colposcopy findings

Normal colposcopic columnar epithelium- red grape like

structures with furrows

Squamous epithelium- homogenous grey

• Abnormal findings-

• White epithelium- leukoplakia

Leucoplakia must be looked for before applying acetic acid

It is a white area of thickened epithelium seen on the portio by

the naked eye or by means of a colposcope

Caused by a layer of keratin on the surface of the epithelium

Immature squamous epithelial cells develops into keratin

producing cells or glycogen producing cells

Keratin production is abnormal in cervicovaginal mucosa

• Caused by HPV; keratinizing CIN; keratinizing carcinoma;
chronic trauma from diaphragm, pessary or tampon and
radiotherapy

• Condylomatous reactions caused by HPV may appear frond-like

or can lead to leucoplakia

• Biopsies should be taken especially when they arise from the

transformation zone.
• Frank invasive carcinoma can be identified before the
application of acetic acid by the presence of the following:

microexophytic epithelium—the surface is irregular, raised or

ulcerated; atypical corkscrew or comma-shaped vessels of
irregular calibre and branching pattern are seen

Viewing the lesion through a green filter allows clearer

demonstration of the vasculature.
• Acetowhite epithelium-

• Epithelium that turns white after application of acetic acid

(3%-5%) is called acetowhite epithelium

• The application of acetic acid coagulates the proteins of

nucleus and cytoplasm and makes the protein opaque and
white

• The acetic acid does not affect mature, glycogen producing

epithelium

• These areas appear pink during colposcopy

• Dysplastic cells are most affected- contains large nuclei with
abnormally large amounts of chromatin

• The columnar villi – Less dark red and the pale

acetowhitening of the villi may resemble a grape-like
appearance

• Metaplastic epithelium- grey and filmy

• Punctation

• Dilated capillaries terminating on the surface appear from the

ends as collection of dots

• Occurs in a well demarcated area of acetowhite epithelium-

abnormal epithelium- CIN

• The punctate vessels are formed as the metaplastic epithelium

migrates over the columnar villi

• CIN- capillary persists and appears more prominent

• Mosaics

• Terminal capillaries surrounding roughly circular or polygonal

shaped blocks of acetowhite epithelium crowded together

• Arise from coalescence of many puntate vessels or from the

vessels that surround the cervical gland openings

• Higher grade lesions, CIN-2 and CIN-3

• Atypical blood vessels with irregular diameter and

branching- invasive carcinoma

• Irregular surface contour with ulceration and friability

• Biopsies may be taken from suspicious areas under colposcopic
guidance

• Bleeding can be controlled with the application of Monsel’s or

silver nitrate solution or by a pack

• The application of Lugol’s iodine used to be done routinely in

the past—abnormal epithelium did not take up the stain as the
dysfunctional dysplastic cells were devoid of glycogen

• However, this is not mandatory if a thorough colposcopic

examination has been done.
• Colposcopy can

Avoid unnecessary biopsy if the findings are normal

Select the appropriate site of biopsy

Reduce the size of biopsy and conization

• Colposcopy-restricted to first trimester pregnancy- causes

bleeding besides causing discomfort once fetal head enters the
pelvis
 • Reid colposcopic index
Colposcopic Zero point One point Two points
signs
Colour of Low-intensity Grey-white AW Dull, oyster-white;
acetowhite acetowhitening; with shiny Grey
(AW) area snow-white, shiny surface
AW; indistinct AW;
transparent AW; AW
beyond the
transformation zone
AW lesion Feathered margins; Regular lesions Rolled, peeling
margin and angular, jagged with smooth, edges; internal
surface lesions; flat lesions straight demarcations (a
configuration with indistinct outlines central area of
margins; highgrade change
microcondylomatous and peripheral
or micropapillary area of lowgrade
surface change)
Vessels Fine/uniform vessels; Absent vessels Well defined coarse
poorly formed patterns punctation or
of fine punctuations coarse mosaic
and/or fine mosaic;
vessels beyond the
margin of
transformation zone;
fine vessels within
microcondylomatous
or micropapillary
lesions
Iodine staining Positive iodine uptake Partial iodine Negative iodine
giving mahogany up-take by a uptake by a lesion
brown colour; negative lesion scoring 4 scoring 4 or more
uptake of lesions or more points points on the above
scoring 3 points or less on above three three criteria
on above three categories –
categories variegated,
speckled
appearance
Colposcopic prediction of histologic
diagnosis using the reid colposcopic index

RCI Overall score Histology

0-2 Likely to be CIN-1
3-4 Overlapping lesion
5-8 Likely to be CIN 2-3