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Colposcopy Training
…Caring Heart, Healing Hands
DR. SHARDA JAIN
Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
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 afte...
Endocervical Sampling
Includes obtaining a specimen
for either histopathological
evaluation using an
endocervical curette ...
Endocervical assessment
Is the process of evaluating the
endocervical canal for the
presence of neoplasia using
either a c...
Diagnostic excisional procedure
Is the process of obtaining a speciman
from the transformation zone and
endocervical canal...
Adequate colposcopy
Indicates that the entire
squamocolumner junction and
the margin of any visible lesion
can be visualiz...
Endometrial sampling
Include obtaining a specimen
for histopathological evaluation
using an endometrial aspiration
or biop...
Every HPV + Case does not become cancer
Disease Progression
Natural History of CIN lesions
Ostor 93
Regression % Persistence
%
Progression
to CIS %
Progression
to invasion
%
CIN 1 60...
Pap Smear Abnormalities
• SQUAMOUSE CELL
- Atypical squamouse cells (ASC)
of unknown Significance (ASC – US)
Cannot exclud...
FIGO Recommendation for management
of abnormal smear
Indications for COLPOSCOPY….
• Abnormal PAP Smear
• Persistent vaginal discharge
• Long standing foul smelling vaginal
dis...
Basic Satisfactory Requirements of
Colposcopic Exam
 Adequate Visualization
 Entire TZ Zone seen
 Abnormal areas seen i...
Colposcopy - Objectives
Determines the presence of invasive cancer
Localizes the squamocolumnar junction
Identifies the...
Accesibility of CERVIX……..
• seen instantly after putting speculum inside the vagina
and becomes apparent.
• The success o...
Benefits of Colposcopy…….
• Non invasive, no anaethesia for pain
• Helps in precise examination of cervix and
TZ
• Guide t...
• A/W LESION
• IODINE NEGATIVE EPITHELIUM
• PUNCTATION
• MOSAIC
• ATYPICAL VESSELS
• LEUCOPLAKIA
Abnormal Colposcopic Find...
Hammond
graph
B
C
A A
ODELLS DIAGRAM
TZ lies between the original squamo-columner junction
and the new (or the present ) squamo-columner junction.
This is a hi...
Understanding of “Transformation Zone”
squamous epitheliumsquamous epithelium
ectocervixectocervix endocervixendocervix
SC...
Columnar EPI
IMMATURE SQUAM EPI
MATURE METAPLASIA DISPLASTIC EPI
HPV
Transform Zone
Mature Metaplasia External os New SCJ
GLAND OPENINGS
NYBOTHIAN
FOLLICLE
COLPOSCOPY
PROCEDURE
PATIENT POSITION
Lithotomy
Position
Consent
Time
Instrumentation Procedure
Colposcope
Vaginal speculum
Endocervical speculum
Large & small swabs
Endocervical curette
...
STEPS FOR PERFORMING VIDEO
COLPOSCOPY….
• Normal Inspection after cleaning with
normal saline
• Inspection through Green f...
NORMAL INSPECTION AFTER CLEANING
WITH NORMAL SALINE….
• To make the tissues and vascular details
more clear.
VIEW WITH GREEN FILTER
• For vascular pattern of cervix.
• This absorbs the red color and makes the
appearance of blood ve...
ACETIC ACID TEST
• Coagulation of cell protein seen an interval of 1 mint.
• If white layer is very thick (opaque) that ar...
Aceto white lesion
• Intensity
• Duration of stay
• speed of Appearance
• speed of disappearance
• margins Relation to SCJ...
Grading of Colposcopy Findings….
• Grade I: Flat acetowhite epithelium, snow white,
regular pattern of fine calibre vessel...
NO AW
LESION
Before AA Snow White After AA
GRADE 1 AW
AW Grade-II
GRADE 2 AW EFFECT
Gray White
HPV / CIN-III
GRADE 3
AW
Dull Oyster White, Grey
LUGOL’S
IODINE TEST
• Rich glycogen area appears dark brown
• Areas which do not stain are considered iodine negative
and ...
