Normal

Colposcopy
Dr. jayesh ahir
Gynaec Oncologist
Associate Professor
Gynec-Oncology Departmentv.s.hospital
 Prevention
is
Better than
Cure
 Cervical CANCER
Raising Awareness &
• Prevention
Cervical Cancer -A major health problem &
Social Burden

• The commonest cancer in women in developing countries

• Diagnosed in advanced stage

• Cancer of Cervix is curable if detected in early stage

Development of Cancer Cervix
Normal Cervix
↓
Pre Cancerous lesions ( CIN – I, CIN - II )
↓
10 -15
Carcinoma in situ ( CIN-III)
years
↓
Invasive Cancer
↓
--------------------------------------------
↓ ↓ ↓ ↓
Stage I Stage II Stage III Stage IV
 Screening for Cervical
Cancer
• Pap’s Smear

• Visual inspection of Cervix

- after application of acetic acid (VIA)
- after application of Schiller’s iodine (VILI)

• HPV DNA testing

What is a Colposcope
Colposcope is a microscope designed to allow
examination of the cervix with magnification
ranging between six- to - 40 fold

It is kept approx. 30cm away from the vagina & a

light source is thrown in it & in return it shows
real, true magnified picture of cervix

Invented by Hinselmann, a German scientist, in

1925
 Colposcope
(Greek word)
__________↓___________
↓ ↓
Kolpos Skope
↓ ↓
Hollow Examine
 The Primary goal of Cervical Screening is to
prevent
Cervical Cancer

“The man who thinks that cytology is

better than colposcopy,
or
that colposcopy is better than cytology,
is a fool who knows nothing of either”
-Hinselmann
 COLPOSCOPY
• The Colposcope is a magnifying instrument
• Its lights are only on THE OUTSIDE
• No anesthesia is required
• Colposcopy is an outpatient procedure

• Helps in identifying the abnormal or diseased area

• It helps in taking biopsy
• Colposcopy is not a Surgery
 Type of Colposcope
Manual Colposcope

 Main objective lens

 Magnification changer
 Binocular lens
 Filter: required for the
study of vascular
architecture
 Light source
 100
Eye piece

80
Knob for
60
magnification
East
40 Light West
Object
source
ive lens North
20

0
1st 3rd
Qtr Qtr Knob for
tilting
Video-Colposcope
• It utilizes video camera
• Electronic green filter
• Motorized zoom magnification
• Fine focus control combined in one unit
• Omission of eye piece
• Along with high resolution
monitor & optional
image management system
• Full screen image display
• With live recording
Digital Video- Colposcope
• Digital Video-colposcopy
:Includes computer with
image software

Images can be captured and

stored digitally for
• Documentation
• Teaching purpose
• Comparison of lesion during
follow up
• Statistical analysis and
• Printing report
• Software data – for Digital Video Colposcopes are the
confirmation of diagnosis latest generation
 Why Do A Colposcopy ?
Colposcope :Low
Low power
power binocular
binocular microscope,
microscope,
Modified
Modified with
with the
the specific
specific purpose
purpose
To
To study
study of
of surface
surface epithelium,
epithelium, stroma
stroma
&
& vascular
vascular pattern
pattern of
of the
the cervix
cervix

Diagnostic
Diagnostic tool
tool –– Identification
Identification of of abnormalities
abnormalities inin CERVIX
CERVIX
Location
Location ofof the
the lesion
lesion
Aid
Aid in
in selection
selection ofof biopsy
biopsy site
site
Significant
Significant role-
role- Evaluation
Evaluation & & treatment
treatment of of CIN,
CIN, HPV,
HPV, Erosion
Erosion
Selection
Selection of
of treatment
treatment of of CIN
CIN
Abnormal
Abnormal pap’s
pap’s smear
smear inin pregnancy
pregnancy
Extension
Extension ofof lesion
lesion in
in vagina
vagina
 Indications
HSIL / LSIL /Persistent LSIL / borderline nuclear changes
ASC-U (HPV Test - High Risk – Positive)
ASC-H
Suggestion of invasive cancer

Persistent unsatisfactory smears

Presence of glandular lesion
Excessive numbers of keratinized cells

Clinically ‘suspicious looking’ cervix

Leucoplakia
Abnormal / unexplained intermenstrual bleeding
Postcoital bleeding
Unexplained, persistent vaginal discharge
Materials required for performing
Colposcopy
Examination table:
• Table allows the woman to be placed in Table: For instruments
a modified lithotomy position
• The women’s feet may be placed either
in heel rests or legs may be supported in
knee crutches

Optional Items :
Computer – for documentation purpose
Printer, Video Recorder, Appropriate
software for recording of
patient data
• CUSCOS speculums - different sizes - metal /
plastic disposable
-inserted gently to widen the opening of the
vagina enables visualization of the cervix
-If lateral walls of the vaginal canal are
obstructing the view, a latex condom can be put on
speculum after cutting its tip

• Sponge holding forceps / larger cotton-tipped swab

sticks
• Cotton or blood holding pads
• Bottles : 1. normal saline
2. 3-5% acetic acid &
3. Lugols Iodine
• Monsel ‘s Solution : Local Haemostatic agent
Acetic Acid
Acetic Acid: It is applied with a cotton
applicator (cotton balls held by
sponge forceps or small swabs)

