Practical manual on colposcopy and colposcopy directed procedures

Practical manual on colposcopy and colposcopy directed procedures
A Practical Manual on
Colposcopy and Cryotherapy Procedures
For Medical Professionals
Jan Swasthya Sahyog, Ganiyari
Dist. - Bilaspur, (C.G.)
`
TABLE OF CONTENT
Chap 1: An introduction to colposcopy: indications for colposcopy,
instrumentation, principles, and documentation of results ....................................................... 2
Chap 2: Colposcopic Appearance of the Normal Cervix ....................................................................... 13
Chap 3: Colposcopic Assessment of Cervical Intraepithelial Neoplasia ............................................... 23
Chap 4: Inflammatory Lesions of the Uterine Cervix ........................................................................... 41
Chap 5: Avoiding Errors in the Colposcopic Assessment Of The Cervix And
Colposcopic Provisional Diagnosis........................................................................................................ 45
Chap 6: Treatment of Cervical lntraepithelial Neoplasia by Cryotherapy............................................ 48
Chap 7: Treatment of cervical intraepithelial neoplasia by loop
electrosurgical excision procedure (LEEP) ...................................................................................... 56
Chap 8: Cleaning of Instruments and Materials Used for Early Detection and
Treatment of Cervical Neoplasia .......................................................................................................... 67
Chap 9: Modified Reid Colposcopic Index (RCI) .......................................................................... 68
Chap 1: An
to
for
and
of
INDICATIONS FOR COLOPOSCOPY
Given the availability of a colposcope and trained colposcopists, there are a number of
indications for this examination, of which positive cervical screening tests constitutes the most
frequent indication for colposcopy (e.g., Positive cytology, positive on visual inspection with
acetic acid etc.)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Suspicious looking cervix
Invasive carcinoma on cytology
CIN 2 or CIN 3 on cytology
Persisting (for more than 12-18 months) low-grade (CIN 1) abnormalities on
cytology
CIN 1 on cytology
Persistently unsatisfactory quality on cytology
Infection with oncologenic Human Papilloma Viruses
Acetopositivity on visual inspection with acetic acid using magnification
Positive on visual inspection with Lugol’s Iodene
INSTRUMENTATION
Hinselmann (1925) first described the basic colposcopic equipment and its use, establishing the
foundation for the practice of colposcopy. A colposcope is a low-power, stereoscopic, binocular,
field microscope with a powerful variable-intensity light source that illuminates the area being
examined (Figure 1.2).
The head of the colposcope, also called the ‘optics carrier’, contains the objective lens (at the
end of the head positioned nearest to the woman being examined), two ocular lenses or
eyepieces (used by the colposcopist to view the cervix), a light source, green and/or blue filters
to be interposed between the light source and the objective lens, a knob to introduce the filter,
a knob to change the magnification of the objective lens, if the colposcope has multiple
magnification facility and a fine focusing handle. The filter is used to remove red light, to
facilitate the visualization of blood vessels by making them appear dark. Using a knob, the
head of the colposcope can be tilted up and down to facilitate examination of the cervix. The
distance between the two ocular lenses can be adjusted to suit the inter-pupillary distance of
the provider, to achieve stereoscopic vision. Each ocular lens has diopter scales engraved on
it to facilitate visual correction of individual colposcopists. The height of the head from the
floor can be adjusted by using the height adjustment knob, so that colposcopy can be carried
2
out with the colposcopist comfortably seated, without strain to the back.
Modern colposcopes usually permit adjustable magnification, commonly 6x to 40x usually
in steps such as, for example, 9x, 15x, 22x. Some sophisticated and expensive equipment may
have electrical zoom capability to alter the magnification. Most simple colposcopes have a
single fixed magnification level such as 6x, 9x, 10x, 12x or 15x. Most of the work with a
colposcope can be accomplished within the magnification range of 6x to 15x. Lower
magnification yields a wider view and greater depth of field for examination of the cervix. More
magnification is not necessarily better, since there are certain tradeoffs as magnification
increases: the field of view becomes smaller, the depth of focus diminishes, and the
illumination requirement increases. However, higher magnifications may reveal finer features
such as abnormal blood vessels.
The location of the light bulb in the colposcope should be easily accessible to facilitate changing
them when necessary. Some colposcopes have bulbs mounted in the head of the instrument; in
others, these are mounted elsewhere and the light is delivered via a fibre-optic cable to the
head of the colposcope. The latter arrangement can use brighter bulbs, but less overall
illumination may result if the cables are bent or twisted. A colposcope may be fitted with
halogen, xenon, tungsten or incandescent bulbs. Halogen bulbs are usually preferred, as they
produce strong white light. The intensity of the light source may be adjusted with a knob.
Focusing the colposcope is accomplished by adjusting the distance between the objective lens
and the woman by positioning the instrument at the right working distance. Colposcopes usually
have fine focus adjustments so that, if the distance between the base of the scope and the
woman is kept fixed, the focus of the scope may be altered slightly using the fine focusing
handle. The working distance (focal length) between the objective lens and the patient is quite
important - if it is too long (greater than 300 mm) it is hard for the colposcopist’s arms to reach
the woman, and if it is too short (less than 200 mm), it may be difficult to use instruments like
biopsy forceps while visualizing the target with the scope. A focal distance of 250 to 300 mm is
usually adequate. Changing the power of the objective lenses alters the magnification and
working distance.
Colposcopes are quite heavy and are either mounted on floor pedestals with wheels,
suspended from a fixed ceiling mount, or fixed to the examination table or to a wall,
sometimes with a floating arm to allow for easier adjustment of position. In developing
countries, it is preferable to use colposcopes mounted vertically on a floor pedestal with
wheels, as they are easier to handle and can be moved within or between clinics.
The instruments needed for colposcopy are few and should be placed on an instrument trolley
or tray (Figure 1.1) beside the examination table. The instruments required are: bivalve
specula (Figure 1.3), vaginal side-wall retractor (Figure 1.4), cotton swabs, sponge-holding
3
forceps, long (at least 20cm long) anatomical dissection forceps, endocervical speculum (Figure
1.5), biopsy forceps (Figure 1.6), endocervical curette (Figure 1.7), cervical polyp forceps and
single-toothed tenaculum. In addition, the instrument tray may contain instruments necessary
for treatment of CIN with cryotherapy or loop electrosurgical excision procedure (LEEP). The
tray should also contain the consumables used for colposcopy and treatment.
In view of the different sizes of vagina, varying widths of bivalve specula should be available.
One may use Cusco's, Grave’s, Collin’s or Pedersen’s specula.
One should use the widest possible speculum that can comfortably be inserted into the vagina
to have optimal visualization of the cervix. Vaginal side-wall retractors are useful to prevent
the lateral walls of a lax vagina from obstructing the view of the cervix. However, they may
cause discomfort to the patient. An alternative approach is to use a latex condom on the
speculum, the tip of which is opened with scissors 1 cm from the "nipple”. Sponge-holding
forceps or long dissection forceps may be used to hold dry or moist cotton balls. The
endocervical speculum or the long dissection forceps may be used to inspect the endocervical
canal. The endocervical curette is used to obtain tissue specimens from the endocervix.
Several types of sharp cervical biopsy punch forceps with long shafts (20-25 cm) such as
Tischler-Morgan, Townsend or Kevrokian, are available. A single-toothed tenaculum or skin
(iris) hook may be used to fix the cervix when obtaining a punch biopsy. Cervical polyps may be
avulsed using the polyp forceps.
4
5
Figure: 1.2 Colposcope
6
7
PRINCIPLES OF COLPOSCOPY EXAMINATION PROCEDURES
SALINE TECHNIQUE
The key ingredients of colposcopic practice are the examination of the features of the cervical
epithelium after application of saline, 5% dilute acetic acid and Lugol’s iodine solution in
successive steps.
The study of the vascular pattern of the cervix may prove difficult after application of acetic
acid and iodine solutions. Hence the application of physiological saline before acetic acid and
iodine application is useful in studying the sub-epithelial vascular architecture in great detail. It
is advisable to use a green filter to see the vessels more clearly.
PRINCIPLES OF ACETIC ACID TEST
The other key ingredient in colposcopic practice, 5% acetic acid, is usually applied with a
cotton applicator (cotton balls held by sponge forceps, or large rectal or small swabs) or with a
small sprayer. It helps in coagulating and clearing the mucus. Acetic acid is thought to cause
swelling of the epithelial tissue, columnar and any abnormal squamous epithelial areas in
particular. It causes a reversible coagulation or precipitation of the nuclear proteins and
cytokeratins. Thus, the effect of acetic acid depends upon the amount of nuclear proteins and
cytokeratins present in the epithelium. When acetic acid is applied to normal squamous
epithelium, little coagulation occurs in the superficial cell layer, as this is sparsely nucleated.
Though the deeper cells contain more nuclear protein, the acetic acid may not penetrate
sufficiently and, hence, the resulting precipitation is not sufficient to obliterate the colour of
the underlying stroma. Areas of CIN undergo maximal coagulation due to their higher content
of nuclear protein and prevent light from passing through the epithelium. As a result, the
subepithelial vessel pattern is obliterated and less easy to see and the epithelium appears
white. This reaction is termed acetowhitening, and produces a noticeable effect compared
with the normal pinkish colour of the surrounding normal squamous epithelium of the cervix,
an effect that is commonly visible to the naked eye.
With low-grade CIN, the acetic acid must penetrate into the lower one-third of the epithelium
(where most of the abnormal cells with high nuclear density are located). Hence, the
appearance of the whiteness is delayed and less intense due to the smaller amount of nuclear
protein compared to areas with high-grade CIN or preclinical invasive cancer. Areas of highgrade CIN and invasive cancer turn densely white and opaque immediately after application of
acetic acid, due to their higher concentration of abnormal nuclear protein and the presence of
large numbers of dysplastic cells in the superficial layers of the epithelium.
The acetowhite appearance is not unique to CIN and early cancer. It is also seen in other
situations when increased nuclear protein is present: for example in immature squamous
8
metaplasia, congenital transformation zone, in healing and regenerating epithelium
(associated with inflammation), leukoplakia (hyperkeratosis) and condyloma.
While the acetowhite epithelium associated with CIN and preclinical early invasive cancer is
more dense, thick and opaque with well demarcated margins from the surrounding normal
epithelium, the acetowhitening associated with immature squamous metaplasia and
regenerating epithelium is less pale, thin, often translucent, and patchily distributed without
well-defined margins. Acetowhitening due to inflammation and healing is usually distributed
widely in the cervix, not restricted to the transformation zone. The acetowhite changes
associated with immature metaplasia and inflammatory changes quickly disappear, usually
within 30-60 seconds.
Acetowhitening associated with CIN and invasive cancer quickly appears and persists for more
