Colposcopy in Gyn Practice

Presenter : DR Joseph G. KimaroFacilitator: DR .Fadhlun

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Outline

• Historical background• The instrument• Applied Anatomy• Indications• Procedure • Findings • Management of abnormal findings• conclusion04/28/23 2

Historical background

• Colposcope is a special microscope with magnification of up to 40x

• Colpo - Vagina, Scope- look into• Provides illuminated and magnified

assessment of lower genital tract• Described by Hans Hinselman in 1925• His theories were incorrect and protocol was

impractical

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Ct..

• His work identified several atypical appearances

• which are still used today:– Leukoplakia– Punctation– Felderung (mosaicism)

• Abandoned until 1960 - used to confirmation and follow-up of abnormal pap smear

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Ct…

• In 1970s, treatment of abnormal Pap smear was cone biopsy

• There was over treatment as most Bx revealed minor epithelial changes

• Colposcopic evaluation procedure to identify those who require surgical therapy decreased unnecessary surgeries.

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Ct…

• Today colposcopy has been accepted as a diagnostic tool in evaluating abnormal pap tests

• Colposcopy elegantly identifies the location of abnormal lesions allowing the practitioner to obtain histologic samples

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Colposcopy Goals

To detect abnormal epithelium,

To identify the area of epithelium with the

highest degree of disease

To take direct biopsies to that area

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Indications

• Abnormal Pap smear, with no gross lesion on cervix

• Persistence of inflammatory cells despite adequate treatment

• Grossly abnormal / unhealthy cervix or vagina• Women with positive high risk HPV DNA test,

even if Pap neg.• Pos-tcoital bleeding

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Ct…

• Trearment of women with CIN• Monitoring of women treated for CIN• Preop evaluation of women diagnosed with

Stage Ia or b cervcal cs on cl ex & bx – to rule out vag involvement

• Evaluation of women with anogenital condylomas

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Contraindications

• No absolute contraindications to the performance of a colposcopic examination exist

• Take precautions in special circumstances, such as a pregnant patient with placenta previa.

• Ability to tolerate a standard speculum examination is the only true limiting factor.

• Active cervicitis and vulvovaginitis should be treated

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Colposcope-Relevant anatomy • Cervix epithelium is composed of squamous and

columnar epithelial- ecto and endo • Pre-menarche columnar extend to cervical portio• Undergoes squamous metaplasia-physiological

change• Ring of squamous metaplasia is referred to as the

transformation zone transformation zone (TZ)• Squamocolumnar junction (Squamocolumnar junction (SCJ) is the border btn

metaplastic epithelium and endocervical colunar epithelium

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Ct..

• Virus commonly infect rapidly dividing epithelium,

• Transformation zone is typically the locus of dysplastic change.

• Complete visualization of the entire transformation zone, most specifically the squamocolumnar junction is required for adequate assessment.

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• Actively dividing cells have increased nuclear–cytoplasm ratio. This is especially true of HPV–infected cells

• Exposure of such tissue to dilute acetic acid results in increased light reflectivity and, therefore, visual contrast with normal tissue

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• Mature squamous epithelial cells contain a large amount of glycogen, which stains a characteristic mahogany color when exposed to iodine (the Schiller reaction),

• Rapidly dividing cells, which contain relatively little glycogen, remain unstained

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• There is in-growth of the perpendicular vessels into the epithelium.

• Viewed end-on under magnification, these vessels appear as small red dots “punctationpunctation”

Left is fine, right is coarse

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• Vessels can become interconnected in intricate patterns that resemble a tiled floor “mosaicism”“mosaicism”

• Irregular vessels eg, sudden vessel termination, “hairpin” or “comma” type vessels, abnormal branching, or increasing diameter of a vessel is suggestive of malignant transformation

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Colposcope • Optical device for

illumination and magnification used for examination of lower genital tract

• Allows close examination of epithelial surface and sub-epithelial blood vessels

• Two types exist:1. Optical colposcope2. Video colposcope04/28/23 17

Video colposcope

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Colposcope • Have focal length of 200 to 350mm• Focusing is done using knob instead of moving

whole colposcope• Have powerful source of light for illumination • Green or blue filters are present for contrast• Green filters block red light hence blood

vessels appears black• Required magnification for cervix examination

is 7.5X to 15X04/28/23 19

Colposcope

• Colposcopes can be affixed to Exam. table, mounted to stand or fitted to swivel arm

