Transcript What is Colposcopy - BiomedicalProjects.com: Biomedical

What is Colposcopy ?
Colposcopy is a medical diagnostic procedure to examine an illuminated,
magnified view of the cervix and the tissues of the vagina and vulva.
The procedure was developed in 1925 by the German physician Hans
Hinselmann.
During the colposcopy, the gynecologist focuses on the areas of the cervix
where light does not pass through.
Abnormal cervical changes are seen as white areas -- the whiter the area,
the worse the cervical dysplasia.
Abnormal vascular (blood vessel) changes are also apparent through the
colposcope. Typically, the worse that the vascular changes are, the worse the
dysplasia.
Colposcope Technique
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Goals of Colposcopy
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The main goal of colposcopy is to prevent cervical
cancer by detecting precancerous lesions early and
treating them Colpocsope consists of a steroscopic
binocular microscopic equipped with a centre illuminating
device of high intensity.
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Many premalignant lesions and malignant lesions in
these areas have discernible characteristics which can
be detected through the examination,which provides an
enlarged view of the areas, allowing the colposcopist to
visually distinguish normal from abnormal appearing
tissue and take directed biopsies for further pathological
examination.
Colposcope Technique
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IFCPC Colposcopic Classification
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Normal Colposcopic findings
Abnormal Colposcopic findings
Colposcopic findings suggestive of invasive
cancer
Unsatisfactory Colposcopy
Miscellaneous findings
Colposcope Technique
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Instrumentation
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Manipulation, magnification, light intensity and
the type of green filter/red filter vary slightly
from one instrument to another.
Most of the colposcope have the microscope
on a movable floor stand to enable easy
transportation.
Also there are light source does not generate
heat, hence convenient to both patient and
examiner.
The main parts are binocular tube,
magnification changer(or stepper) with
5x10x20xmagnification,field of vision
32nm.angle leveller- tilting 30(deg) up &
downwards, objective lens-300nm,eye piece15x,source:24-250w,halogen cold light source
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Materials Required
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Sponge- holders
Sigleys forceps and self retaining endo cervical speculum
Karvokian forceps, punch biopsy forceps
Endo cervical curettes of different size
Cotton tipped swabs, gloves,finger stalks,glass slides,
diamond marking pencil, slide fixatives, spatulas(ayres),
bottles containing 10% formalin for biopsy materials.
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Materials Required
SOLUTION:
 Normal saline, 3% of acetic acid, lugols iodine, meta cresol sulphonic acid 5 grams of
salicylic acid in 100 ml of 70% alcohol is available.
 Different size of the speculum with blade curvature varying must be available to suit the
individual needs very high speculum cause discomfort to the patients and may slip off.
Length more than 10cm is hardly required. Cut the rubber glove insertion for speculum
facilitates to keep the vaginal wall apart especially in pregnant women. Sim’s speculum
is not normally used because two speculums are required and a assistant is also
necessary to hold the forceps, disposable light plastic speculum are ideal and causes
very light deiscomfort to the patient.
COLPOSCOPY TECHNIC:
 Examination of vulva and vagina must be done initially as a conventional method then
a suitable sized bivalve cusco’s speculum should be inserted gently and examined.
Intial examination of cervix should be made for type of mucous and bleeding.
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How to Prepare ?
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First - Relax, it will not be as bad as you
think it will be.
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Take 600-800 mg of Aleve or Advil one hour
before leaving for your doctor's office. If you
are allergic to ibuprofen, take two ExtraStrength Tylenol.
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Make sure you have not started nor will start
your period for about two weeks.
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Do not use anything in the vagina for 24-48
hours before the procedure. This includes
spermicides, vaginal medications, douching
products or tampons. These all interfere with
the accuracy of the test.
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Do not have vaginal sex 24 - 48 hours before
the procedure because this can also interfere
with the test's accuracy.
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How to Perform Colposcopy
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It is performed by woman lying on her back, legs placed on stirrups
and buttocks at the lower edge of the table.
The height of table should be comfortable for both patient and the
doctor.
The colposcope when postioned to 6-7cm for the introitus,portio
vaginalis of cervix, and the outer third of endocervical canal can be
seen and examined at a magnification of 5x10x20x in stepped
manner.
Working distance between the microscope objective and the patient
should be minimum 300mm(1 foot) 400mm working distance
objective may be required as per the examiner choice
A speculum is placed in vagina after the vulva is examined by any
suspicious lesion.