than one minute. The acetic acid effect reverses much more slowly in high-grade CIN lesions
and in early pre-clinical invasive cancer than in low-grade lesions, immature metaplasia and
sub-clinical HPV changes. It may last for 2-4 minutes in the case of high-grade lesions and
invasive cancer.
Acetowhitening also occurs in the vagina, external anogenital skin, and anal mucosa. The
acetowhite reaction varies in intensity, within and between patients. The reaction is often
associated with other visual signs in the same area, and is not specific for intraepithelial
preneoplasia. Invasive cancer may or may not be acetowhite; it usually has other
distinguishing features that will alert the colposcopist.
As previously stated, the main goal of colposcopy is to detect the presence of high-grade CIN
and invasive cancer. To effectively achieve this, the entire epithelium at risk should be well
visualized, abnormalities should be identified accurately and assessed for their degree of
abnormality, and appropriate biopsies must be taken. The colposcopic documentation and the
biopsies taken by a colposcopist are important indicators for quality management in
colposcopy clinics.
PRINCIPLES OF SCHILLER'S (LUGOL’S) IODINE TEST
The principle behind the iodine test is that original and newly formed mature squamous
metaplastic epithelium is glycogenated, whereas CIN and invasive cancer contain little or no
glycogen. Columnar epithelium does not contain glycogen. Immature squamous metaplastic
epithelium usually lacks glycogen or, occasionally, may be partially glycogenated. Iodine is
glycophilic and hence the application of iodine solution results in uptake of iodine in glycogencontaining epithelium. Therefore, the normal glycogen-containing squamous epithelium stains
mahogany brown or black after application of iodine. Columnar epithelium does not take up
iodine and remains unstained, but may look slightly discoloured due to a thin film of iodine
solution; areas of immature squamous metaplastic epithelium may remain unstained with
9
iodine or may be only partially stained. If there is shedding (or erosion) of superficial and
intermediate cell layers associated with inflammatory conditions of the squamous epithelium,
these areas do not stain with iodine and remain distinctly colourless in a surrounding black or
brown background. Areas of CIN and invasive cancer do not take up iodine (as they lack
glycogen) and appear as thick mustard yellow or saffron- coloured areas. Areas with
leukoplakia (hyperkeratosis) do not stain with iodine. Condyloma may not, or occasionally may
only partially, stain with iodine.
Routine use of iodine application in colposcopic practice is recommended; as this may help in
identifying lesions overlooked during examination with saline and acetic acid and will help in
delineating the anatomical extent of abnormal areas much more clearly, thereby facilitating
treatment.
DOCUMENTATION OF COLPOSCOPIC FINDINGS
The record of colposcopic findings for each visit should be documented carefully by the
colposcopists themselves, immediately after the examination. This record, which can be stored
on paper or electronically, forms the backbone of any medical record system that can be used
for continuing patient care and performance.
PERFORM CERVICAL BIOPSIES, IF NECESSARY
Once an abnormal transformation zone is detected, the area is evaluated and compared with
other areas of the cervix. If any other abnormal zones are present, the colposcopist should
then decide from where a biopsy or biopsies should be taken. It is essential to obtain one or
more directed punch biopsies from areas colposcopically identified as abnormal and/or
doubtful. Biopsy should be obtained from the area of the lesion with worst features and
closest to the squamocolumnar junction. Biopsy always should be done under colposcopic
control by firmly applying the biopsy instrument (Figure 1.6), with the jaws wide open (Figure
1.8), to the cervical surface to be sampled. The cervix may move back somewhat with this
manoeuvre, but that is normal.
To obtain a tissue sample, the biopsy forceps is guided under colposcopic visualization to the
area from which the tissue specimen is to be obtained. The cervix may tend to slip away on
pressure, but it is usually easy to grasp and remove tissue if the forceps used for biopsy has
wide and sharp cutting edges, with one or two teeth to anchor the forceps while taking the
biopsy (Figure 1.8). A tenaculum may be also used to fix the cervix before taking the biopsy.
The jaws are then closed completely, and the specimen is removed and immediately placed in
formalin. The biopsy performed should be deep enough to obtain adequate stroma, in order to
exclude invasion. Cutting the specimen should be carried out by quick and firm closure of the
jaws. Repeated cutting and rotation of the forceps should be avoided, as they can crush the
tissue sample. The procedure is usually painless if carried out efficiently using a sharp and
10
toothed biopsy forceps. A skin hook is sometimes useful to anchor a potential biopsy site if it is
difficult to grasp with the biopsy instrument.
FIGURE 1.8: Biopsy technique: A toothed and sharp cutting biopsy forceps should be used for
biopsy. Firmly apply the biopsy punch onto the cervix with the jaws wide open; fix the lower lip
of the biopsy punch and close the jaws completely. Cutting the specimen should be carried out
by quick and firm closure of the jaws. Repeated cutting and rotation of the forceps should be
avoided, as this can crush the tissue sample. The removed specimen should be immediately
placed in formalin. The biopsy site may be cauterized.
After the biopsy has been obtained, it is advisable to indicate the site of the target area which
has been biopsied, on the diagram of cervix in the reporting form. It is important to place the
freshly obtained biopsy specimen in a labeled bottle containing 1O% formalin. The biopsy
site(s) may be cauterized immediately after the procedure to control any bleeding.
PERFORM ENDOCERVICAL CURETTAGE. IF NECESSARY
There are three commonly encountered circumstances, in which endocervical curettage (ECC)
should be performed using an endocervical curette (Figure 1.7).
1. First, if the colposcopic examination of the ectocervix has not revealed any
abnormality, yet the woman has been referred because of a cytological abnormality an
ECC should be performed to properly evaluate the endocen/ical canal, which may
contain a hidden invasive cancer or other lesion.
2. Second, if the referral cytology indicated that a glandular lesion may be present, an ECC
should be performed (regardless of the findings of the colpocopic examination).
3. Third, an ECC should be performed if the colposcopic examination has been
unsatisfactory (whether or not a cervical lesion has been detected).
However, it should be mentioned that the yield of an ECC is very low in inexperienced hand as
it is frequently associated with inadequate tissue sampling. Thus, in such situations, a negative
ECC should not be taken as unequivocal evidence of the absence of neoplasia in the
endocervical canal. In the above three situations, and particularly in the case of an acetowhite
11
lesion extending into the canal, it may be prudent to excise the cervix with a cone (by LEEP or
cold knife conization, as appropriate).
However, this approach places a large work load on histopathology services. ln the assessment
of women in such situations, it is left to the discretion of the colposcopist to decide whether
an ECC and/or cone biopsy should be performed.
Before ECC is performed, the posterior fornix must be dry to avoid the loss of curetted tissue
in the acetic acid solution which accumulated during its application on the cervix. When
performing ECC, the colposcopist holds the curette like a pen and scrapes the endocervical
canal in firm, short, linear strokes until it has been completely sampled. During the procedure
the curette should remain in the canal. When extracting the curette, care should be taken to
twirl it in order to encourage the contents of the curette basket to remain trapped therein.
The curettings should be put onto a piece of either gauze or brown paper, and then promptly
placed into formalin. Any residual tissue can be removed from the canal with forceps.
Awareness of and ability to identify the colposcopic features of the normal cervix provide the
basis for differentiating between normal and abnormal colposcopic findings.
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Chap 2: Colposcopic Appearance of the Normal Cervix
AFTER APPLICATION OF NORMAL SALINE SOLUTION
SQUAMOUS EPITHELIUM
The original squamous epithelium is darker pink in colour compared with the light pink or
whitish-pink colour of the metaplastic squamous epithelium. If one looks closely, it is apparent
in some women that a few crypt openings, which look like tiny circular holes, are scattered over
the surface of the squamous epithelium (Figure 2.1 & 2.2). In some women, alternatively, one
may look for the nabothian follicles. Looking distally, away from the os towards the outer part
of the ectocervix, one comes to a point where no more crypt openings and/or nabothian
follicles are apparent. An imaginary line drawn connecting the most distal crypt openings
and/or nabothian follicles that one can see in the cervical lips colposcopically define the original
squamocolumnar junction (the junction between the original or native squamous epithelium
and the metaplastic squamous epithelium). The original squamocolumnar junction forms the
outer, distal, or caudal border of the transformation zone through its entire 360-degree
circumference. Sometimes, it is the subtle colour variation between the native and metaplastic
squamous epithelium that defines the original squamocolumnar junction.
The next task is to identify the proximal or inner border of the transformation zone, which is
defined by the new squamocolumnar junction (the line of demarcation where the metaplastic
squamous and columnar epithelia meet), throughout its entire 360-degree circumference. If the
colposcopist is able to trace the entire new squamocolumnar junction successfully, the
colposcopic examination is classified as adequate or satisfactory with respect to evaluation of
the transformation zone (Figure 2.1 & 2.2).
The new squamocolumnar junction tends to recede towards, and eventually into, the canal as a
woman ages (Figure 2.3). If the junction is proximal to the os, in the canal, it requires additional
effort to visualize the entire junction. Opening the blades of the vaginal speculum and using a
cotton-tipped applicator to pry the anterior lip upward or the posterior lip downward will often
allow visualization of the squamocolumnar junction, if it is close enough to the os. The
endocervical speculum (Figure 2.4) or the tips of a long dissection forceps also can be used, and
will often allow a greater length of canal to be inspected. The skill for these manoeuvres comes
with practice. The vast majority of CIN lesions occur in the transformation zone and the most
severe changes tend to be closer to or abutting, rather than farther from, the new
squamocolumnar junction.
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COLUMNAR EPITHELIUM,
On first looking at the normal cervix in a young woman, one sees the cervical os. It usually
appears to be encircled by the columnar epithelium, appearing dark red in colour with a grapelike or sea anemone tentacles-like or a villous appearance in contrast to the smooth, light pink
squamous epithelium. Each columnar villous structure contains a fine capillary and the blood in
the capillary and the vascularity of the underlying connective tissue give the columnar
epithelium its strikingly reddish appearance. Small polyps may be detected during examination
of the endocervical canal.
VASCULATURE
The next most important feature to observe is the vasculature. The examination of the blood
vessels is facilitated by applying normal saline on the cervix and using the green (or blue) filter
on the colposcope to enhance the contrast of the vessels. Use of a higher power of
magnification (about 15x), if available in the colposcope, also is helpful. Depending on the
thickness or opacity of the overlying squamous epithelium, smaller vessels may or may not be
visible. The smaller vessels that may be visible are capillaries that are in the stroma below the
epithelium.
Two types of capillaries are apparent in the native or original squamous epithelium: reticular