NORMAL
27
IODINE
PARTIAL
POSITIVITY
28
I
IODINE
NEGATIVITY
MAJOR CHANGES
Mustard yellow
Mustard yellow
Type 2 TZ
• Eversion of
columnar epi
• Fine
punctations
within
columnar epi
Type – 3 TZ
SQUAMOUS
METAPLASIA
&
GLAND OPENING
IMMATURE METAPLASIA
Step I = Loss of tranlucency,
Grape like configuration +
Step II = Loss of grape like
configuration
St...
METAPLASIA /GLAND OPENINGS
METAPLASIA
CUFFED
GLAND
OPENING
NORMAL TZ
IODINE
NEGATIVE
ARROWHEAD
IMMATURE
ARROW
MATURE
24
IMMATURE
METAPLASIA
(BIG ARROW)
MATURE
METAPLASIA
(SMALL ARROW)
25
Fine
keratosis
COARSE
KERATOSIS
CANCER
KERATOSIS
CANCER
EXAMINATION OF VAGINA
& BIOPSY
• The vault of vagina should be carefully
examined for evidence of vaginitis,
leucoplakia a...
COLPOSCOPY DIRECTED
• Biopsy forceps: Punch biopsy forcep is preferred
• Tissue specimen is sent to Lab for testing furthe...
UNSATISFACTORY
COLPOSCOPY
• Squamocolumnar junction not
visible
• Severe inflammation or severe
atrophy
• Cervix not visib...
UNSATISFACTORY
COLPOCSOPY
UNSATIFECTORY
COLPOSCOPY
MILD INFL
GRADE 2
AW
Unsatisfactory
Colposcopy
MISCELLANEOUS
CATEGORY
POLYP
ADENOMATOUS
Polyps
Inflamed cervix
Chronic Cervicitis
Nabothean CYST
NYBOTHIAN
FOLLICLE
Condyloma
• Lesions may be located within or
outside TZ
• Surface hyperkeratotic
• Multiple (Satellite) lesions
• Types
– ...
White Punctation SPI
HPV
MICROPAPILLARY
HPV EXOPHYTIC CANDYLOMA
Condyloma
Beforeacid applied After acid applied
After iodine liquor applied
Mustard Yellow
Cervical Exophytic CondylomaCervical Exophytic Condyloma
Postmenopausel
women showing
pale
atrophic
squamouse
epithelium
ATROPHIC
CERVICITID
PROMINENT
STROMAL BV
RESEMBLING
COARSE
PUNCTATIONS
ECTROPIAN
TV infection
A Typical Infectious CERVIX….
TUBERCULOSIS
ATYPICAL BV
HERPETIC VESICLES
ANY QUESTION ?
THANKS !
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
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Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker

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

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Colposcopy training part 1 ,DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker

  1. 1. Colposcopy Training …Caring Heart, Healing Hands DR. SHARDA JAIN Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
  2. 2. Definition used in the consensus guidelines ASCCP +24 organizations 2013
  3. 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. 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. 5. Endocervical assessment Is the process of evaluating the endocervical canal for the presence of neoplasia using either a colposcope or endocervical sampling
  6. 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. 7. Adequate colposcopy Indicates that the entire squamocolumner junction and the margin of any visible lesion can be visualized with the colposcope .
  8. 8. Endometrial sampling Include obtaining a specimen for histopathological evaluation using an endometrial aspiration or biopsy device a “dilatation and curettage oh hysteroscopy
  9. 9. Every HPV + Case does not become cancer
  10. 10. Disease Progression
  11. 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. 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
  13. 13. FIGO Recommendation for management of abnormal smear
  14. 14. 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
  15. 15. 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)
  16. 16. Colposcopy - Objectives Determines the presence of invasive cancer Localizes the squamocolumnar junction Identifies the most severe disease for biopsy Evaluates the extent of disease
  17. 17. 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.
  18. 18. 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
  19. 19. • A/W LESION • IODINE NEGATIVE EPITHELIUM • PUNCTATION • MOSAIC • ATYPICAL VESSELS • LEUCOPLAKIA Abnormal Colposcopic Findings
  20. 20. Hammond graph B C A A
  21. 21. ODELLS DIAGRAM
  22. 22. 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.
