4. Cervical intraepithelial neoplasia (CIN):
It includes Dysplasia & CIS
CIN 1 =Mild D.
CIN 2=moderate D.
CIN 3=Severe D or CIS.
Low grade CIN=CIN 1 or HPV.
High grade CIN=CIN 2 or 3
Aboubakr Elnashar
10. Historic events related to colposcopy
1925: Invention of colposcope (Hinselman)
1928: Schiller test
1938: Acetic acid test (Hinselman)
1939: Green filter (Kratz)
1940: Pap test
1942: First photographs of cervix (Treite)
1960: Cryosurgery
1980: Laser surgery
1988: Computer-aided colposcope
1989: LLETZ (Prendiville & Cullimore)
1991: Pap Net
2000: Telecolposcopy (Harper et al)Aboubakr Elnashar
11. Instrument
low power stereoscopic microscope.
Its fundamental parts are 3:
1. An optical system that offers magnification
between 6 & 40.
The focal length is between 20 & 30 cm.
2. An axial illumination system (tungsten or
halogen lamp)
3. A mounting device that permits easy
movements of the apparatus.
Aboubakr Elnashar
12. It is fitted with 3:
1.Green filter for easier observation of the vessels
2.Camera for photography
3.Monocular teaching arm.
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16. Equipments needed
1.Examination table.
2.Instruments:
a.Self-retaining vaginal speculum
b. Endocervical speculum
c. Dressing forceps
d. Equipments for biopsy:
punch biopsy forceps,
endocervical curette,
Iris hooks,
single toothed tenaculum,
solutions to stop the bleeding,
formalin
e. Equipments for cytology:
spatula,
fixatives Aboubakr Elnashar
18. 3. Solutions:
a. Saline
b. Acetic acid (3-5%)
c. Lugol, s iodine solution
4. Cotton swabs or dry gauze.
5.Documentation facilities:
special form
cervicogram
Aboubakr Elnashar
20. Modern colposcopes
New optical lenses,
fiberoptic light sources &
Videocameras, digital
computer
Enhancement
Manipulation according to physician,s preference.
Telecolposcopy (Harper et al,2000)
Aboubakr Elnashar
22. Indications of colposcopy
1. Part of any gynecologic examination
2. Primary screening for cervical cancer.
3. Clinically suspicious cervix.
4. Abnormal Pap smear.
5. Evaluation & treatment of CIN.
6. Follow up after conservative therapy of CIN.
7. Postcoital bleeding.
8. Patients with external vulval warts
9. Evaluation of sexual assault victims.
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23. •Screening colposcopy
More sensitive & more cost effective than
cytological screening.
When access to cytopathology is difficult
(Cecchini et al,1997).
•Portable colposcopy in rural areas is cost
effective & highly acceptable (Martin et al,1998).
Aboubakr Elnashar
24. Recent recommendations of FIGO for management of abnormal
smear (Benedet,2000)
Persistent inflam., persistent ASCUS, LSIL, HSIL, AGCUS,Invasive
Colposcopy±biopsy
Normal or LSIL HGSIL Invasive
6 mo smear x 2 LEEP Appropriate TT
Normal Persistent
Annual screening
Aboubakr Elnashar
25. Steps
1.Inspection of unprepared cervix
2.Inspection of the cervix after application of
saline
3.Inspection with green filter
4.Inspection after application of acetic acid
5.Inspection after application of Lugol s
iodine
Aboubakr Elnashar
26. .± Exposure of the lower cervical canal (endocervical
speculum)
.± Biopsy: from that part with greatest degree of
abnormality
1. Punch. False negative rate up to 54% (Buxton et
al,1991) Multiple biopsies
Excisional techniques are superior to destructive
techniques
2. Loop excision
3.Endocervical curette: ECB has replaced ECC
4. Cone.
Aboubakr Elnashar
30. Colposcopy evaluates changes in the: terminal
vascular network
surface epithelium after application of acetic acid.
Colposcopy is based on evaluation of the
transformation zone (T.Z).
Colposcopy:
Cervix
Vulva
Vagina.
Aboubakr Elnashar
31. Diagnostic criteria
.Vascular pattern:
1.Normal & benign: branched, hairpin &
network. It is tree like branching
2.Preinvasive & invasive: Mosaic, punctation &
atypical vessels
Matue-Aragones classification:
I.Normal fine capillary network
II.Increased as in vaginitis
III. Dilated as in ATZ G1
IV. Irregular as in ATZ G2 &3
V. Atypical as in invasive cancer.
Aboubakr Elnashar
32. .Inter-capillary distance (ICD):
Increased in preinvasive & invasive lesions.
Decreased in inflammatory lesions
Measured by comparing with that of adjacent
normal epithelium or colpophtograph.
Aboubakr Elnashar
34. .Color:
Contrast is more important.
CIS is darker than dysplasia & much darker than
normal epi.
Invasive cancer is whitish with glazed gelatinous
appearance.
Aboubakr Elnashar
36. .Whiteness after acetic acid:
.Density of whiteness
.Time needed for whiteness to appear &
disappear
.Sharpness of demarcation
.Presence of punctation or mosaic
Aboubakr Elnashar
37. .Negativity of Iodine test: beneficial test.
.Appearance of gland opening.
.Surface extent of the lesion:
The larger the colposcopic lesion, the more likely
it is to be high grade
large CIN 3 lesions are more likely to have areas
of micro-invasion than small lesions.
The size of the lesion being considered to be a
more important prognostic indicator for invasion
than histological grading
Aboubakr Elnashar
38. Advantages
1.Can be applied at each gynecologic
examination
2.Immediate & exact diagnosis
3.Determine the site & the extent of the lesion
4.The method is not very expensive.
5.The method can be learned by every physician
through self-study or continuing education.
Aboubakr Elnashar
39. 6.Differentiate between inflammatory atypia &
neoplasia, between invasive & non-invasive
lesions.
7.HPV are best detected by colposcopy.
8.Helps to avoid unnecessary smear, biopsy,
conization, hystrectomy
9.Cytologic smears may be obtained under
colposcopic direction
10.Good for follow-up.
Aboubakr Elnashar
67. Colposcopy of the vulva
*Steps:
1.Examination after smearing with a water soluble
lubricant.
2. Prolonged acetic acid test
3.Toludine blue test: little clinical value.
* The junction between the glycogen bearing
vaginal epithelium & keratin producing vulval
epithelium: high risk for intraepithelial neoplasia.
*Abnormalities: diffuse acetowhite, localized
acetowhite,leukoplakia,micropapillae, papules.
Aboubakr Elnashar