(network) or hairpin-shaped capillaries (Figure2.5). The reticular pattern is especially visible
because the epithelium is thinner in women taking oral contraceptives and in postmenopausal
women. The hairpin capillaries actually ascend vertically, loop over, and then descend back into
the stroma from where they came. Since these loops are seen 'end on', the colposcopic view
usually is of dots with only a slight, if any, appearance of a loop at each. Inflammation of the
cervix (e.g., trichomoniasis) often causes hairpin vessels to form stag horn-like shapes so that
the vessels become more prominent and the loop appearance is more apparent (Figure 2.5).
Often no vascular pattern is seen on the original squamous epithelium.
The ectocervical vessel appearances described above are more prominence towards the outer
transformation zone, nearer to the original squamocolumnar junction. In the more recently
formed immature metaplastic squamous epithelium nearer the new squamocolumnar junction,
other vascular patterns become more prominent. These are large (compared to capillaries)
branching surface vessels with three recognizable basic patterns (Figure2.5). The first pattern is
much like a tree branching and the second is commonly seen overlying nabothian cysts (Figure
2.6). The regular structure and decrease in the calibre of the vessels towards the ends of the
branches all suggest a benign (normal) nature. A third pattern sometimes occurs when healing
has taken place after therapy for CIN (Figures 2.5 and 2.7): the vessels are long and run parallel
to one another. The lack of other abnormal epithelial features that would suggest neoplasia is a
14
helpful clue that the vasculature is normal. If there is any doubt, it is always prudent to take a
biopsy.
The vessels in the columnar epithelium actually are terminal capillary networks. One capillary
network is confined to the stromal core of each grape-like villus, which projects up to the
epithelial surface. With the colposcope, the rounded tips of the individual villi are the main
features seen and the top of the vessel network in each villus appears as a dot. Large, deep
branching vessels may be seen in some cases.
AFTER APPLICATION OF 5% ACETIC ACID SOLUTION
SQUAMOUS EPITHELIUM
After acetic acid has been allowed to take effect (1-2 minutes), certain changes in the features
seen with saline are usually apparent in the normal cervix of a young woman. The colour of the
squamous epithelium tends to be somewhat dull in contrast to the usual pink hue, and the
translucence is diminished so that it looks somewhat pale (Figure 2.2). In postmenopausal
women the colour usually is paler than in a premenopausal woman. The landmarks and full
extent of the transformation zone should again be observed carefully. The squamocolumnar
junction may be prominently visible as a sharp, step like white line due to the presence of
actively dividing immature squamous metaplasia around the edge, medial (proximal) to the
junction (Figure 2.8). The atrophic postmenopausal squamous epithelium looks more pale,
brittle, without lustre, sometimes with sub-epithelial petechiae due to the trauma to subepithelial capillaries resulting from the insertion of the bivalved vaginal speculum (Figure 2.9).
Often the new squamocolumnar junction may not be visible in postmenopausal women as it
recedes into the endocervical canal.
COLUMNAR EPITHELIUM
The columnar epithelium should be inspected next. It is usually noticeably less dark red than it
was with saline and the pale acetowhitening of the villi may resemble a grape-like appearance
(Figure2.10). After the endocervical mucus among the villi has been coagulated by the acetic
acid and wiped away, the topography may be seen more easily. If a polyp is covered by the
columnar epithelium (which has not yet undergone metaplastic changes), the typical grape-like
appearance may be visible. More often, especially when it protrudes, the epithelium covering
the polyp undergoes metaplastic changes and presents features of various stages of metaplasia.
SQUAMOUS METAPLASIA
During the different stages of the development of metaplasia, a vast range of colposcopic
appearances may be seen. This can present a challenge to an inexperienced colposcopist, who
needs to differentiate between these normal findings and the abnormal features associated
15
with CIN. Immature metaplastic squamous epithelium that may turn mildly white after the
application of acetic acid is a common source of confusion for the beginners. It is acceptable to
take a biopsy when in doubt.
Colposcopically, three stages of development of squamous metaplasia may be recognized
(Coppleson & Reid, 1986). In the earliest stage, the translucence of the columnar epithelial villi
is lost and the villi become opaque at their tips; the villi widen and flatten and successive villi
fuse in clusters and sheets with a pale pink colour (Figures 2.11, 2.12 and 2.13). Consequently
the metaplastic epithelium looks like a patchily distributed pale cluster, or sheet-like areas, in
the ectopic columnar epithelium.
As the metaplasia progresses, the grape-like configuration of the columnar epithelium
disappears and the spaces between the villi are fused with glassy, pinkish-white, finger- or
tongue-like membranes pointing towards the external os (Figures 2.14 and 2.15). There may be
numerous crypt openings and islands of columnar epithelium scattered throughout the
metaplastic epithelium. The rims of the crypt openings may not turn white with acetic acid
early in the process of metaplasia, but may turn mildly white as the metaplastic process
progresses. Gradually, the tongue-like metaplastic areas fuse together to form a continuously
advancing glassy, shining, pinkish-white or mildly pale membrane-like area (Figure 2.16).
Finally, the immature metaplastic epithelium becomes a fully developed mature metaplastic
squamous epithelium resembling the original native squamous epithelium, except for the
presence of some crypt openings (Figure 6.1) and nabothian retention follicles in the
metaplastic epithelium.
AFTER APPLICATION OF LUGOL’S IODINE SOLUTION
As described in the previous chapter, glycogenated cells take iodine, so that they have a
uniform dark mahogany brown colour when stained with Lugol’s iodine solution. Therefore, the
normal vaginal and cervical squamous (both native and mature metaplastic) epithelium in
women in the reproductive age group will take up the stain and become mahogany brown or
black (Figure 2.17). This is helpful in distinguishing normal from abnormal areas in the
transformation zone that have show faint acetowhitening. The columnar epithelium does not
stain with iodine (Figure 2.17). The immature squamous metaplastic epithelium usually does
not stain with iodine or may partially stain if it is partially glycogenated (Figure 2.18). The
vascular features, so easily seen with saline, may be difficult to observe after application of
Lugol’s iodine solution. Cervical polyps do not stain with iodine, as they are usually covered
with columnar or immature metaplastic epithelium (Figure 2.19). lf the maturation of the
metaplastic epithelium varies, one may observe various fields of no uptake or partial to full
iodine uptake on the polyp. In postmenopausal women, the ectocervix may not stain fully' with
iodine, due to atrophy of the epithelium.
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CONGENITAL TRANSFORMATION ZONE
The congenital transformation zone stains white after application of acetic acid. In this
condition, the metaplastic epithelium formed during the latter portion of fetal life, lying distal
to the transformation zone formed after birth, is located far out on the ectocervix, some
distance from the cervical os and, in some cases, may even extend onto the vagina. It is
important to recognize this as a normal condition for which no treatment is necessary.
With acetic acid, the congenital transformation zone will usually take on a mild acetowhite stain
and the capillary vasculature may have a fine mosaic pattern vasculature.
The most important feature to observe is the vasculature. The examination of the blood vessels
is facilitated by applying normal saline on the cervix and using the green (or blue) filter on the
colposcope to enhance the contrast of the vessels. Use of a higher power of magnification
(about 15x), if available in the colposcope, also is helpful. Depending on the thickness or opacity
of the overlying squamous epithelium, smaller vessels may or may not be visible. The smaller
vessels that may be visible are capillaries that are in the stroma below the epithelium,
Two types of capillaries are apparent in the native or original squamous epithelium: reticular
(network) or hairpin-shaped capillaries (Figure 2.5). The reticular pattern is especially visible
because the epithelium is thinner in women taking oral contraceptives and in postmenopausal
women. The hairpin capillaries actually ascend vertically, loop over, and then descend back into
the stroma from where they came.
Since these loops are seen 'end on', the colposcopic view confined to the stromal core of each
grape-like villus (Figure 2.20), which projects up to the epithelial surface. With the colposcope,
the rounded tips of the individual villi are the main features seen and the top of the vessel
network in each villus appears as a dot. Large, deep branching vessels may be seen in some
cases.
17
18
19
20
21
22
Chap 3: Colposcopic Assessment of Cervical Intraepithelial
Neoplasia
The colposcopic features that differentiate an abnormal transformation zone from the normal
include the following: colour tone of acetowhite areas; surface pattern of acetowhite areas;
borderline between acetowhite areas and the rest of the epithelium; vascular features and
colour changes after application of iodine.
AFTER APPLICATION OF NORMAL SALINE SOLUTION
Following application of saline, abnormal epithelium may appear much darker than the normal
epithelium.
VASCULATURE
Using the green (or blue) filter and higher-power magnification when necessary, the best
opportunity to evaluate any abnormal vasculature patterns is before the application of acetic
acid, the effect of which may obscure some or all of the changes, especially in an acetowhite
area. The abnormalities of interest are punctation, mosaics and atypical vessels.
CAPILLARIES
The afferent and efferent capillaries within the villi (Figure 2.20) of columnar epithelium
become compressed during the normal metaplastic process and are not incorporated within
the newly formed squamous epithelium. Instead, they form a fine network below the basement
membrane. When CIN develops as a result of HPV infection and atypical metaplasia, the
afferent and efferent capillary system may be trapped (incorporated) into the diseased
dysplastic epithelium through several elongated stromal papillae (Figures 2.3 and 2.4), and a
thin layer of epithelium may remain on top of these vessels. This forms the basis of the
punctate and mosaic blood vessel patterns (Figures 3.1, 3.2 and 3.3). The terminating vessels in
the stromal papillae underlying the thin epithelium appear as black points in a stippling pattern
in an end-on view under the colposcope, making what are called punctate areas (Figures 3.1,
3.2 and 3.3). The inter-connecting blood vessels in the stromal papillae surrounding the rete
pegs of the epithelium, running parallel to the surface, are observed colposcopically as cobbled
areas of mosaic pattern (Figures 3.1 and 3.2). In mosaic areas, the epithelium appears as
individual small, large, round, polygonal, regular or irregular blocks. Punctation and mosaic
areas may be classified as either fine or coarse. Coarse changes tend to be associated with
more severe degrees of abnormality. When both punctation and mosaic patterns are found to
coexist, the same evaluation criteria for colposcopic prediction of disease are used as when
they exist separately.
23
Vessels exhibiting punctation and mosaics are usually more strikingly obvious than the normal
stromal vessels because these vessels penetrate into the epithelium and are thus closer to the
surface. When acetic acid is applied, these abnormal vascular patterns seen to be confined to
the acetowhite areas.
Fine punctation refers to looped capillaries - viewed end-on - that appear to be of fine calibre
and located close to one another, producing a delicate stippling effect (Figures 3.1 and 3.2).
Fine mosaics are a network of fine-calibre blood vessels that appear in close proximity to one
another, as a mosaic pattern, when viewed with the colposcope (Figure 3.1). These two
