Introduction to
colposcopy
Introduction
The Papanicolaou smear (Pap smear) is a commonly
used screening test for dysplasia and cancer of the
uterine cervix.
Colposcopy is the diagnostic test to evaluate
patients with an abnormal cervical cytological smear
or abnormal-appearing cervix.
It entails the use of a field microscope to examine the
cervix after acetic acid and Lougol's iodine are
applied to temporarily stain the cervix.
Introduction
The cervix and vagina are examined under
magnification, and all abnormal areas are identified.
If the colposcopy is satisfactory (the entire
transformation zone is examined and the extent of all
lesions is seen), directed biopsies of all lesions and
especially the most severe lesions are performed.
This leads to a tissue diagnosis of the disease
present
Normal transformation zone
Indications for
colposcopy
Pap smear consistent with HPV infection,
dysplasia, or cancer (LSIL or HSIL).
Pap smear with ASCUS favor dysplasia or
repeated ASCUS.
Pap smear with repeated unexplained
inflammation.
Abnormal-appearing cervix.
Patients with a history of intrauterine
diethylstilbestrol (DES) exposure .
NORMAL
COLPOSCOPIC
FINDINGS
NORMAL COLPOSCOPIC FINDINGS
Original Squamous Epithelium.
The original squamous epithelium is a featureless,
smooth, pink epithelium. There are no features
suggesting columnar epithelium such as gland
openings or Nabothian cysts.
Epithelium is considered "always" squamous and was
not transformed from columnar to squamous.
NORMAL COLPOSCOPIC FINDINGS
Columnar Epithelium.
The columnar epithelium is a single-cell layer, mucous
producing, tall epithelium that extends between the
endometrium and the squamous epithelium.
Columnar epithelium appears red and irregular with
stromal papillae and clefts. With acetic acid
application and magnification, columnar epithelium
has a grape-like or "sea-anemone" appearance.
It is found in the endocervix, surrounding the cervical
OS, or (rarely) extending into the vagina
Columnar Epithelium
NORMAL COLPOSCOPIC FINDINGS
Squamocolumnar
Junction(SCJ)
Generally, a clinically visible line seen on the
ectocervix or within the distal canal (e.g.,
post-cryotherapy), which demarcates
endocervical tissue from squamous (or
squamous metaplastic tissue). This is an
anatomical feature
Squamocolumnar junction
NORMAL COLPOSCOPIC FINDINGS
Transformation Zone (Tz)
The geographic area between the original
squamous epithelium (before puberty) and
the current squamocolumnar junction is the
Transformation Zone.
It may contain gland openings, Nabothian
cysts, and islands of columnar epithelium
surrounded by metaplastic squamous
epithelium
NORMAL COLPOSCOPIC FINDINGS
Squamous Metaplasia
The physiologic, normal process whereby columnar
epithelium matures into squamous epithelium.
Squamous metaplasia typically occupies part of the
transformation zone. At the squamocolumnar
junction it appears as a "ghost white" or white-blue
film with the application of acetic acid.
It is usually sharply demarcated toward the cervical os
and has very diffuse borders peripherally
Squamous Metaplasia
ABNORMAL
COLPOSCOPIC
FINDINGS
Atypical Transformation Zone
A transformation zone with findings
suggesting cervical dysplasia or
neoplasia:
Acetowhite (AW).
A transient, white-appearing epithelium
following the application of acetic acid.
Areas of acetowhiteness correlate with
higher nuclear density
Acetowhite(AW)
Acetowhite(AW)
Atypical Transformation Zone
A transformation zone with findings
suggesting cervical dysplasia or neoplasia:
Punctuation
A stippled appearance to capillaries seen
end-on, often found within acetowhite area
appearing as fine to coarse red dots.
Punctuation
Atypical Transformation Zone
A transformation zone with findings
suggesting cervical dysplasia or
neoplasia:
Mosaicism.
An abnormal pattern of small blood
vessels suggesting a confluence of "tile"
or "chickenwire" reddish borders
Atypical Transformation Zone
A transformation zone with findings
suggesting cervical dysplasia or
neoplasia:
Leukoplakia .
Typically an elevated, white plaque seen
prior to the application of acetic acid.
Atypical Transformation Zone
A transformation zone with findings
suggesting cervical dysplasia or neoplasia:
Abnormal blood vessels .
Atypical, irregular vessels with abrupt courses and patterns, often
appearing as commas, corkscrews, or spaghetti. No definite
pattern is recognized, as with punctation or mosaicism. Suspect
invasive cancer. Complex pattern consisting of roughened,
irregular cervical epithelium, typically with abundant irregular
vessel patterns. Blood vessels take bizzare forms, which appear
as commas, hair pins, spaghetti, or long, dilated, unbranching
vessels with irregular diameters
Abnormal blood vessels
OTHER
COLPOSCOPIC
FINDINGS
Vaginocervicitis
Cervicitis may cause abnormal Pap
smears and make colposcopic
assessment more difficult. Many
authorities recommend treatment
before biopsy when a STD is strongly
suspected
Traumatic erosion
Traumatic erosions are most
commonly caused by speculum
insertion and over vigerous Pap
smears but can also result from such
irritants as tampons, diaphrams, and
intercourse.
Atrophic epithelium
Atrophic vaginal or cervical epithelium may
also cause abnormal Papancolaou smears.
