CHAPTER 137 Colposcopic Examination

Colposcopy is the examination of the cervix, vagina, and genital organs with light and magnification to identify abnormal areas for biopsy, so that the patient can be triaged to appropriate care. Topical application of saline, acetic acid, and iodine solutions helps identify biopsy sites.

Addressing the widespread human papillomavirus (HPV) and genital epithelial dysplasia epidemic requires mastery of the skills to perform colposcopy, cervical biopsy, and endocervical curettage (ECC). The most frequent indications for these procedures include evaluation of an abnormal Papanicolaou (Pap) smear (see Chapter 151, Pap Smear and Related Techniques for Cervical Cancer Screening), visible cervical abnormalities, evidence of clinical HPV infection, and follow-up of prior cervical treatment. Most cases of cervical dysplasia can be managed entirely in the outpatient setting. Successful colposcopy requires strict compliance with established protocol and often the support of the pathologist, urologist, and gynecologist. Mechanisms for excellent documentation and rigorous follow-up are mandatory. Physicians who assimilate colposcopy skills into their practices will respond to a major public health problem and enhance their patients’ access to care.

The colposcope is essentially a stereoscopic, portable operating microscope (3× to 40×) with a focal distance appropriate to examine the genitalia and cervix. The colposcopic examination serves to (1) identify normal landmarks, (2) identify abnormal areas in relation to these landmarks, (3) facilitate directed biopsy of abnormal areas for histologic diagnosis, and (4) rule out invasive cancer. Based on the findings, patients are triaged for observation, for procedures (e.g., cryotherapy, loop electrosurgical excision procedure [LEEP], cervical cold conization), and for definitive staged therapy for invasive carcinoma.

Colposcopic-directed biopsy provides histologic clarification of abnormal Pap smears; this is mandatory before definitive therapy. Premalignant and malignant cervical conditions produce colposcopically identifiable epithelial changes that are often characteristic and generally occur within the transformation zone (TZ), which can be examined carefully during the colposcopic examination. Ultimately, the pathologist is the one who provides the histologic diagnoses for abnormalities identified during the colposcopic examination. Therefore, the major challenge for the colposcopist is to distinguish the normal from the abnormal and to sample the most abnormal-appearing changes for histologic confirmation. When there is any question about the colposcopic impression, biopsy should be undertaken. The ECC, or other cervical assessment methods such as endocervical brushing techniques, is performed as part of the routine colposcopic examination (contraindicated in pregnancy) to confirm the absence of occult disease in the endocervical canal. Nearly all agree that traditional ECC should be performed (1) if there is any question of invasive disease within the canal; (2) before ablative therapy such as cryotherapy or laser ablation; (3) as part of the work-up for atypical glandular cell abnormalities; (4) when either the initial or follow-up cytology indicates a high-grade squamous intraepithelial lesion and colposcopy of the cervix does not yield a clear source; and (5) when the entire TZ/squamocolumnar junction (SCJ) cannot be evaluated (known as an “unsatisfactory colposcopy”). Other common reasons for performing a traditional ECC include follow-up of the treatment of severe dysplasia, especially when a cone resection (including LEEP) was performed and histology indicates positive margins with significant dysplasia, or if the ECC immediately after a cone resection was positive.

Colposcopy itself, without the benefit of histologic confirmation, is not considered a diagnostic tool. Even though colposcopically defined visual abnormalities correlate with cervical dysplasia or frank carcinoma, the ultimate diagnosis rests on the traditional histologic interpretation of submitted samples and not with the visual pattern recognition. Accordingly, diagnostic accuracy requires that the colposcopist perform liberal biopsy of the abnormal cervix.

In the past decade, major changes in our understanding of the epidemiology and science of cervical carcinoma have yielded efforts to develop a unified terminology to be used throughout the international scientific community. The International Federation for Cervical Pathology and Colposcopy (IFCPC) approved a basic colposcopic terminology at its 7th World Congress in Rome in May 1990 and further refined the terminology at its 11th World Congress in Barcelona, June 9, 2002 (Fig. 137-1). These terms should be used to describe findings during the colposcopic examination. Those terms marked with an asterisk are correlated with a higher likelihood of the histology demonstrating more severe dysplasia or cancer.

Figure 137-1 Colposcopic terminology. *See text for definitions. ^†For the effects of acetic acid and iodine to be appreciated, the cervical and vaginal tissues must have estrogen stimulation.

(Adapted from Stafl A, Wilbanks GD: An international terminology of colposcopy: Report of the Nomenclature Committee of the International Federation of Cervical Pathology and Colposcopy. Obstet Gynecol 77:313–314, 1991.)

Colposcopic Anatomy and Findings

The prudent colposcopist must be completely familiar with the normal findings and the visual abnormalities that correlate with dysplasia and malignancy on the cervix. Basic Pap smear terminology and cervical anatomy are reviewed in Chapter 151, Pap Smear and Related Techniques for Cervical Cancer Screening. Colposcopy terminology is summarized in Figure 137-1. It is also important to consider the appearance of the cervix in different age groups because the anatomy varies developmentally in response to hormonal stimulation (Figs. 137-2 to 137-4).