vascular appearances may occur together and may be found in low-grade (CIN 1) lesions. The
patterns do not necessarily appear throughout the whole lesion.
Coarse punctation (Figure 8.3) and coarse mosaics (Figures 3.1 and 3.2) are formed by vessels
having larger calibre and larger intercapillary distances, in contrast to the corresponding fine
changes. Coarse punctation and mosaicism tend to occur in more severe neoplastic lesions such
as CIN 2, CIN 3 lesions and early preclinical invasive cancer. Sometimes, the two patterns are
superimposed in an area so that the capillary loops occur in the center of each mosaic 'ti|e'.
This appearance is called umbilication (Figure 3.1).
LEUKOPLAKIA (HYPERKERATOSIS)
Leukoplakia or hyperkeratosis (Figure 3.4) is a white, well-demarcated area of the cervix that
may be apparent to the unaided eye, before the application of acetic acid. The white colour is
due to the presence of keratin and is an important observation. Usually leukoplakia is
idiopathic, but it may also be caused by chronic foreign body irritation, HPV infection or
squamous neoplasia. No matter where the area or leukoplakia is located on the cervix, it should
be biopsied to rule out high-grade CIN or malignancy. It is not usually possible to
colposcopically evaluate the vasculature beneath such an area.
CONDYLOMATA
An exophytic lesion on the cervix usually represents and exhibits the characteristic features of a
condyloma (Figures 3.5- 3.8). Condylomata are multiple, exophytic lesions, that are infrequently
found on the cervix, but more commonly in the vagina or on the vulva. Depending on their size,
they may be obvious to the naked eye. The present as soft pink or white vascular growths with
multiple, fine, finger-like projections on the surface, before the application of acetic acid. Under
the colposcope condylomata have a typical appearance, with a vascular papilliferous or frondlike surface, each element of which contains a central capillary. Occasionally, the surface of a
condyloma may have a whorled, heaped-up appearance with a brain-like texture, known as an
encephaloid pattern (Figure 3.8). Often, the surface of the lesion may be densely hyperplastic.
These lesions may be located within, but are more often found outside the transformation
zone. After application of acetic acid, there is blanching of the surface with acetowhite change
24
persisting for some time. A condyloma at the squamocolumnar junction can sometimes be
confused with a prominent area of columnar epithelial villi. Both tend to be acetowhite, but
condyloma is whiter. lt is always prudent to obtain a biopsy to confirm the diagnosis of any
exophytic lesion and to rule out malignancy. Condylomatous lesions may not take up iodine
stain or may stain only partially brown.
AFTER THE APPLICATION OF 5% ACETIC ACID SOLUTION
The observation of a well demarcated, dense, opaque, acetowhite area closer to or abutting the
squamocolumnar junction in the transformation zone after application of 3% acetic acid is
critical. In fact, it is the most important of all colposcopic signs, and is the hallmark of
colposcopic diagnosis of cervical neoplasia. The degree to which the epithelium takes up the
acetic acid stain is correlated with the colour tone or intensity, the surface shine, and the
duration of the effect, and, in turn, with the degree of neoplastic change in the lesion. Highergrade lesions are more likely to turn dense white rapidly. Abnormal vascular features such as
punctation, mosaicism and atypical vessels are significant only if these are seen in acetowhite
areas.
The acetic acid dehydrates cells and reversibly coagulates the nuclear proteins. Thus, areas of
increased nuclear activity and DNA content exhibit the most dramatic colour change. The most
pronounced effects are observed in high-grade lesions and invasive cancer. A direct correlation
exists between the intensity of the dull, white colour and the severity of the lesion. Less
differentiated areas are associated with an intensely opaque, dull-white appearance of lesions
in the transformation zone.
Flat condyloma and low-grade CIN may uncommonly present as thin, satellite acetowhite
lesions detached (far away) from the squamocolumnar junction with geographical patterns
(resembling geographical regions) and with irregular, angular or digitating or feathery margins
(Figures 3.9 - 3.13). Many low-grade CIN lesions reveal less dense, less extensive and less
complex acetowhite areas close to or abutting the squamocolumnar junction with well
demarcated, but irregular, feathery or digitating margins (Figures 7.10-7.16) compared with
high-grade CIN lesions (Figures 3.17-3.27). High-grade lesions show well demarcated, regular
margins, which may sometimes have raised and rolled out edges (Figures 3.25 and 3.26). Highgrade lesions like CIN 2 or CIN 3 have a thick or dense, dull, chalk-white or greyish-white
appearance (Figures 3.17-3.27). They may be more extensive and complex lesions extending
into the endocervical canal (Figures 3.22-3.27) compared with low-grade lesions. High-grade
lesions often tend to involve both the lips (Burghardt et al., 1992 (Table 7.1). Severe or early
malignant lesions may obliterate the external os (Figure 3.22 and 3.25).
25
As lesions become more severe, their surfaces tend to be less smooth and less reflective of
light, as in normal squamous epithelium. The surfaces can become irregular, elevated and
nodular relative to the surrounding epithelium (Figures 3.2 and 3.23-3.27).
The line of demarcation between normal and abnormal areas in the transformation zone is
sharp and well delineated. High-grade lesions tend to have regular sharper borders (Figures
3.17, 3.18, 3.19, 3.21, 3.23, 3.25, 3.26) than low-grade Iesions (3.13, 3.14, 3.15, 3.16).
Visualization of one or more borders within an acetowhite lesion (’lesion within lesion’) (Figure
3.21) or a lesion with differing colour intensity (Figure 3.16) is a important observation
indicating neoplastic lesions, particularly high-grade lesion. The crypt openings that are
involved in high-grade precursor lesions may have thick dense and wide acetowhite rims called
cuffed crypt openings (Figure 3.26). These are whiter and wider than the mild, line-like
acetowhite rings that are sometimes seen around normal crypt openings.
The cardinal features that should differentiate between the CIN lesions and immature
metaplasia are the less dense and translucent nature of the acetowhitening associated with
metaplasia, and the lack of a distinct margin between the acetowhite areas of immature
metaplasia and the normal epithelium. The line of demarcation between normal epithelium
and acetowhite areas of metaplasia in the transformation zone is diffuse and invariably blends
with the rest of the epithelium (Figures 2.1 and 2.16). The finger-like or tongue-like projections
of the metaplastic epithelium often point towards the external os centripetally (Figures 2.14
and 2.15). The acetowhite lesions associated with CIN are invariably located in the
transformation zone close to or abutting, and appearing to arise from, the squamocolumnar
junction (Figure 3.11, 3.21). They spread centrifugally, pointing away from the external os. The
line of demarcation between normal squamous epithelium, inflammatory lesions, are
regenerating epithelium is also diffuse (Figures 5.2-5.5).
To summarize, acetowhite staining is not specific for CIN and may also occur, to some extent, in
areas of immature squamous metaplasia, the congenital transformation zone, inflammation
and healing and regenerative epithelium. However, acetowhite changes associated with CIN are
found localized in the transformation zone abutting the squamocolumnar junction and well
demarcated from the surrounding epithelium. Low-grade lesions tend to be thin, less dense,
less extensive, with irregular, feathery, geographic or angular margins and with fine punctation
and/or mosaic; sometimes, low-grade lesions may be detached from the squamocolumnar
junction; and atypical vessels are seldom observed in low-grade lesions. On the other hand,
high-grade lesions are associated with dense, opaque, grey white, acetowhite areas with coarse
punctation and/or mosaic and with regular and well demarcated borders; these lesions often
involve both lips and may occasionally harbour atypical vessels; CIN 3 lesions tend to be
complex, involving the os.
26
AFTER APPLICATION OF LUGOUS IODINE SOLUTION
Lugol's iodine solution is abundantly applied with a cotton swab to the whole of the cervix and
visible parts of the vagina. The periphery of the cervix, fornices and vaginal walls must be
observed until the epithelium is strongly stained dark brown or almost black by iodine. Normal
vaginal and cervical squamous epithelium and mature metaplastic epithelium contain glycogenrich cells, and thus take up the iodine stain and turn black or brown. Dysplastic epithelium
contains little or no glycogen, and thus does not stain with iodine and remains mustard or
saffron yellow (Figures 3.28-3.32). This colour difference is helpful in distinguishing normal from
abnormal areas in the transformation zone that have shown faint acetowhitening. Columnar
epithelium does not stain with iodine and immature metaplasia only partially stains, if at all.
Atrophic epithelium also stains partially with iodine and this makes interpretation difficult in
post menopausal women. Condylomatous lesions also do not, or only partially, stain with iodine
(Figure 3.33).
Atypical epithelium of CIN may be less firmly attached to the underlying stroma, from which it
may easily detach or peel off, after repeated application with different solutions, resulting in a
true erosion (epithelial defect) exposing the stroma. Such true erosions may easily be observed
after iodine application, as the stroma does not stain with iodine.
DETERMINING THE NATURE OF THE LESION
The colposcopic detection of CIN essentially involves recognizing the following characteristics:
the colour tone, margin and surface contour of the acetowhite epithetlium in the
transformation zone, as well as the arrangement of the terminal vascular bed and iodine
staining. Variations in quality and quantity of the above atypical appearances help in
differentiating CIN from physiological, benign, infective, inflammatory and reactive changes in
the cervix. Grading schemes, based on these variations may guide the colposcopic diagnosis.
The colposcopist is also encouraged to make a colposcopic prediction (or 'diagnosis’) at the end
of the colposcopic session in terms of normal (or negative), low-grade CIN, high-grade CIN,
invasive cancer, other (e.g., inflammation etc.) and un-satisfactory colposcopy. Use of a scoring
or grading system may guide colposcopic interpretation and diagnosis in a less subjective
manner and helps developing a systematic approach to colposcopy. The modified Reid
colposcopic score based on the colposcopic index proposed by Reid & Scalzi (1985) is quite
useful for this purpose.
27
PRECLINICAL INVASIVE CARCINOMA OF THE CERVIX
The primary responsibility of a colposcopist is to ensure that if preclinical invasive carcinoma of
the cervix is present in a woman, it will be diagnosed.
The colposcopist should be well aware that invasive cancers are more common in older women
and in those referred with high-grade cytological abnormalities. Large high-grade lesions,
involving more than three quadrants of the cervix, should be thoroughly investigated for the
possibility of early invasive cancer, especially if associated with atypical vessels. Other warning
signs include the presence of a wide abnormal transformation zone (greater than 40 mm2),
complex acetowhite lesion involving both lips of the cervix, lesions obliterating the os, lesions
with irregular and exophytic surface contour, strikingly thick chalky white lesions with raised
and rolled out margins, strikingly excessive atypical vessels, bleeding on touch or the presence
of symptoms such as vaginal bleeding.
The colposcopic findings of preclinical invasive cervical cancer vary depending upon specific
growth characteristics of the individual lesions, particularly early invasive lesions. The early
preclinical invasive lesions turn densely greyish-white or yellowish-white very rapidly after the
application of acetic acid (Figure 3.34). The acetowhiteness persists for several minutes.
One of the earliest colposcopic signs of possible invasion is blood vessels breaking out from the
mosaic formations and producing irregular longitudinal vessels (Figure 3.35). As the neoplastic
