Definition used in the consensus guidelines ASCCP +24 organizations 2013 Colposcopy Colposcopy is the examination of the cervix , vagina and, in some instances the vulva, with the colposcope after the application of a 3--5% acetic solution coupled with obtaining colposcopically – directed biopsies of all lesions suspected of representing neoplasia

1. Colposcopy Training
…Caring Heart, Healing Hands
DR. SHARDA JAIN
Dr. Jyoti Agarwal / Dr. Jyoti Bhasker

2. Definition used in the consensus
guidelines ASCCP +24
organizations 2013

3. Colposcopy
Colposcopy is the examination of the
cervix , vagina and, in some instances
the vulva, with the colposcope after the
application of a 3--5% acetic solution
coupled with obtaining colposcopically
– directed biopsies of all lesions
suspected of representing neoplasia .

4. Endocervical Sampling
Includes obtaining a specimen
for either histopathological
evaluation using an
endocervical curette or a
cytobrush or for cytological
evaluation using a cytobrush

5. Endocervical assessment
Is the process of evaluating the
endocervical canal for the
presence of neoplasia using
either a colposcope or
endocervical sampling

6. Diagnostic excisional procedure
Is the process of obtaining a speciman
from the transformation zone and
endocervical canal for
histopathological evaluation and
includes laser conization, cold – knife
conization, loop electrosurgical
excision procedure (leep), and loop
electrosurgical conization

7. Adequate colposcopy
Indicates that the entire
squamocolumner junction and
the margin of any visible lesion
can be visualized with the
colposcope .

8. Endometrial sampling
Include obtaining a specimen
for histopathological evaluation
using an endometrial aspiration
or biopsy device a “dilatation
and curettage oh hysteroscopy

9. Every HPV + Case does not become cancer

10. Disease Progression

11. Natural History of CIN lesions
Ostor 93
Regression % Persistence
%
Progression
to CIS %
Progression
to invasion
%
CIN 1 60 30 11 1
CIN 2 40 30 22 5
CIN 3 30 <60 - Over 12

12. Pap Smear Abnormalities
• SQUAMOUSE CELL
- Atypical squamouse cells (ASC)
of unknown Significance (ASC – US)
Cannot exclude HSIL (ASC- H)
- Low – grade squamouse intraepithelial lesion (LSIL)
- High – grade squamouse intraepithelial lesion (HSIL)
• GLANDULAR CELL
Atypical glandular cells (AGC)
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma
Solomon , 2002

14. FIGO Recommendation for management
of abnormal smear

15. Indications for COLPOSCOPY….
• Abnormal PAP Smear
• Persistent vaginal discharge
• Long standing foul smelling vaginal
discharge
• Unhealthy Cervix
• Bleeding- post coital/ Postmenopausal
• HPV positive / external vulval warts
• Post treatment follow up

16. 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)

17. Colposcopy - Objectives
Determines the presence of invasive cancer
Localizes the squamocolumnar junction
Identifies the most severe disease for biopsy
Evaluates the extent of disease

18. Accesibility of CERVIX……..
• seen instantly after putting speculum inside the vagina
and becomes apparent.
• The success of colposcopy lies in visualising the
cervical epithelia in the region of transformation zone
in its entirely.

19. Benefits of Colposcopy…….
• Non invasive, no anaethesia for pain
• Helps in precise examination of cervix and
TZ
• Guide to locate the biopsy, improve accuracy
of early diagnosis
• Reduce over-treatment
• Easy for follow up
• This is an outpatient procedure
• It takes only a few minutes

21. • A/W LESION
• IODINE NEGATIVE EPITHELIUM
• PUNCTATION
• MOSAIC
• ATYPICAL VESSELS
• LEUCOPLAKIA
Abnormal Colposcopic Findings

22. Hammond
graph
B
C
A A

23. ODELLS DIAGRAM

24. TZ lies between the original squamo-columner junction
and the new (or the present ) squamo-columner junction.
This is a highly active zone of metaplastic tissues in
which the single layered columnar epithelium is transformed
by metaplastic cellular divisions into multilayered squamous
epithelium.

25. Understanding of “Transformation Zone”
squamous epitheliumsquamous epithelium
ectocervixectocervix endocervixendocervix
SCJSCJ

26. Columnar EPI
IMMATURE SQUAM EPI
MATURE METAPLASIA DISPLASTIC EPI
HPV

27. Transform Zone
Mature Metaplasia External os New SCJ

28. GLAND OPENINGS

29. NYBOTHIAN
FOLLICLE

30. COLPOSCOPY
PROCEDURE

31. PATIENT POSITION
Lithotomy
Position
Consent
Time

32. Instrumentation Procedure
Colposcope
Vaginal speculum
Endocervical speculum
Large & small swabs
Endocervical curette
Cervical biopsy forceps
Solutions:
 Normal saline
 Acetic Acid
 Monsel’s

34. STEPS FOR PERFORMING VIDEO
COLPOSCOPY….
• Normal Inspection after cleaning with
normal saline
• Inspection through Green filter
• Inspection after application of acetic acid
• Inspection after application of lugols Iodine
• Examination of Vagina
• Directed Biopsy.

