Colposcopy

What is SCJ? Factors influence the position

What is squamous metaplasia?

When exposed vaginal PH, columnar epithelium of endocervix converts to squamomus epithelium as an physiological adaptation to withstand the acidity.

What is TZ

Types of TZ

Colposcopy procedure

What is the principle of Colposcopy?

Colposcopic examination involves magnified stereoscopic visualization of the cervix.

What is the basis behind aceto-whitening?

5%acetic acid is usually applied with cotton balls held by sponge forceps.

Acetic acid is thought to cause swelling of the epithelial tissue, columnar and any abnormal squamous epithelial areas in particular

It causes a reversible coagulation or precipitation, dehydration of the nuclear proteins and cytokeratins

When acetic acid is applied to normal squamous epithelium, little coagulation occurs in the superficial cell layer, as this is less nucleated. So light can go through.

Areas of CIN undergo maximal coagulation due to their higher content of nuclear protein and prevent light from passing through the epithelium.

As a result, the sub-epithelial vessel pattern is obliterated and less easy to see and the epithelium appears white.

This reaction is termed aceto-whitening.

What is the basis behind Lugos iodine application?

Original and mature squamous metaplastic epithelium is glycogenated.

Iodine is glycophilic and glycogen-containing squamous pithelium stains mahogany brown or black.

Columnar epithelium does not contain glycogen and does not take up iodine and remains unstained.

Areas of CIN and invasive cancer do not take up iodine (as they lack glycogen) and appear as thick mustard yellow or saffron-colored areas.

What are the normal vessel pattern?

The examination of the blood vessels is facilitated by applying normal saline on the cervix and using the green filter on the colposcope to enhance the contrast of the vessels. Use of a higher power of magnification (about 15x) is useful.

What colposcopic features would suggest CIN?

• Diagnosis of cervical neoplasia depends on the recognition of 4 main features:

Intensity (colour tone) of acetowhitening
Low-grade CIN is often seen as thin, smooth acetowhite lesions with well-demarcated

High-grade CIN are associated with thick, dense, dull, opaque or greyish-white acetowhite areas with well-demarcated, regular margins, which sometimes may be raised and rolled out

Margins and surface contour of aceto-white areas

well-demarcated, dense, opaque, acetowhite area in the transformation zone or squamocolumnar junction is the hallmark of colposcopic diagnosis of CIN

Vascular features
Punctuation and mosaics.

Fine punctuation/ mosaics- LSIL

Coarse punctuation/mosaics- HISIL

punctuation and mosaics are significant only if these are seen confined to aceto-white areas.

Colour changes after iodine application.

CIN lesions do not contain glycogen and thus do not stain with iodine and remain mustard or saffron yellow areas

What is punctataions?

Types ?

When CIN develops as a result of HPV infection and atypical metaplasia, the afferent and efferent capillary system may be trapped (incorporated) into the diseased dysplastic epithelium through several elongated stromal papillae and a thin layer of epithelium may remain on top of these vessels. This forms the basis of the punctate and mosaic blood vessel patterns. The terminating vessels in the stromal papillae underlying the thin epithelium appear as black points in a stippling pattern in an end-on view under the colposcope, making what are called punctate areas.

Who should get colposcopy done?

Any HSIL in PAP smear
Persisting LSIL in 2 consecutive PAP smears.
ASCUS high grade in PAP smear.
Persisting ASCUS low grade in 2 smears.
Macroscopically unhealthy cervix.
Detection of high risk HPV DNA in screening.

Colposcopy machine

Instruments for Colposcopy and LLETZ biopsy

Insulated speculum with suction channel

2. Sponge holder with cotton swabs

3. N.saline for cleaning

4. 2% Lignocain+ adrenalin 10cc+diluted in N.saline 10cc in 20 cc syringe

5. Epidural /spinal needle

6. 3% Acetic acid

7. Iodine solution

8. Diathermy machine

9. Loop diathermy probe –appropriate size

10. Ball diathermy

11 . Silversufurdiazine

Procedure

Speculum insertion and visualization of Cx

Focusing the Colposcopy

Clean Cx with N. Saline

Infiltrate Cx with Lidnocain+adrenaline at 12,3,6,9 ‘o’clock positions, 5ml to each

Acetic acid application

Iodine solution application

Look for the transformation zone.

If all the margins of suspicious areas are visible within the ectocervix go ahead with LLETZ

Cut with fulgration

pack

Diathermize with ball diathermy

Apply SSD

Vaginal

If it is extending in to the endo cerviclal canal consider cone biopsy. If margins are free of pathology repeat PAP in 6 months/HR-HPV DNA in 6 months.

If not repeat procedure/ discuss TAH.

If CIN 3 in histology –margins free-

Dummy run of loop from bottom to top of the Cx

What are the indications for cone biopsy?

The lesion extends into the endocervical canal and it is not possible to confirm the exact extent.

• The lesion extends into the canal and the farthest extent exceeds the excisional capability of the LEEP .cone technique (maximum excisional depth of 1.5 cm).

• The lesion extends into the canal and the farthest extent exceeds the excisional capability of the colposcopist.

• The cytology is repeatedly abnormal, suggesting neoplasia, but there is no corresponding colposcopic abnormality of the cervix or vagina on which to perform biopsy.

• Cytology shows atypical glandular cells that suggest the possibility of glandular dysplasia or adenocarcinoma.

• Endocervical curettage reveals abnormal histology

What advice you would give on discharge?

Be observant on PV bleeding on 1^st day (1ry bleeding) or 4-5^th day. (2ry bleeding) If fresh PV bleeding noticed admit.
Can have blood stained discharge up to 1-2 weeks days –It’s normal.
Can have a cramping pain- PCM.
Avoid sexual intercourse for 4 weeks.
R/V with histology

Why we should not do hysterectomies for LSIL/HSIL skipping Colposcopy?

LSIL/HSIL are screening tests only.

Need proper tissue diagnosis prior to surgical interventions.

Always colposcopy should be done. Acetowhite areas should be assessed and LLETZ should be done if not extending to canal.

If not in case diagnosis is upgraded following a routine hysterectomy we may have to reconsider pelvic node dissection/ colpotomy/ in a second surgery.

Or else un-necessary RT is given for nodes and to vault due to sub-optimal surgery.

Why a colposcopy is needed for an unhealthy cervix irrespective of a normal cytology smear?

Necrotic tumour may not exfoliate malignant cells in smear testing.