process closely approaches the stage of invasive cancer, the blood vessels can take on
increasingly irregular, bizarre patterns. Appearance of atypical vessels usually indicates the first
signs of invasion (Figures 3.34- 3.38). The key characteristics of these atypical surface vessels
are that there is no gradual decrease in calibre (tapering) in the terminal branches and that the
regular branching seen in normal surface vessels, is absent. The atypical blood vessels, thought
to be result of horizontal pressure of the expanding neoplastic epithelium on the vascular
spaces, show completely irregular and haphazard distribution, great variation in calibre with
abrupt, angular changes in direction with bizarre branching and patterns. These vessel shapes
have been described by labels such as wide hairpin, waste thread, bizarre waste thread, cork
screw, tendril, root-like or tree-like vessels (Figure 3.38).
They are irregular in size, shape, course and arrangement, and the intercapillary distance is
substantially greater and more variable than that seen in normal epithelium.
If the cancer is predominantly exophytic, the lesion may appear as a raised growth with contact
bleeding or capillary oozing. Early invasive carcinomas that are mainly exophytic tend to be soft
and densely greyish-white in colour, with raised and rolled out margins (Figures 3.37 and 3.31).
28
Surface bleeding or oozing is not uncommon, especially if there is a marked proliferation of
atypical surface vessels (Figures 3.34, 3.37 and 3.40). The bleeding may obliterate the
acetowhiteness of the epithelium (Figures 3.34, 3.37 and 3.40). The atypical surface vessel
types are varied and characteristically have widened inter-capillary distances. These may take
the form of hairpins, corkscrews, waste thread, commas, tadpole and other bizarre, irregular
branching patterns and irregular calibre (Figures 3.34, 3.38, 3.40). The abnormal branching
vessels show a pattern of large vessels suddenly becoming smaller and then abruptly opening
up again into a larger vessel. All of these abnormalities can best be detected with the green (or
blue) filter and the use of a higher power of magnification; Proper evaluation of these abnormal
vessel patterns, particularly with the green filter, constitutes a very important step in the
colposcopic diagnosis of early invasive cervical cancers.
Early preclinical invasive cancer may also appear as dense, thick, chalky-white areas with
surface irregularity and nodularity and with raised and rolled out margins (Figure 8.6). Such
lesions may not present atypical blood vessel patterns and may not bleed on touch. Irregular
surface contour with a mountains- and valleys- appearance is also characteristic of early
invasive cancers (Figures 8.2-8.4, 8.6 and 8.7). Colposcopically suspect early, preclinical invasive
cancers are often very extensive, complex lesions involving all the quadrants of the cervix. Such
lesions frequently involve the endocervical canal and may obliterate the external os. Infiltrating
lesions appear as hard nodular white areas and may present necrotic areas in the center.
Invasive cancers of the cervix rarely produce glycogen and therefore, the lesions turn mustard
yellow or saffron yellow after application of Lugol's iodine (Figures 3.34, 3.36, 3.37, 3.40).
lf a biopsy is taken of a lesion that is suspicious for invasive carcinoma and the report is
negative for invasion, the responsibility rests with the colposcopist to ensure that a possibly
more generous biopsy and an endocervical curettage (ECC) be taken at a subsequent
examination. It is mandatory to take another biopsy if the pathologist reports that there is
inadequate stromal tissue present on which to base a pathological decision as to whether
invasion is present.
GLANDULAR LESIONS:
There are no obvious colposcopic features that allow definite diagnosis of adenocarcinoma in
situ (AIS) and adenocarcinoma, as no firm criteria have been established and widely accepted
for recognizing glandular lesions. Most cervical AIS or early adenocarcinoma is discovered
incidentally after biopsy for squamous intraepithelial neoplasia. It is worth noting that often AIS
co-exists with CIN. The colposcopic diagnosis of AIS and adenocarcinoma require a high degree
of training and skill.
It has been suggested that most glandular lesions originate within the transformation zone and
colposcopic recognition of the stark acetowhiteness of either the individual or fused villi in
29
discrete patches (in contrast to the surrounding pinkish white columnar villi) may lead to a
colposcopic suspicion of glandular lesions. While CIN lesions are almost always connected with
the squamocolumnar junction, glandular lesions may present densely white island lesions in the
columnar epithelium (Figure 3.41). In approximately half of women with AIS, the lesion is
entirely within the canal (Figure 3.41) and may easily be missed if the endocervical canal is not
properly visualized and investigated.
A lesion in the columnar epithelium containing branch-like or root-like vessels (Figure 3.38) may
also suggest glandular disease. Strikingly acetowhite columnar villi in stark contrast to the
surrounding villi may suggest glandular lesions (Figure 3.42)
Elevated lesions with an irregular acetowhite surface, papillary patterns and atypical blood
vessels overlying the columnar epithelium may be associated with glandular lesions (Figure
3.43). A variegated patchy red and white lesion with small papillary excrescences and epithelial
buddings and large crypt openings in the columnar epithelium may also be associated with
glandular lesions.
Invasive adenocarcinoma may present as greyish-white dense acetowhite lesions with papillary
excrescences and waste threadlike or character writing-like atypical blood vessels (Figure 3.34).
The soft surface may come off easily when touched with a cotton applicator. Adenocarcinoma
may also present as strikingly atypical villous structures with atypical vessels replacing normal
aectocervical columnar epithelium (Figure 3.45). Closely placed, multiple cuffed crypt openings
in a dense acetowhite lesion with irregular surface may also indicate a glandular lesion (Figure
3.46).
The test outcome after application of Lugol's iodine solution depends upon the desquamation
and the loss of cell layers containing glycogen. If desquamation is limited to the summit of the
stromal papillae where the squamous epithelium is thinnest, a series of thin yellow spots are
seen on a mahogany-brown background, giving a stippled appearance (Figure 4.6). When the
inflammation persists and the infection becomes chronic, the small desquamated areas become
confluent to form large desquamated areas leading to the so-called leopard- skin appearance
(Figure 4.7). These features are often found with Trichomonas infection, but also may be seen
with fungal and bacterial infections. If there is marked desquamation, the cervix appears
yellowish-red in colour, with involvement of vagina (Figure 4.8).
30
31
32
33
34
35
36
37
38
39
4
40
Chap 4: Inflammatory Lesions of the Uterine Cervix
BEFORE THE APPLICATION OF ACETIC ACID
Examination, before application of acetic acid, reveals moderate to excessive cervical and
vaginal secretions, which may sometimes indicate the nature of underlying infection. ln T.
vaginalis infection (trichomoniasis), which is very common in tropical areas, there is copious,
bubbly, frothy, malodorous, greenish-yellow, mucopurulent discharge. Bacterial infections are
associated with thin, liquid, seropurulent discharge. The secretion may be foul-smelling in the
case of anaerobic bacterial overgrowth, bacterial vaginosis, and Trichomonas infection. In the
case of candidiasis (moniliasis) and other yeast infections, the secretion is thick and curdy
(cheesy) white with intense itching resulting in a reddened vulva. Foul-smelling, dark-coloured
mucopurulent discharges are associated with inflammatory states due to foreign bodies (e.g., a
retained tampon). Gonorrhoea results in purulent vaginal discharge and cervical tenderness.
Small vesicles filled with serous fluid may be observed in the cervix and vagina in the vesicular
phase of herpes simplex viral infection. Herpetic infections are associated with episodes of
painful vulvar, vaginal and cervical ulceration lasting for two weeks. Excoriation marks are
evident with trichomoniasis, moniliasis and mixed bacterial infections.
A large coalesced ulcer due to herpes, or other inflammatory conditions, may mimic the
appearance of invasive cancer. Chronic inflammation may cause recurrent ulceration and
healing of the cervix, resulting in distortion of the cervix due to healing by fibrosis. There may
be associated necrotic areas as well. A biopsy should be directed if in doubt. Rare and
uncommon cervical infections, due to tuberculosis, schistosomiasis and amoebiasis, cause
extensive ulceration and necrosis of the cervix with symptoms and signs mimicking invasive
cancer; a biopsy will confirm the diagnosis.
If the infectious process is accompanied by marked ulceration (with or without necrosis), the
ulcerated area may be covered with purulent exudate, with marked differences in the surface
level of the cervix. There may be exudation of serous droplets.
Longstanding bacterial, fungal or protozoal infection and inflammation may lead to fibrosis,
which appears white or pink, depending on the degree of fibrosis. The epithelium covering the
connective tissue is fragile, leading to ulceration and bleeding. Appearances following acetic
acid and iodine application are variable, depending on the integrity of the surface epithelium.
In the case of cervicitis, the columnar epithelium is intensely red, bleeds on contact and opaque
purulent discharge is present. The columnar villous or grape-like appearance may be lost due to
flattening of the VILLI, to repeated inflammation and to the fact that there are no clearly
defined papillae (Figure 4.1). Extensive areas of the cervix and infected vaginal mucosa appear
red due to congestion of the underlying connective tissue.
41
AFTER APPLICATION OF ACETIC ACID
The liberal application of acetic acid clears the cervix and vagina of secretions, but may cause
pain. Cervicovaginitis is associated with oedema, capillary dilatation, enlargement of the
stromal papillae, which contain the vascular bundles, and infiltration of the stroma with
inflammatory cells. Chronically inflamed cervix may appear reddish, with ill-defined, patchy
acetowhite areas scattered in the cervix, not restricted to the transformation zone and may
bleed on touch (Figures 4.2,4.3). The enlarged stromal papillae appear as red spots (red
punctation) in a pinkish-white background, usually in the case of T. vaginalis infection, after
application of acetic acid. An inexperienced colposcopist may confuse the inflammatory
punctations with those seen in cervical intraepithelial neoplasia (CIN). However, one can
differentiate using the following criteria: inflammatory punctations are fine, with extremely
minimal intercapillary distances, and diffusely distributed (not restricted to the transformation
zone) and they involve the original squamous epithelium and vagina with intervening inflamed
mucosa. As the inflammation persists and becomes chronic, it results in large, focal red
punctations due to large collections of capillaries grouped together, which appear as several
red spots of different sizes visible in a pinkish-white background, producing the so-called
'strawberry spots’ (Figure 4.4). Colposcopically, a chronically inflamed cervix may sometimes
resemble invasive cervical cancer (Figure 4.5).
AFTER APPLICATION OF LUGOIIS IODINE
The test outcome after application of Lugol’s iodine solution depends upon the desquamation
and the loss of cell layers containing glycogen. If desquamation is limited to the summit of the
stromal papillae where the squamous epithelium is thinnest, a series of thin yellow spots are
seen on a mahogany-brown background, giving a stippled appearance (Figure 4.6). When the
inflammation persists and the infection becomes chronic, the small desquamated areas become
confluent to form large desquamated areas leading to the so-called leopard-skin appearance
(Figure 4.7). These features are often found with Trichomonas infection, but also may be seen
with fungal and bacterial infections. If there is marked desquamation, the cervix appears
yellowish-red in colour, with involvement of vagina (Figure 4.8).
42
43
44
Chap 5: Avoiding Errors in the Colposcopic Assessment Of The
Cervix And Colposcopic Provisional Diagnosis
COMMON SOURCES OF COLPOSCOPIC ERRORS