• Mobile units are most practical• Three types of support available

• Centre post• Flexible articulating arm• Overhead boon type

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Colposcopy procedure STEPSSTEPS• Take detailed gyn, obst,FSH and past medical History• Explain procedure & obtain consent• Insert speculum n visualise• Apply normal saline• Apply 3 – 5 % acetic acid• Apply Lugol’s iodine• Perform cervical biopsy from abnormal area• Perform ECC , if indicated• Inspect vagina, vulva, perineal areas.• Bimanual & rectal examination04/28/23 21

Pt Prep

• Take a gynacological history-immunosupression, haemorrhagic diasthesis, use of anticoagulants

• H/O tobacco use, LNMP, EDD if preg., PID, • Inquire about prior H/O of STI~HPV,

premalignant and treatment• Ask about abnormal Vaginal bleeding,

postcoital bleeding

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When?• Menstrual cycle : day8 – day 12 as cervical

mucus abundant & clear, and ext os open.• Postmenopausal women should ideally

receive estrogen for 7-21 days, colpo performed on last day of oestrogen. Not after stopping as mucosa reverts rapidly.

• Colpo under adequate oestrogen reduces chances of unsatisfactory colpo, need for ECC

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Ct..

• Systematic approach is essential• Consist of four distinct and orderly tasks

i. Visualizationii. Assessmentiii. Sampling and iv. Correlation

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Colposcopy procedure• RequirementsRequirements 1. Colposcope2. Kevokian punch biopsy forceps3. Bivalve or/and Sims vagina

speculum4. Cervical speculum5. Endocervical brush6. Edocervical curette7. Normal saline, acetic acid, Lugols

Iodine8. Silver nitrate stick or monsels

solution04/28/23 25

Ct.. • Ensure equipment and supplies

availability• Position her on examination

table• Communication-patients’ co-

operation• Insert adequate size of speculum• If obese may apply glove around

speculum• Move scope to the working focal

length04/28/23 26

Technique• Orient colposcope so that a panoramic view is

obtained• Start with normal light and 2X to 10×

magnification• Entire cervix should be visualized• Clean off obscuring mucous or discharge with

normal saline• Look for blood vessels and SCJ • Apply generous amount acetic acid or Lugols

iodine04/28/23 27

Stains 15% or 3% Acetic Acid5% or 3% Acetic Acid• Works as a desiccant• The cellular cytoplasm is reduced enhancing a

prominent nucleus• The nucleus is enlarged secondary to HPV

replication• This nuclear enlargement is seen as acetowhite

changes

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Stains 2

Lugol’s iodine solution (Schiller test)Lugol’s iodine solution (Schiller test)• Works by staining glycogen• Dysplastic tissue has an increased metabolic

rate thereby lowering cellular glycogen• Normal tissue stains black/brown while

dysplastic tissue appears highlighted or yellow• Useful stain for hard to see lesions

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Technique – Evaluation • Evaluate the squamocolumnar junctionEvaluate the squamocolumnar junction(SCJ) or (SCJ) or

transformation zone (TZ)transformation zone (TZ)• Dysplasia originates from this boundary and

spreads lateral to this junction• Medial to this border are columnar

cells/glandular cells• A large volume of glandular cells are called

ectropion• Young women and pregnant women generally

have ectropion04/28/23 30

Technique-Evaluation• Evaluate areas of acetowhite changesEvaluate areas of acetowhite changes

• Are they small or larges patches?• Does it have a sharp or indistinct border?• Is it a bright white or a dull, pearly grey?

• Evaluate areas of punctationEvaluate areas of punctation• Are the punctations small or large caliber?• Are the punctations sparse or numerous?

• Evaluate areas of mosaicismEvaluate areas of mosaicism• Evaluate areas of abnormal blood vesselsEvaluate areas of abnormal blood vessels

• Are the blood vessels uniform or sporadic?• Are the vessels large caliber or small caliber?