Figure 137-2 Normal colposcopic findings. A, Normal cervix showing squamous epithelium (SE), columnar epithelium (CE), and the squamocolumnar junction (SCJ). B, Cervix after application of acetic acid. C, Normal cervix with nabothian cyst (NC) and mucus. D, Predominant squamous metaplasia (SM) after application of acetic acid. E, Columnar epithelium (CE). F, Cervix before application of Lugol’s solution. G, Cervix after application of Lugol’s solution. Estrogenized squamous epithelium will stain dark.

Figure 137-3 Normal colposcopic variants. A, Cervix with irregular contour due to birth trauma. SCJ, squamocolumnar junction. B, Pregnant cervix with mucus, thin, bluish epithelium, and metaplasia. C, SCJ unable to be seen (often encountered after treatment and in older patients). D, Prominent vessels can overlie nabothian cysts (NC), some of which may appear atypical. Biopsy is recommended if there is any doubt. AV, atypical vessel. E, Blue/green filter can enhance visualization of vessels, allowing the red vessels to appear black against a greenish background.

Figure 137-4 Abnormal colposcopic findings. A, Cervix before application of acetic acid. B, Cervix after application of acetic acid, showing acetowhite epithelium (AWE) extending into cervical canal. C, Use of Kogan forceps to demonstrate AWE in the endocervical canal. D, Leukoplakia (LK), a white lesion seen before application of acetic acid. E, AWE lesion before application of Lugol’s solution. F, After application of Lugol’s solution, the same AWE is now iodine negative. G, AWE with mosaic pattern (MO) and endocervical involvement. H, AWE with endocervical involvement seen with Kogan endocervical dilators. I, AWE showing a coarse mosaic pattern before green light application. J, AWE showing a coarse mosaic pattern after green light application. K, Large, protruding lesion with coarse punctation (PT). L, Friable, peeling cervical epithelium and atypical vessels (AV) suspect for invasive carcinoma are seen in this example of invasive cervical carcinoma. M, Grossly deformed mass replacing the cervix consistent with invasive carcinoma. N, Colposcopic view of the vulva with both condylomata and vulvar intraepithelial neoplasia (VIN). Remember, colposcopy includes inspection of the vulva. O, Central cervical polyp.

Normal Colposcopic Findings

See Figures 137-2 and 137-3.

Abnormal Colposcopic Findings

See Figure 137-4.

Atypical Transformation Zone

A TZ with findings suggesting cervical dysplasia or neoplasia is considered abnormal. Usually, acetic acid (3% to 5% vinegar) is applied and the cervix is viewed under magnification with the colposcope.

1 Acetowhite epithelium (AWE): Epithelium that transiently whitens after the application of acetic acid. Areas of acetowhite correlate with higher nuclear density. The white staining fades within minutes. The more abnormal the changes, the more quickly they will turn white, the more dense they will be, and the longer they will last. All AWE is not necessarily abnormal because metaplasia also has a higher nuclear ratio owing to a more rapid growth rate and turns white with acetic acid.

2 Punctation: A stippled appearance of capillaries viewed end-on; often found within acetowhite areas, where they appear as fine to coarse red dots.

3 Mosaicism: An abnormal change made up of small red blood vessels appearing in linear form, suggesting a confluence of tile or chicken-wire patterns. This is best viewed after staining with acetic acid under magnification.

4 Leukoplakia (hyperkeratosis): Typically an elevated white plaque seen before the application of acetic acid. There is generally no change, or the area becomes more densely white, after application of acetic acid.

5 Abnormal blood vessels: Atypical, irregular, true vessels with abrupt courses and patterns; often appear as commas, corkscrews, or spaghetti-like shapes. No definite pattern is recognized, as there is with punctation or mosaicism. Abnormal blood vessels are seen in cancer and occasionally in advanced dysplasias.

6 Iodine-negative epithelium: Estrogenized epithelium will stain with Lugol’s solution to a deep brown color. Abnormal tissue and nonestrogenized tissue do not stain.

Suspect Invasive Cancer

A complex pattern consisting of roughened, irregular cervical epithelium, typically with abundant abnormal vessel patterns and dense acetowhite change, often with a dense eggshell-white or slightly yellowish hue. It may also appear as ulcerated, friable, necrotic tissue. There may be a bulk effect or tumor-like appearance.

Unsatisfactory Colposcopy

In an unsatisfactory colposcopy, the entire SCJ or the limits of all lesions cannot be completely visualized. Proper examination can also be hampered if an active inflammatory process is present, if the patient is not estrogen primed (e.g., postmenopausal without replacement therapy, on progesterone-only types of contraception, lactation), or if heavy menses is present.