Inadequate training and experience

Inadequate understanding of the natural history of disease

Failure to use an established diagnostic protocol or deviation from the protocol

Failure to use the largest speculum possible False squamocolumnar junction
caused by abrasion

Failure to choose appropriate biopsy sites and failure to take enough biopsies

Failure to take a biopsy when in doubt

Using a blunt, non-sharp biopsy punch to obtain tissue specimens

Failure to take a colposcopically directed biopsy Failure to perform biopsies from
condylomata or Ieukoplakia

Failure to wait for the full effect of acetic acid Failure to apply Lugol’s iodine
solution and examine

Failure to examine the endocervical canal adequately when the lesion limit or
squamocolumnar junction is not seen

Failure to do endocervical curettage (ECC) when the lesion limit is not seen

Failure to perform excision when the lesion limit is not seen with an endocervical
speculum or when ECC is equivocal or positive

Failure to perform excision when microinvasion is suspected

Failure to inspect the vagina and vulva

Failure to properly and legibly record colposcopic findings

Failure to communicate with the pathologist Failure to correlate histological and
colposcopic findings

Failure to consult experts in difficult cases Failure to keep up with continuing
education Failure to self-audit.
45
Table 5.1: A summary of colposcopic features guiding provisional diagnosis
Acetowhitening
Diagnosis
Colour tone
Demarcatio
Margin
n
Surface
Relation to TZ
and SCJ
Duratio
n of
effect
Normal
Vascular
features
Iodine uptake
Bleedi
ng on
touch
Ulcera
tion
Discharge
Normal
vascular
pattern
Squamous
epithelium black
in colour;
columnar
epithelium, no
change in colour
Nil
Nil
Clear secretion
from the
columnar
epithelium
-
-
-
-
-
-
Normal,
immature
metaplasia
Pinkish white,
or snow white,
translucent,
patchy
acetowhite
areas
Nil
Indistinct,
blends with
the rest of the
epithelium
Smooth; crypt
openings,
islands of
columnar
epithelium
seen
Restricted to
TZ; prominent
near the SCJ
< 1 minute
Normal
vascular
pattern
No or partial
uptake
Nil
Nil
Clear secretion
from the
columnar
epithelium
Normal,
mature
metaplasia
Light pinkish
white hue. No
confluent
acetowhite
area
Nil
Blends with
Smooth,
the rest of the reveals crypt
epithelium
openings,
nabothian
follicles
Restricted to TZ
-
Normal
vascular
pattern
Takes up iodine,
turns black or
brown
Nil
Nil
Clear secretion
from the
columnar
epithelium
Inflammatio
n
Pale, patchy
areas, with
intervening red
areas and/or
necrotic areas
Nil
Indistinct,
Irregular,
blends with
variegated
the rest of the appearance
epithelium
Not restricted
to TZ, may be
widely
disseminated
<2
minutes
Diffusely
distributed,
fine red
punctation
involving
cervix and
vagina
Partial iodine
uptake
May be
present
May be
present
Malodorous,
profuse,
mucopurulent or
seropurulent or
non-odorous
thick, sticky,
white discharge
Low-grade
CIN
Moderately
dense, shiny,
opaque, thin
lesions
Well
demarcated
confluent
lesions
Irregular,
feathery,
jagged,
digitating,
angular or
geographic
Mostly seen in
the TZ, abuts
the SCJ. Very
early lesions
may be outside
TZ as satellite
lesions
1-2
minutes
Fine
punctation
and/or mosaic
with in the
AW lesion
may be seen
No uptake
Nil
Nil
Nil
Flat, smooth
or
microcondylo
matous or
micropapillary
46
Table 5 . 1 (cont.): A summary of colposcopic features guiding provisional diagnosis
Acetowhitening
Diagnosis
Relation to TZ
and
SCJ
Colour tone
Demarcation
Margin
Surface
High-grade
CIN
Dull, dense,
greyishwhite or
oysterwhite
opaque
lesion
Well
demarcated
confluent
lesions;
internal
demarcations
and borders
may be
present
Regular,
smooth
outlines;
occasiona
lly may
be raised
and
rolled out
Less smooth,
more irregular
and/or
occasionally
nodular
surface
Preclinical
invasive
cancer
Chalky
white,
thick,
dense,
opaque
lesions
Well
demarcated
Raised
and
rolled
out
margin
s
Irregular,
nodular or
mountainsand- valley
pattern
May involve the
entire cervix,
large complex
lesions
obliterating the
os
Overt
invasive
cancer
Dense
white areas,
may be
obliterated
by profuse
bleeding
Entire cervix
replaced by
growth
Entire
cervix
replaced
by
growth
Ulceroproliferative
growth
Entire cervix
replaced by
growth
extending to
adjacent
tissues
Restricted
to TZ,
abutting the
SCJ
47
Bleeding
on touch
Ulcerati
on
Discharge
No iodine
uptake
May be
present in
severe
lesions
Nil
Nil
Coarse raised
mosaics and/or
breaking mosaics
and/or, coarse
punctations;
atypical vessels
always present
(+++++)
No iodine
uptake
Surface
bleeding/oozing
common
May be
seen
May be
present due
to secondary
infection
Atypical vessels
always present
(++++++)
No uptake,
but bleeding
obliterates
iodine
uptake
patterns
Profuse
bleeding
Always
present
Malodorous,
blood
stained,
purulent
discharge
due to
secondary
infection
Dura
tion
of
effe
2-4
ct
minutes
Vascular features
Iodine uptake
Coarse punctation
and/or coarse
mosaic within the
AW lesion may be
seen; atypical
vessels may be
seen
(+)
>3
minutes
Whiten
ess
usually
oblitera
ted by
bleedin
g
Chap 6: Treatment of Cervical lntraepithelial Neoplasia by
Cryotherapy
Cryotherapy is a suitable and effective out patient treatment option for CIN in both low- and
high-resource settings, as it requires less financial investment for equipment and maintenance,
and can be learnt in a short period of time.
CRYOTHERAPY EQUIPMENT (FIGURE 6.1)
FIGURE 6.1: Components of cryotherapy equipment
The cryotherapy unit consists of a compressed gas cylinder (tank), a yoke with a tightening knob
and an inlet of gas to connect the gas cylinder to the cryotherapy gun through a flexible gasconveying tube, a pressure gauge showing the cylinder gas pressure, an outlet silencer, a
cryotherapy gun with handle grip, a gas trigger to allow the gas to be released to the
cryotherapy probe at high pressure and the cryotherapy probe. In most equipment, the
pressure gauge shows three colour zones: yellow, green and red. When the gas cylinder is
opened, if the pressure indicator in the gauge moves to the green zone, there is adequate gas
pressure for treatment; if the needle remains in the yellow zone, the pressure is too low and
the gas cylinder should be changed before commencing treatment; if the needle moves to the
red zone, excess pressure is indicated and this excess pressure should be released. One should
consult the manual provided by the manufacturer thoroughly for operational instructions.
CRYOTHERAPY FOR ECTOCERVICAL LESIONS
Eligibility criteria that must be met for cryotherapy are given in Table 6.1. lf the woman is
suffering from cervicitis, trichomoniasis or bacterial vaginosis, she may be offered a choice of
having either cryotherapy immediately with simultaneous antimicrobial treatment or
48
antimicrobial treatment and returning two to three weeks later for cryotherapy. If there is
evidence of pelvic inflammatory disease (PID), it is advisable to delay cryotherapy until the
infection has been treated and resolved. If there is marked atrophy due to estrogen deficiency
in an older woman and staining of the outer margin of a lesion is indistinct, cryotherapy may be
carried out after a course of topical estrogen treatment and colposcopic reassessment. The
woman must give written consent to have the treatment, after being thoroughly informed as to
how it will be performed and the probabilities of its effectiveness, adverse effects,
complications, long-term sequelae, and alternative ways that can be used to manage her
problem.
It is advisable to use the largest cylinder of refrigerant gas possible, so that a sufficient amount
of refrigerant is available to complete the treatment and the pressure forcing the refrigerant
through the probe tip is maintained at a high level so that the effectiveness of the procedure is
maintained. Standard-size tanks only allow adequate pressure to treat three women. A large
tank has the advantage of treating more women, but transport from clinic to clinic may pose a
problem.
Table 6.1: Eligibility Criteria for Cryotherapy