Colposcope Technique
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Indications For Colposcopy
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Most women undergo a colposcopic examination to further
investigate a cytological abnormality on their pap smears. Other
indications for a woman to have a colposcopy include:
The Papanicolaou test (also called Pap smear, Pap test, cervical
smear, or smear test) is a screening test used in gynecology to
detect premalignant and malignant (cancerous) processes in the
ectocervix. Significant changes can be treated, thus preventing
cervical cancer. The test was invented by and named after the
prominent Greek doctor Georgios Papanikolaou. An anal Pap smear
is an adaptation of the procedure to screen and detect anal cancers.
assessment of diethylstilbestrol (DES) exposure in utero
Diethylstilbestrol (DES) is a drug, an orally active synthetic
nonsteroidal estrogen that was first synthesized in 1938. In 1971 it
was found to be a teratogen when given to pregnant women.
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Indications and Uses
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Colposcopic examination with biopsy is indicated for the following
reasons:
Persistent minimal abnormality on Pap smear
Major abnormality on Pap smear
Lesion noted on routine gynaecologic examination
In utero exposure to diethylstilbestrol(DES) or drugs.
Criteria for colposcopic examination in a woman with abnormal
papsmear followed by the hospital of the university of Pennsylvania
If the mild dysplasia (CIN I ) persist on 2-3 or more pap smears over a
6-12 month period, the patient should undergo colposcopic evaluation
If hyperkeratosis or parakeratosis persist for more than one year
colposcopic examination is valuable to rule out a potentially serious
lesions.
Colposcope Technique
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Procedure
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During the initial evaluation, a medical history is obtained, including
gravidity (number of prior pregnancies), parity (number of prior
deliveries), last menstrual period, contraception use, prior abnormal pap
smear results, allergies, significant past medical history, other
medications, prior cervical procedures, and smoking history. In some
cases, a pregnancy test may be performed before the procedure. The
procedure is fully described to the patient, questions are asked and
answered, and she then signs a consent form.
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A colposcope is used to identify visible clues suggestive of abnormal
tissue. It functions as a lighted binocular microscope to magnify the
view of the cervix, vagina, and vulvar surface. Low power (2× to 6×)
may be used to obtain a general impression of the surface architecture.
Medium (8× to 15×) and high (15× to 25×) powers are utilized to
evaluate the vagina and cervix. The higher powers are often necessary
to identify certain vascular patterns that may indicate the presence of
more advanced precancerous or cancerous lesions. Various light filters
are available to highlight different aspects of the surface of the cervix.
Acetic acid solution and iodine solution (Lugol's or Schiller's) are
applied to the surface to improve visualization of abnormal areas.
Colposcope Technique
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Procedure
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Colposcopy is performed with the woman lying on her
back, legs in stirrups, and buttocks at the lower edge
of the table (a position known as the dorsal lithotomy
position). A speculum is placed in the vagina after the
vulva is examined for any suspicious lesions.
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Three percent acetic acid is applied to the cervix
using cotton swabs. The transformation zone is a
critical area on the cervix where many precancerous
and cancerous lesions most often arise. The ability to
see the transformation zone and the entire extent of
any lesion visualized determines whether an
adequate colposcopic examination is attainable.
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Areas of the cervix which turn white after the
application of acetic acid or have an abnormal
vascular pattern are often considered for biopsy. If no
lesions are visible, an iodine solution may be applied
to the cervix to help highlight areas of abnormality
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Procedure
After a complete examination, the colposcopist determines the areas with the highest degree
of visible abnormality and may obtain biopsies from these areas using a long biopsy
instrument. Some doctors consider anesthesia unnecessary, however, many colposcopists
now recommend and use a topical anesthetic such as lidocaine or a cervical block to diminish
patient discomfort, particularly if many biopsy samples are taken.
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Following any biopsies, an endocervical curettage (ECC)
is often done. The ECC utilizes a long straight curette to
scrape the inside of the cervical canal. The ECC should
never be done on a pregnant woman. Monsel's solution
is applied with large cotton swabs to the surface of the
cervix to control bleeding. This solution looks like
mustard and becomes black in color when exposed to
blood. After the procedure this material will be expelled
naturally: women can expect to have a thin coffeeground like discharge for up to several days after the
procedure.
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Experience some degree of pain during the curettage,
and almost all experience pain during the biopsy.