  23. 23. Understanding of “Transformation Zone” squamous epitheliumsquamous epithelium ectocervixectocervix endocervixendocervix SCJSCJ
  24. 24. Columnar EPI IMMATURE SQUAM EPI MATURE METAPLASIA DISPLASTIC EPI HPV
  25. 25. Transform Zone Mature Metaplasia External os New SCJ
  26. 26. GLAND OPENINGS
  27. 27. NYBOTHIAN FOLLICLE
  28. 28. COLPOSCOPY PROCEDURE
  29. 29. PATIENT POSITION Lithotomy Position Consent Time
  30. 30. Instrumentation Procedure Colposcope Vaginal speculum Endocervical speculum Large & small swabs Endocervical curette Cervical biopsy forceps Solutions:  Normal saline  Acetic Acid  Monsel’s
  31. 31. 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.
  32. 32. NORMAL INSPECTION AFTER CLEANING WITH NORMAL SALINE…. • To make the tissues and vascular details more clear.
  33. 33. 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.
  34. 34. 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.
  35. 35. Aceto white lesion • Intensity • Duration of stay • speed of Appearance • speed of disappearance • margins Relation to SCJ Inside TZ/ outside TZ
  36. 36. 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.
  37. 37. NO AW LESION
  38. 38. Before AA Snow White After AA GRADE 1 AW
  39. 39. AW Grade-II
  40. 40. GRADE 2 AW EFFECT Gray White
  41. 41. HPV / CIN-III
  42. 42. GRADE 3 AW Dull Oyster White, Grey
  43. 43. 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.
  44. 44. NORMAL
  45. 45. 27 IODINE PARTIAL POSITIVITY
  46. 46. 28 I IODINE NEGATIVITY MAJOR CHANGES
  47. 47. Mustard yellow
  48. 48. Mustard yellow
  49. 49. Type 2 TZ • Eversion of columnar epi • Fine punctations within columnar epi
  50. 50. Type – 3 TZ
  51. 51. SQUAMOUS METAPLASIA & GLAND OPENING
  52. 52. IMMATURE METAPLASIA Step I = Loss of tranlucency, Grape like configuration + Step II = Loss of grape like configuration Step III = villus pattern is lossed
  53. 53. METAPLASIA /GLAND OPENINGS
  54. 54. METAPLASIA
  55. 55. CUFFED GLAND OPENING NORMAL TZ IODINE NEGATIVE
  56. 56. ARROWHEAD IMMATURE ARROW MATURE 24
  57. 57. IMMATURE METAPLASIA (BIG ARROW) MATURE METAPLASIA (SMALL ARROW) 25
  58. 58. Fine keratosis
  59. 59. COARSE KERATOSIS CANCER
  60. 60. KERATOSIS CANCER
  61. 61. 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
  62. 62. COLPOSCOPY DIRECTED • Biopsy forceps: Punch biopsy forcep is preferred • Tissue specimen is sent to Lab for testing further.
  63. 63. UNSATISFACTORY COLPOSCOPY • Squamocolumnar junction not visible • Severe inflammation or severe atrophy • Cervix not visible
  64. 64. UNSATISFACTORY COLPOCSOPY
  65. 65. UNSATIFECTORY COLPOSCOPY
  66. 66. MILD INFL GRADE 2 AW Unsatisfactory Colposcopy
  67. 67. MISCELLANEOUS CATEGORY
  68. 68. POLYP
  69. 69. ADENOMATOUS Polyps
  70. 70. Inflamed cervix Chronic Cervicitis
  71. 71. Nabothean CYST
  72. 72. NYBOTHIAN FOLLICLE
  73. 73. Condyloma • Lesions may be located within or outside TZ • Surface hyperkeratotic • Multiple (Satellite) lesions • Types – Flat – Papillary – Spiked
  74. 74. White Punctation SPI
  75. 75. HPV MICROPAPILLARY
  76. 76. HPV EXOPHYTIC CANDYLOMA
  77. 77. Condyloma Beforeacid applied After acid applied After iodine liquor applied Mustard Yellow
  78. 78. Cervical Exophytic CondylomaCervical Exophytic Condyloma
  79. 79. Postmenopausel women showing pale atrophic squamouse epithelium
  80. 80. ATROPHIC CERVICITID PROMINENT STROMAL BV RESEMBLING COARSE PUNCTATIONS
  81. 81. ECTROPIAN
  82. 82. TV infection
  83. 83. A Typical Infectious CERVIX….
  84. 84. TUBERCULOSIS ATYPICAL BV
  85. 85. HERPETIC VESICLES
  86. 86. ANY QUESTION ?
  87. 87. THANKS !

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