The entire lesion is located in the ectocervix without extension to the vagina and/or
endocervix
The lesion is visible in its entire extent and does not extend more than 2 to 3 mm into the
canal
The lesion can be adequately covered by the largest available cryotherapy probe (2.5
cm); the lesion extends less than 2 mm beyond the cryotherapy probe
CIN is confirmed by cervical biopsy/colposcopy
There is no evidence of invasive cancer
The endocervical canal is normal and there is no suggestion of glandular dysplasia
The woman is not pregnant
If the woman has recently delivered, she is at least three months post-partum
There is no evidence of pelvic inflammatory disease
The woman has given informed written consent to have the treatment
If excellent contact is achieved between the probe tip and the ectocervix (Figures 6.2 and 6.3b),
a nitrous oxide-based cryotherapy will achieve temperatures of about -89°C and the carbon
dioxide-based system will achieve -68° C at the core of the tissue ice ball. The temperature at
the edges of the frozen tissue may be around - 2O°C. Cells held at -20°C for one minute or more
will undergo cryonecrosis. The minimum temperature at the probe tip for effective freezing
49
should be -60° C. It is critical to establish and maintain good contact throughout the procedure
between the probe tip and the tissue - poor contact means a relatively large variation in the
temperatures achieved within the ice ball and therefore variable effectiveness in the target
tissue.
STEP-BY-STEP APPROACH TO CRYOTHERAPY (FIGURES 6.2 AND 6.3):
A woman should meet the eligibility criteria in Table 6.1. Generally, it is preferable to have the
diagnosis of CIN firmly established before cryotherapy is performed. However, there may be
exceptions to this general rule, and women may be offered treatment at their first colposcopy
visit to maximize treatment coverage (otherwise patients lost to follow-up would not receive
treatment for lesions) on the basis of a colposcopy diagnosis. However, directed biopsy may be
carried out before instituting cryotherapy, so that a histological diagnosis will be available to
establish the nature of the lesion treated a posteriori. The consequences of such an approach in
terms of possible over-treatment or unnecessary treatment, as well as the side-effects and
complications of the treatment procedure, should be explained and informed consent
obtained.
Figure 6.2: Positioning of the cryoprobe tip on the lesion.
50
The provider should be familiar with the cryotherapy equipment and its different components
(Figure 6.1) that will be used in a given setting. The instructions for operational use and safety
provided by the manufacturer should be read carefully. The safety regulations should be strictly
followed. Before cryotherapy is initiated, the gas tank pressure should be checked to ensure
that it is sufficient to provide an effective flow of the refrigerant through the probe tip for the
required duration of treatment. One should follow the instruction of the manufacturer in this
regard. In most models of cryotherapy equipment, a green zone in the pressure gauge indicates
adequate pressure (40-70 kg per cm2) and a yellow zone indicates low pressure (less than 40
kg/cm2). If there is adequate gas pressure in the cylinder, the indicator moves to the green
zone in the gauge, after the cylinder is opened to release the gas. If the pressure is low, there
will be insufficient freezing to give the required extent of cryonecrosis. The minimum working
pressure shown on the gauge should be 40 kg/cm2, and the freezing will be inadequate if the
pressure falls below this level. In such an event, the gas cylinder should be changed before
continuing treatment.
lf the woman is returning to the clinic on a second visit (after histological confirmation) for
treatment, colposcopic assessment should be done immediately before cryotherapy to confirm
that the location and linear extent of the lesion are amenable to effective cryotherapy.
The physician or the nurse should explain the treatment procedure to the woman and reassure
her. This is important to help the woman to relax during the procedure. After ensuring she has
emptied her bladder, she should be placed in a modified lithotomy position and the cervix
should be exposed with the largest speculum that can be introduced comfortably. The
secretions are removed with a cotton swab soaked in saline. Then 5% acetic acid is applied and
the cervix is examined with the colposcope. Following this, Lugol’s iodine is applied to delineate
the limits of the lesion. There is no need for local anaesthesia when performing cryotherapy.
The cryoprobe surface is wiped with saline to ensure adequate thermal contact with the cervix
and optimal lowering of the tissue temperature. The cryotherapy probe tip is then firmly
applied, with the centre of the tip on the os. It is obligatory to ensure that the vaginal walls are
not in contact with the cryoprobe tip. The timer is then set and the gas trigger in the cryogun is
released or squeezed to cool the cryoprobe in contact with the cervix. The gas escapes through
the pressure gauge with a hissing noise. One should be able to observe ice being formed on the
tip of the cryoprobe and on the cervix as freezing progresses. Make sure that the probe
adequately covers the lesion and the tip does not inadvertently contact and d freeze any part of
the vagina during the procedure.
51
a
d
b
c
e
f
FIGURE 6.3: Cryofreezing in progress. Note the cryoprobe covers the lesion well (a, b). Note the iceball
formation in c, d and e. Note the appearance after thawing in (f).
Cryotherapy should consist of two sequential freeze-thaw cycles, each cycle consisting of 3
minutes of freezing followed by 5 minutes of thawing (3 minutes freeze-5 minutes thaw-3
minutes freeze-thaw). The treatment time should be monitored using a stop watch. Adequate
freezing has been achieved when the margin of the ice ball extends 4-5 mm past the outer edge
of the cryotip. This will ensure that cryonecrosis occurs down to at least 5 mm depth. To
achieve this effect evenly throughout the treatment field, it is extremely important to establish
and maintain excellent contact between the probe tip and the ectocervical surface. Once the
second freeze for 3 minutes is completed, allow time for adequate thawing before removing
the probe from the cervix. When thawing is completed, the ice formation on the cryoprobe tip
is totally cleared and the probe is removed by gently rotating on the cervix. Do not attempt to
remove the probe tip from the cervix until complete thawing has occurred. After removing the
probe, examine the cervix for any bleeding. The appearance of the cervix immediately after
cryotherapy is shown in Figure 6.4a. Note the iceball formed in the cervix. The vagina should
not be packed with gauze or cotton after cryotherapy to allow the secretions to escape.
Women may be provided with a supply of sanitary pads to prevent the secretions staining their
clothes. After use, the probe tip should be wiped with 60-90% ethyl or isopropyl alcohol and
then cleaned well with boiled water and disinfected with 2% glutaradehyde and kept dry. After
the procedure is completed, the cryogun, tubing, pressure gauge and gas tank should be decontaminated by wiping with cotton soaked with 60-90% ethyl or isopropyl alcohol.
52
(a)
(b)
(c)
(d)
FIGURE 6.4: (a) The iceball on the cervix immediately after cryotherapy, (b) Appearance 2
weeks after cryotherapy. (c) 3 months after cryotherapy. (d) 1 year after cryotherapy
FOLLOW-UP AFTER CRYOTHERAPY
Women should receive instructions on self-care and what symptoms to expect after
treatment. They should be informed that they may experience some mild cramps and a clear
or lightly blood-stained watery discharge for up to 4-6 weeks after treatment. Women should
be advised not to use a vaginal douche or tampons or to have sexual intercourse for one
month after treatment. They should be instructed to report if they have any one of the
following symptoms in the six weeks after treatment: fever for more than two days, severe
lower abdominal pain, foul-smelling- pus coloured discharge, bleeding with clots or bleeding
for over two days. It is preferable to give written instructions on the above aspects and on
follow-up.
Healing takes place during the first six weeks after cryotherapy. Granulation tissue is present in
the wound during the first 2-3 weeks after cryotherapy (Figure 6.4b), which is followed by reepithelialization of the surface. Normally, the wound is totally healed within 6- 8 weeks of
treatment. The appearance of the cervix 3 months and 12 months after cryotherapy is shown in
figures 6.4c and 6.4d.
53
The effect of cryotherapy on the potential transmissibility of human immunodeficiency virus
(HIV) infection (to or from women) during the healing phase is not known. HIV-1 shedding in
the vaginal secretions after treatment of CIN in HIV- positive women has been demonstrated
(Wright et al., 2001). Therefore, the authors suggest advising all women that cryotherapy
may increase the transmissibility of HIV and that using condoms is an effective means of
prevention. Condoms should be used for a period of at least four but preferably six weeks.
Ideally, a supply of condoms should be available free of charge at colposcopy clinics in
settings where HIV infection is endemic.
Appointments should be made for a follow-up visit 6-12 months after treatment. During the
follow-up, cytology and/or VIA should be performed, followed by colposcopy and directed biopsy
depending upon the colposcopy findings, to assess the regression or persistence of lesions.
Retreatment is carried out if lesions persist. Women who are negative for neoplasia may be
referred back to a screening programme (if one exists) or advised to undergo follow-up after three
or five years.
MANAGEMENT OF WOMEN FOR WHOM CRYOTHERAPY FAILS