Other Colposcopic Findings

• Vaginocervicitis

• Traumatic erosion

• Atrophic epithelium

• Endocervical polyps

• Changes from diethylstilbestrol (DES)

• Abnormal pigmentation

• Nabothian cysts

• Post-traumatic clefts, deformities from birth or treatment

• Vaginal, vulvar, perineal, perianal lesions

Guidelines regarding visual colposcopic findings help ensure sampling of the most advanced sites of cervical dysplasia. The classic hallmark of cervical dysplasia includes the change that dysplastic epithelium undergoes after the application of 3% to 5% acetic acid (vinegar) or Lugol’s (concentrated iodine) solution.

After the application of acetic acid to estrogenized tissue, dysplastic epithelium typically turns whiter than the surrounding normal epithelium (AWE). More advanced dysplasia typically appears more densely white, thicker, and smoother with raised borders. The surface of advanced dysplasia often becomes rougher or thicker as the severity of dysplasia advances and satellite lesions (multiple small abnormal areas) are less common. There may begin to be a “yellowish” hue. Changes in the vasculature pattern also correlate with cervical dysplasia. These abnormal patterns, which often occur in an acetowhite or leukoplakia patch, include punctation, mosaicism, and frankly abnormal vessel variations. The more coarse the punctation or mosaicism, the more severe the dysplasia is. Frankly abnormal vessel patterns imply severe dysplasia or potential invasive carcinoma.

After the application of Lugol’s solution to estrogenized tissue, there is an immediate blackening (staining) of normal epithelium (iodine uptake is high in normal cells that are rich in cytologic glycogen). Abnormal dysplastic tissue, which has cells that contain much less intracellular glycogen, are not stained by iodine (Lugol’s-negative epithelium) and remain white or faint yellow. The same pattern is seen if there is little or no estrogen stimulation.

Squamous metaplasia, a normal finding, may appear slightly acetowhite and may take up Lugol’s solution incompletely; therefore, this tissue can cause some degree of confusion for the colposcopist. Squamous metaplasia is the physiologically normal tissue present where the columnar epithelium is being transformed into mature squamous epithelium. This occurs in the TZ—the same site where dysplasia generally occurs. Squamous metaplasia is especially prominent with certain conditions, such as active cervicitis, and where healing and reparative activities occur, such as after treatment. Questionable areas always warrant biopsy. If squamous metaplasia without dysplasia is reported on biopsy, but the Pap smear was abnormal, the prudent colposcopist must look elsewhere to explain the finding of dysplasia on the Pap smear (see Appendix K). A report of squamous metaplasia among other biopsies revealing dysplasia reflects the difficulty encountered by the colposcopist in evaluating this normal variant of acetowhite change. (Indeed, neither are all appendices removed for an acute abdomen the source of the pain!) The only other common areas that normally turn slightly white with acetic acid are the endocervical (columnar) cells, which are typically located in the cervical canal and extend a variable distance onto the exocervix. Endocervical tissue can usually be differentiated from abnormal areas by colposcopic examination because of its grapelike appearance on high-power magnification. Biopsy is still warranted if there is any confusion.

This chapter focuses on the evaluation of the abnormal Pap smear as it typically relates to cervical disease. The complete examination also includes the colposcopic examination of the remainder of the genital system in women. The colposcope can also be used for other purposes, such as to examine male genitalia or the anus, and to evaluate sexual abuse victims (see Chapter 99, High-Resolution Anoscopy, Chapter 118, Androscopy, and Chapter 157, Treatment of the Adult Victim of Sexual Assault). Ultimately, the patient’s cytologic, colposcopic, and histologic data are used in concert to direct appropriate management. A well-managed colposcopy program provides effective evaluation and treatment for all patients with identified abnormalities of the cervix and genital tract.

Many colposcopists keep their scopes immediately available to augment the routine Pap and pelvic examination, especially if abnormalities are seen and both time and patient preference are favorable. Although complete formal colposcopic examination and biopsy can be performed when visual abnormalities are identified, many clinicians prefer to reschedule patients for full colposcopic examination at a later date. This allows more time for patient education and thorough evaluation.

Indications

Refer to Appendix K for the 2006 American Society for Colposcopy and Cervical Pathology (ASCCP) Consensus Guidelines on the management of cytologic and histologic cervical abnormalities, and the indications and clinical scenarios in which colposcopy is indicated. The most common indications include the following:

• Pap smear consistent with dysplasia or cancer (see Chapter 151, Pap Smear and Related Techniques for Cervical Cancer Screening, for detailed recommendations regarding abnormal Pap smears)

• Pap smear with atypical glandular cells (always perform colposcopy)

• Worrisome history despite normal Pap smear findings (e.g., postcoital bleeding)

• An atypical Pap smear in which the patient tests positive for high-risk HPV

• Suspect visible lesion or palpable lesion of the cervix

• Abnormal vaginal bleeding, especially if postcoital, regardless of Pap smear status

• History of intrauterine DES exposure

• Evaluation or follow-up of previously treated or high-risk patients

The colposcope can be used for other reasons, such as removal of a cervical polyp, to find a lost intrauterine contraceptive device string, or to evaluate a rape victim, but in these instances a full colposcopic examination protocol is generally not indicated.