35. NORMAL INSPECTION AFTER CLEANING
WITH NORMAL SALINE….
• To make the tissues and vascular details
more clear.

36. VIEW WITH GREEN FILTER
• For vascular pattern of cervix.
• This absorbs the red color and makes the
appearance of blood vessels black
• Black blood vessels can be viewed clearly.

38. ACETIC ACID TEST
• Coagulation of cell protein seen an interval of 1 mint.
• If white layer is very thick (opaque) that area becomes
area of concern.
• The impact of acetic acid fades away normally in 1-3 mints,
So repeated application is recommended for proper
visualization of pathological lesions.

39. Aceto white lesion
• Intensity
• Duration of stay
• speed of Appearance
• speed of disappearance
• margins Relation to SCJ
Inside TZ/ outside TZ

40. Grading of Colposcopy Findings….
• Grade I: Flat acetowhite epithelium, snow white,
regular pattern of fine calibre vessels . CIN I , HPV
• Grade II: Flat but whiter acetowhite epithelium, gray
white, irregular blood vessel often coarse. CIN I to
carcinoma-in-situ.
• Grade-III dull oyster white, gray acetowhite
epithelium with irregular surface contour and
irregular coarse and coiled blood vessel. Carcinoma-
in-situ early invasive carcinoma.

41. NO AW
LESION

42. Before AA Snow White After AA
GRADE 1 AW

43. AW Grade-II

44. GRADE 2 AW EFFECT
Gray White

45. HPV / CIN-III

46. GRADE 3
AW
Dull Oyster White, Grey

47. LUGOL’S
IODINE TEST
• Rich glycogen area appears dark brown
• Areas which do not stain are considered iodine negative
and needs attention.
• Iodine doesn’t stain columnar, immature matalplastic,
regenerating squamous epithelium after surgical trauma,
intra epithelial neoplasia and invasive carcinoma.
• Staining is superficial and fades off in 8-10 mints.

48. NORMAL

49. 27
IODINE
PARTIAL
POSITIVITY

51. 28
I
IODINE
NEGATIVITY
MAJOR CHANGES

53. Mustard yellow

54. Mustard yellow

57. Type 2 TZ
• Eversion of
columnar epi
• Fine
punctations
within
columnar epi

58. Type – 3 TZ

59. SQUAMOUS
METAPLASIA
&
GLAND OPENING

60. IMMATURE METAPLASIA
Step I = Loss of tranlucency,
Grape like configuration +
Step II = Loss of grape like
configuration
Step III = villus pattern is lossed

61. METAPLASIA /GLAND OPENINGS

62. METAPLASIA

63. CUFFED
GLAND
OPENING
NORMAL TZ
IODINE
NEGATIVE

64. ARROWHEAD
IMMATURE
ARROW
MATURE
24

65. IMMATURE
METAPLASIA
(BIG ARROW)
MATURE
METAPLASIA
(SMALL ARROW)
25

66. Fine
keratosis

67. COARSE
KERATOSIS
CANCER

68. KERATOSIS
CANCER

69. EXAMINATION OF VAGINA
& BIOPSY
• The vault of vagina should be carefully
examined for evidence of vaginitis,
leucoplakia and any growth while
withdrawing the speculum
• Colposcopy directed biopsy should be
taken whenever necessary

70. COLPOSCOPY DIRECTED
• Biopsy forceps: Punch biopsy forcep is preferred
• Tissue specimen is sent to Lab for testing further.

72. UNSATISFACTORY
COLPOSCOPY
• Squamocolumnar junction not
visible
• Severe inflammation or severe
atrophy
• Cervix not visible

73. UNSATISFACTORY
COLPOCSOPY

75. UNSATIFECTORY
COLPOSCOPY

76. MILD INFL
GRADE 2
AW
Unsatisfactory
Colposcopy

77. MISCELLANEOUS
CATEGORY

78. POLYP

79. ADENOMATOUS
Polyps

80. Inflamed cervix
Chronic Cervicitis

81. Nabothean CYST

82. NYBOTHIAN
FOLLICLE

83. Condyloma
• Lesions may be located within or
outside TZ
• Surface hyperkeratotic
• Multiple (Satellite) lesions
• Types
– Flat
– Papillary
– Spiked

84. White Punctation SPI

85. HPV
MICROPAPILLARY

86. HPV EXOPHYTIC CANDYLOMA

87. Condyloma
Beforeacid applied After acid applied
After iodine liquor applied
Mustard Yellow

88. Cervical Exophytic CondylomaCervical Exophytic Condyloma

89. Postmenopausel
women showing
pale
atrophic
squamouse
epithelium

90. ATROPHIC
CERVICITID
PROMINENT
STROMAL BV
RESEMBLING
COARSE
PUNCTATIONS

91. ECTROPIAN

92. TV infection

93. A Typical Infectious CERVIX….

94. TUBERCULOSIS
ATYPICAL BV

95. HERPETIC VESICLES

96. ANY QUESTION ?

97. THANKS !