Colposcopic Examination

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.




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).






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.











Other Colposcopic Findings












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.




May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Colposcopic Examination

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