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Significance of Colposcopy finding in Non NeoPlastic Lesions
Some colposcopic findings that often the signal a neoplastic change may occur in non-neoplastic condition such
as
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Normal metaplasia
Infection
Infiammation
Regeneration and repair following trauma
Cautery and Cryo Surgery
The presence of an a typical TZ though highly suggestive does not
prove that neoplasia exists there are three grades
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Significance of Colposcopy finding in Non NeoPlastic Lesions
GRADING
COLPOSCOPIC FINDINGS
Grade I
Flat, white epithelium with or without a regular pattern of fine
calibre vessels fine caliber vessels
Grade II
Flat, white epithelium with or without a irregular pattern of
coarse caliber vessels
Grade III
Very white epithelium with or without a irregular pattern of
Coarse caliber coiled or bizarre branching BVS usuall Wide
intercapillary distance an a irregular surface contour.
Histological Correlation
Grade I
Normal to CIN-I
Grade II
CIN-II
Grade III
CIN-III – early invasion to Frank Carcinoma
Colposcope Technique
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Unsatisfactory Colposcopy
There are certain situations where Colposcopic examinations remains unsatisfactory.
They are
 Atrophy (postmenopausal)
 Following conization or Hysterectomy.
 Following Cryotherapy.
 Following laser therapy.
– ATROPHY: In post menopausal woman the squamo-columnar junction is not seen on
Colposcopy while mucosa is found to be thin with fine branching blood vessels.
Pretreatment with estrogen may help. An endocervical curettage is mandatory.
– CONIZATION: Squamo-columnar junction is not seen adequately; rather it is
distosted due to scarring .Endocervical curettage is important. Diagram of intial lesion
is useful for localization of likely source of reccurrence.
– HYTERECTOMY: Aceto-white epithelium in vagina ,vascular appearance of
puncatations , schiller’s testing may be helpful
– CRYO – THERAPY :Following this squamo-columnar junction is not seen in 15-20%
cases. Further treatment depends on cytology. If normal no problem.
– LASER THERAPY :Squamu-columnar junction is easily visible – with large areas of
acetowhite epithelium. It is narmal. It sheds immature cells.
 Following local therapy cytology remains abnormal for atleast 3-4 months. Cells shed from
original lesions or reparative cells. So initial correct diagnosis isrequired. Other situations
when Colposcopy is unsatisfactory is when lesion extent into the endocervical
canal.Husbond and wife both must be investigated for papillomatous lesion .Real solution
is long term follow-up.
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Points to Remember
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Before starting Colposcopy one should have in hand detailed history examination and
cervical smear report. If smear report is abnormal one should thoroughly search the
ectocervix, endocervix and vagina.
To perform a Colposcopy , it is essential to
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Devote time for careful and methodical examinations .rapid Colposcopy is
useless. Largest
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size cusco’s speculum should be used.
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Diagrammatic documentation should be precise and accurate, even if
Colpophotographs are
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taken.
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To take biopsy whenever any unexpected lesion is found and its appearance
cannot be
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explained.
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Beginner should take many more biopsies.
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A through knowledge of Colposcopy and histopathological findings.
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Endocervical curettage should be done, when Colposcopy is unsatisfactory.
Person should be properly and adequately trained before he starts interpreting the
Colposcopic findings. Doctors has attempted to classify the three levels of expertise.
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Ability to recognize the lesion , which in his opinion 3-4 months of staining .
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The ability to sample by directly biopsy of most advanced area of the lesion
which requires a year of training.
The ability to predict histopathology from colposcopic Pattern a skill which may take
several years respective of time taken, the requirement for adequate training cannot
be over emphasized to forestall the un fortunate consequences.
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Conclusion
Colposcopy is regarded as "gold standard" tool for diagnosing cervical
abnormalities after an abnormal pap smear. Colposcopy is used to evaluate
women with genital tract abnormalities and abnormal cervical cytology. It is an
office-based procedure during which the cervix is examined under illumination
and magnification before and after application of dilute acetic acid. This paper has
discussed in detail the Colposcope instrument, its technical features, accessories,
and various applications where it can be effectively used. The paper also
discussed newer visualization techniques like direct visualization, speculoscopy,
cervicography, and colposcopy and electronic detection methods , which are less
expensive and can be performed with significantly less training.
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Acknowledgements
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The authors wish to thank the Chairperson and Principal, for all
the facilities provided and all the staff members of the department
of Biomedical Engineering who have rendered their support,
guidance and encouragement to us in the making of this paper.
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References
Dr. Lakshmi Dhandapandian (gynaecologist)
Sundaram Medical Foundation
Chennai
Mr.Subash (Biomedical engineer)
Sundaram Medical Foundation
Chennai
Dr.Revathi Ananth BASCO
Chennai.
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