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Adequacy of procedure• Visualization of entire TZ in 360

degrees360 of columnar epithelium360 squamous epithelium360 of current SCJ

• Entire lesion should be visible i.e distal an proximal margins must be colposcopically visible

• If lesion/SCJ can not entirely visualized then- unsatisfactory colposcopy may need Rx

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Technique-Biopsy

• Best to obtain biopsy of lesions• Try to incorporate SCJ if at all possible• Multiple biopsies are recommended (2-3)

reasonable• Endocervical curettage (ECC) should generally

be included as part of each colposcopy

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Technique-ECC• It is uncomfortable portion of colposcopic

directed biopsies• Good to have patient take NSAID 30 min before

colposcopy• Apply curette at four cardinal directions• Swirl curette in fixative then take endocervical

brush to collect rest of sample• Prospective randomized trial revealed better

results with curette and brush than either alone04/28/23 34

Normal colposcopic finding

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Normal colposcopic finding

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Normal colposcopic finding

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Normal colposcopy- SCJ

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Normal histologic finding

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Abnormal colposcopic findingAcetowhite changesAcetowhite changes

• Grade of lesion correlates with intensity of whiteness, surface shine, rapidity of appearance and duration of whiteness.

Low-grade LesionsLow-grade Lesions– Less dense, less extensive and less complex acetowhite

areas close to or abutting the squamocolumnar junction with well demarcated, but irregular, feathery or digitating margins

– Satellite acetowhite lesions detached (far away) from the squamocolumnar junction

– Geographical patterns (resembling geographical regions).04/28/23 40

Acetowhite Changes CIN 1

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High Grade Lesions dense, opaque, grey white acetowhite areas coarse punctation and/or mosaic regular and well demarcated borders Raised / rolled edge; extensive and often involve both lips and may occasionally harbour atypical vessels

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HGL

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HGL

A dense acetowhite, opaque, complex,circumorificial CIN 3 lesion

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Ct.. Visualization of one or more

borders within an acetowhite lesion (‘lesion within lesion’) or a lesion with differing colour intensity.

The crypt openings may have thick, dense and wide acetowhite rims called cuffed crypt openings . These are whiter and wider than the mild, line-like acetowhite rings that are sometimes seen around normal crypt openings.

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Mosaicim

• A mosaic is a large image pieced together by smaller usually colorful tiles

• In colposcopy it is essentially the same- a larger lesion made of small heaped epithelial islands and tiny vessels

• These islands look like a cobblestone road• Islands are separated by vessels running

parallel to the portio or colposcopist

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Mosaicim

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Invasive cancer• Collection of all

colposcopic finding: acetowhite, punctations, mosaicism, and vessels

• Necrotic tissue results in anaerobic odors

• Take biopsy from lesion, be ware of bleeding

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Invasive carcinoma- cotton wool appearance

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Abnormal colposcopic findings

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Leukoplakia• Well demarcated white area prior to AA

application.

• Usually leukoplakia is idiopathic, but it may also be caused by chronic foreign body irritation, HPV infection or squamous neoplasia.

• It is not usually possible to colposcopically evaluate the vasculature beneath such an area

• No matter where the area of leukoplakia is located on the cervix, it should be biopsied to rule out high-grade CIN or malignancy.

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Colposcope-Grading

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Treatment modalities for abnormal findings

• Cryosugery• Loop Electricosurgical Excision Procedure

(LEEP)• Laser Ablation• Cold Knife Conization• Hysterectomy

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Post colposcopy advice

• Ant pains-NSAIDS should be prescribed• Woman to avoid sex for a day or two• Counseled on findings and given the date on

when to return• Should report any excessive vagina bleeding

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Relevant study• Interventions for reducing anxiety in women undergoing

colposcopy. Cochrane review of 15 papers• Galaal KA• Women experience high levels of anxiety and negative

emotional responses at all stages of cervical screening. High levels of anxiety before and during colposcopy can have adverse consequences, including pain and discomfort during the procedure and high loss to follow-up rates.

• Objectives:To compare the efficacy of various interventions aimed at reducing anxiety during colposcopic examination in women

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• Finding: Listening to music during colposcopy: this intervention was associated with reduction in anxiety levels (p < 0.002). Video colposcopy was associated with reduction in anxiety levels, and the reduction in anxiety was significant (p < 0.0002 There was a reduction in anxiety levels in the intervention group compared to the control group (p < 0.00001).

Conclusion: Anxiety appears to be reduced by playing music during colposcopy, showing information videos prior to colposcopy and viewing video colposcopy during the procedure

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Conclusion

• Colposcopy is important procedure in confirming abnormal cytology

• It has reduced unnecessary surgical interventions among women with abnormal cytology

• Biopsy should be taken from colposcopically abnormal areas.

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