Colposcopists will often prescribe estrogen for
2 to 4 weeks before a colposcopy in order to
"normalize" the epithelium before the
examination. This is generally felt to be safe
even if dysplasia or cancer is present because
the duration of therapy is short and these
lesions do not express any more estrogen
receptors than a normal cervix.
Nabothian cysts
Nabothian cysts are normal. They are
areas of mucus producing epithelium
that are "roofed over" with squamous
epitelium. They do not require any
treatment. They provide markers for
the transformation zone since they are
in squamous areas but are remnants of
columnar epithelium
UNSATISFACTORY
COLPOSCOPY
The practice of colposcopy assumes that the worst
parts of the worst lesions will be biopsied.
This requires that the borders of all lesions be
entirely seen. The entire transformation zone,
including all the squamocolumnar junction, also
must be visualized in order for a colposcopy to be
considered adequate.
Unsatisfactory colposcopy with cytologic evidence
of dysplasia or extensive canal disease frequently
requires cervical cone biopsy for work-up.
If the entire squamocolumnar junction or the limits
of all lesions cannot be completely visualized, a
diagnostic conization with a cold knife cone, laser
cone, or LEEP conization is necessary
Grading lesions
Carefully note the shape, position, and
findings of all lesions in order to draw a
picture of the lesions and biopsy sites.
Classically, the following parameters
are used to grade severity of lesions:
Less Severe > > More Severe
1. Mild acetowhite epithelium > Intensely acetowhite
2. No blood vessel pattern > Punctation > Mosaic
3. Diffuse vague borders > Sharp demarcated
borders
4. Follows normal contours of the cervix > "humped
up"
5. Normal iodine reaction (dark) > Iodine-negative
epithelium (yellow)
6. Leukoplakia - usually a very good (condylomata) or
a very bad sign (SCC)
ECC and Biopsy
.Perform cervical biopsy
Biopsy posterior areas first to avoid blood dripping over
future biopsy sites. The cervix can be manipulated with a
Q-tip or hook if necessary to provide an adequate angle
for biopsy
Align the forceps radially from the os so that the fixed
jaw of the forcep is placed on the most posterior part of
the site. The jaws should be centered over the area to be
biopsied.
Biopsies should be approximately 3 mm deep and should
include all areas with vessel atypism. It is not necessary
to include normal margins with biopsy samples.
If bleeding is profuse from a particular site and more
biopsies are needed, apply a Q-tip to the area and
proceed with the next biopsy.
.Perform cervical biopsy
Biopsy posterior areas first to avoid blood dripping over
future biopsy sites. The cervix can be manipulated with a
Q-tip or hook if necessary to provide an adequate angle
for biopsy
Align the forceps radially from the os so that the fixed
jaw of the forcep is placed on the most posterior part of
the site. The jaws should be centered over the area to be
biopsied.
Biopsies should be approximately 3 mm deep and should
include all areas with vessel atypism. It is not necessary
to include normal margins with biopsy samples.
If bleeding is profuse from a particular site and more
biopsies are needed, apply a Q-tip to the area and
proceed with the next biopsy.
Follow-up
Follow-up is usually in 2 to 3 weeks to discuss
pathology results and plan treatment if
necessary.
With the high regression rate of CIN 1, patients
can be followed with serial colposcopy and Pap
smears if adequate follow-up can be assured.
CIN 2 and 3 are usually treated. Be concerned if
a significant discrepancy is found between the
colposcopic impression, Pap cytology, and
biopsy histology.
Be especially concerned if the biopsy reports
are significantly less than Pap cytology.
Follow-up
For instance, a Pap smear indicating HSIL and
normal biopsies could signify that the worst
area was not biopsied.
In general, a difference of one grade (i.e., Pap
= LSIL and biopsy = CIN 3) is common and
acceptable.
Do not freeze any cervix until you have
adequately and sufficiently explained any
discrepancy between histology and cytology.
If the discrepancy cannot be explained,
conization is indicated.
Repeating colposcopy is forgivable, even in
the hands of the best. Freezing invasive
cancer is not.
Follow-up
Cone biopsy (cold cone, laser, or LEEP
cone) is indicated if the endocervical
curettage sample reveals dysplasia.
It is a sin to freeze the cervix with
disease in the canal. "Positive" ECC's
are sometimes a result of contamination
with dysplastic lesions at the verge of
the os.
Nonetheless, do not assume this
TREATMENT
Candidates for outpatient cervical cryotherapy are patients with
smaller lesions that do not enter the cervical os.
Large lesions (over 1" in diameter, more than 1/2" from the os, or
involving more than two cervical quadrants), even if they are only
mild dysplasia, may be more appropriate loop or laser therapy
candidates than a small focal severe dysplasia that may respond
to ambulatory cryotherapy very well.
Large lesions, lesions that enter the cervical os, or CIN 3 / CIS
lesions are most appropiately treated with LEEP or laser therapy.
Follow-up after treatment is in 4- to 6-month intervals for 2 years,
with colposcopy or colposcopy intersperced with Pap smears.
Recurrence is most common in the first 2 years after therapy.
Recurrences are most common in the os and on the outside
margins. A positive margin on a LEEP specimen requires
colposcopic follow-up
THANK YOU