• Acetic acid dissolves & coagulates

the protein available on cervix in
order to make it more clear
Duration : 1-3 minutes
• Acetonic effect: After application a
white layer
appears
GREEN FILTER
• It is used to study the
vascular pattern of cervix

• Actually, this absorbs the

red from the color &
enhance the image of blood
vessels which appear black
 Lugol’s Iodine
Lugol’s Iodine Application :

• This solution is also known as Schiller’s test

• Reaction obtained when iodine solution is painted on cervix

• Normal epithelium is glucogen rich - stains brown

• Abnormal epithelium -contains little or no glycogen doesn’t
take up the stain

• Hence abnormal area can be easily marked

• Help in selection of area -for biopsy
Schiller’s Iodine :
 Technique
OPD procedure

No Anesthesia required

Insertion of cusco’s speculum

Inspection of unprepared cervix

Excess mucus is
is removed -saline soaked
soaked cotton wool
wool swab

Colposcopy after application of 3-5% acetic acid

Examine of Cervix under green filter

filter
Application of
of Schiller’s iodine
International Colposcopic
Terminology
Normal colposcopic findings:
• Original squamous epithelium
Abnormal ( within the TZ )
• Columnar epithelium
• Normal Transformation zone
• Acetowhite epithelium*
Unsatisfactory colposcopy:
• Punctation*
• Squamocolumnar junction not • Mosaic*
visible
• Leukoplakia*
Miscellaneous findings: • Iodine negative
• Micropapillary surface • Atypical vessels
• Condyloma • Colposcopically suspect
• Inflammation / Atrophy / invasive carcinoma
Ulcer
• Other
Anatomy of the Cervix
Cervical Epithelium
Colposcopic Appearances

 Original Squamous epithelium

 Original Columnar epithelium

 Transformation zone
 Original Squamous Epithelia

 Smooth, usually
featureless covering of
the cervix
 Uniform pink colour
 It joins the columnar
epithelium at the
original SCJ
Original Columnar Epithelia

 An area with multiple

villi / grapelike
projections
 Characteristic reddish
colour
 Each villus has one /
more capillary loops
with a thin overlying
epithelium
Original Squamo-columnar
Junction
 Permanent point of meeting
between original squamous
and columnar epithelia

 Outlines the lateral border of

the TZ

 It is fixed, but moves in

relation to the whole cervix
Transformation zone
 The area lying between the original squamo-columnar
junction and the colposcopic new squamo-columnar
junction

 Zone in which transformation will occur during fetal

life, adolescence and pregnancy

 Characterized by presence of metaplastic epithelium

 This is the area where transformation to CIN occurs

which may lead to invasive cancer
Transformation Zone
Squamous Metaplasia
Conversion of Columnar epithelium to Squamous
epithelium
Squamous Metaplasia
 Periods of development – late fetal life, menarche, first
pregnancy

 Early / Immature stage – villi opaque at tips pale

 Mature – difficult to distinguish between metaplastic and

original squamous epithelia

 Gland openings – Patent preexisting clefts

(lateral margin of TZ)
 Nabothian follicles – occluded clefts
Tissue basis for Colposcopy
The colposcopic appearances of the cervix are a
summation of various factors

These include:-
1.The architecture of the epithelium and possible
variations in its thickness & formation

2.The composition of the underlying stroma

3.The surface configuration of the tissue of the

cervix
Surface configuration

 Smooth / papillary
 Vascular patterns
- Punctations
- Mosaics
 Leukoplakia (white patches on surface), due to thick
keratin which may overlie normal / abnormal
epithelium
 Irregular surface
Miscellaneous findings
:- Colposcopic
appearance
Cervical Ectopy / Ectropion
 Menarche, pregnancy and oral contraceptives
 SCJ situated outside external os
 Surface columnar epithelium displaced outward
 Gives an exophytic appearance
 Only colposcopy can differentiate between a perfectly
benign effect and malignant changes
Cervical Polps
Inflammatory Lesions
Trichomonas vaginalis---strawberry appearance
Schillers iodine test--- leopard skin appearance
 Human Papilloma Virus
Infection
Lesions can be single/multiple
Flat plaque of acetowhite epithelium -mosaics & punctations
With increasing keratinization surface appear heaped up
resembling the surface of cerebral cortex
May even occur outside the T.Z.
FINAL DIAGNOSIS BY HPE
Cervical epithelium
Menopause
 TZ tends to retract
 Squamous epithelium becomes atrophic
 Glycogenation is lost
 Subepithelial capillaries – much more readily
traumatized
Unsatisfactory Colposcopy
Abnormal epithelium extending high into the
endocervix
Entire T.Z. not seen
Selection of biopsy
Diagnosis

Four basic Colposcopic diagnosis

1. Normal & satisfactory / Unsatisfactory

2. Low-grade disease (HPV / CIN-1)
3. High-grade disease (CIN-2 or 3)
4. Invasive cancer
To Conclude
Colposcopy is a important aid in diagnosis
Pap's smear & Colposcopy are complementary

Requires specialized training, skill & knowledge

Colposcopist should be aware of all the terminology

Colposcopy is totally subjective

FINAL DIAGNOSIS BY HISTO-PATHOLOGY

Management depends on the histo-pathology reports
CYTOLOGY IDENTIFIES THE
CRIME
WHILE
COLPOSCOPE LOCATES THE
CULPRIT