Treatment failure is detected in about 5-10% of women during the follow-up in the first year.
These persistent, local or multifocal lesions are more likely to occur if the original lesion was large.
To rule out the presence of unsuspected invasive carcinoma, it is advisable to biopsy all
persistent lesions and then re-treat with cryotherapy, LEEP, or cold-knife conization, as
appropriate. Follow-up evaluation may be carried out after 9-12 months in which screening
examinations such as cytology and/or VIA and colposcopy should be carried out. Those negative
for neoplasia may be referred back to a screening programme (if one exists in the region) or
advised to undergo follow-up after three or five years.
ADVERSE EFFECTS, COMPLICATIONS, AND LONG-TERM SEQUELAE
Cryotherapy is usually a painless procedure, if women have been properly reassured, their cooperation is obtained, and the procedure is carried out properly. Some women may experience
some lower abdominal pain or cramps during and after cryotherapy. Once in a while, a woman
may faint due to a vasovagal reaction. In such a situation, there is no need for panic and the
women may be revived easily. Bleeding is extremely rare after cryotherapy.
Treated women experience a watery vaginal discharge for about 3-4 weeks after treatment.
Vaginal bleeding is extremely unusual; it may be more likely to occur if freezing has been too
aggressive and the ice ball has extended well past 5 mm in depth. The risk of post-operative
infection is very slight and can probably be reduced further by delaying cryotherapy until any
woman with a likely diagnosis of pelvic inflammatory disease (PID), sexually transmitted
cervicitis (e.g., chlamydia or gonorrhea), vaginal trichomoniasis or bacterial vaginosis has been
adequately treated and recovered. If a woman presents post-operatively with a malodorous
discharge, pelvic pain and fever, the discharge may be cultured if possible, and empirical
treatment should be prescribed with antibiotics that are effective for PID. Sexual partners
54
should also be treated if the woman is diagnosed with PID, sexually transmitted cervicitis, or
trichomoniasis. In developing countries, one may consider providing presumptive treatment
with antibiotics routinely after cryotherapy (doxycycline 100 mg orally, two times a day, for
seven days and metronidazole 400 mg orally, three times a day, for seven days).
Cervical stenosis occurs in less than 1% of women; reduced mucus production occurs in 5-10%
of women. Cryotherapy has no known adverse effect on fertility and pregnancy. Invasive
cancer has rarely been reported after cryotherapy, it is usually due to missed diagnosis as a
result of poor diagnostic workup before cryotherapy.
55
Chap 7: Treatment of
by
Points to remember:
• Electrosurgical current applied to tissues can have one of three effects on
the tissue, depending on the power setting and the waveform of the
current used: desiccation, cutting, and fulguration.
• Loop electrosurgical excision procedure (LEEP) is a relatively simple
procedure that can be readily learnt.
• The key advantage of LEEP over cryotherapy is that it removes rather than
destroying the affected epithelium, allowing histological examination of
the excised tissue.
• A loop wider than the lesion(s) and the transformation zone to be
removed should be used; otherwise, the lesion should be removed with
multiple passes.
• If the lesion involves the endocervical canal, a two-layer excisional method
should be used.
• Women will have a brown or black discharge for up to two weeks after
LEEP.
• Women should be advised not to use a vaginal douche, tampon, or have
sexual intercourse for one month after LEEP.
• Moderate to severe post-operative bleeding occurs in less than 2% of
treated women and they should be seen promptly.
Electro-surgery is the use of radiofrequency electric current to cut tissue or achieve
haemostasis. A loop electrosurgical excision procedure (LEEP) operator needs to keep in mind
that electricity flows to ground along the path of the least electrical resistance. The electrical
energy used in electro-surgery is transformed into heat and light energy. The heat from a highvoltage electrical arc between the operating electrode and tissue allows the practitioner to cut by
vaporizing tissue (at 1000C) or to coagulate by dehydrating tissue (above 1000C). The cutting
56
electrodes are loops of very fine (0.2 mm) stainless steel or tungsten wire to achieve different
widths, depths, and configurations of cut (Figure 7.1).
FIGURE 7.1: Ball electrode, macro-needle style
electrode, loops.
FIGURE 7.2: Electrosurgical generator (1) and the
smoke evacuator (2)
Manufacturers of modern electrosurgical generators (Figure 7.2) are aware of the need to
control bleeding. They offer electrosurgical cutting settings that lead to some coagulation by
blending electrical currents, one with a cutting waveform and another with a coagulation
waveform. This combination is called a blended cutting waveform, and is the type of waveform
that will be referred to in this manual when electrosurgical cutting is discussed.
Coagulation using the fulguration setting and a 3- to 5- mm ball electrode is the type of
coagulation that is normally referred to in this manual (one exception is be the use of a needle
electrode to fulgurate a stubborn area of bleeding).
Electro-surgery must not be performed in the presence of flammable gases, flammable
anesthetics, flammable liquids (e.g., alcohol-containing skin- preparation solutions or
tinctures), flammable objects, oxidizing agents, or an oxygen-enriched atmosphere.
PRACTICING LEEP AND DEMONSTRATING COMPETENCE BEFORE
USE ON PATIENTS
It is mandatory that every colposcopist has practiced and demonstrated the ability to perform
LEEP adequately by simulating the excision of cervical lesions on meat (beef, pork etc.) or fruits
on which mock lesions have been painted to scale. Typewriter correction fluid or trichloroacetic
acid work well for painting mock lesions. LEEP should always be practiced using the colposcope,
as is done in actual practice. If possible, colposcopists should have experience and demonstrated
competence with cryotherapy before learning LEEP.
57
Table 7.1: The eligibility criteria that must be met before LEEP is performed
• CIN is confirmed by cervical biopsy, when possible
• If the lesion involves or extends into the endocervical canal, the distal or cranial
limit of the lesion should be seen; the furthest (distal) extent is no more than 1
cm in depth
• There is no evidence of invasive cancer or glandular dysplasia
• There is no evidence of pelvic inflammatory disease (PID), cervicitis, vaginal
trichomoniasis, bacterial vaginosis, anogenital ulcer or bleeding disorder
• If the woman has recently delivered, she should be at least three months postpartum
• Women with hypertension should have their blood pressure well controlled
• The woman must give written consent to have the treatment after being
thoroughly informed as to how it is performed and the probabilities of its
effectiveness, adverse effects, complications, long-term sequelae, and
alternative ways that are available to manage her problem
THE STEP-BY-STEP APPROACH TO LEEP
First, it must be confirmed that the woman meets the eligibility criteria in Table 7.1. If there is
evidence of pelvic inflammatory disease (PID), cervicitis, vaginal trichomoniasis, bacterial
vaginosis or anogenital ulcer, it is advisable to delay LEEP until that condition has been treated
and resolved. If there is marked atrophy due to estrogen deficiency in an older woman and
staining of the outer margin of a lesion is indistinct, it is advisable to delay LEEP until after a
course of topical estrogen treatment.
It is generally preferable to have the diagnosis of CIN firmly established before LEEP is
performed. However, there may be exceptions to this general rule, for example, in the
context of developing country settings, women may be offered treatment at their first
colposcopy visit to maximize treatment coverage (otherwise patients lost to follow-up would
not receive treatment for lesions). Expert colposcopists also may use this approach to
maximize treatment coverage and to minimize the number of clinic visits in some clinical
settings.
58
The instruments needed for LEEP should be placed on an instrument trolley or tray (Figure 7.3).
If the woman is returning to the clinic on a second visit for treatment, colposcopic assessment
should be carried out immediately before LEEP to confirm that the location and linear extent of
the lesion are amenable to effective LEEP. The application of Lugol’s iodine solution is helpful to
outline lesion margins before the start of treatment. An insulated vaginal speculum (Figure 7.3)
with an electrically insulating coating or a speculum covered with a latex condom should be used
to avoid an electrical shock to the woman in the event that the activated electrode inadvertently
touches the speculum (though this type of event usually does not cause any tissue damage
because of the relatively large area of contact). Similarly, care must be taken to avoid causing
pain by inadvertently touching the vaginal walls with the activated electrode. The later
possibility may be avoided by using an insulated vaginal sidewall retractor in addition to an
insulated vaginal speculum (Figure 7.3) or by using a speculum covered by a condom.
FIGURE 7.3: Instrument tray for LEEP
1. Kidney tray
6. Syringe for local
2. Bottles with normal
anaesthesia
saline, 5% acetic acid and
7. Needle and suture material
Lugol's iodine
8. Loops and ball electrode
3. Monsel's solution
9. Patient return electrode or
4. Bottle containing formalin
dispersive plate
5. Bottle containing local
10. Pencil with the hand switch
anaesthetic agent
11. Cotton swabs
59
Insulated vaginal speculum
Sponge-holding forceps
Insulated vaginal side-wall
retractor
15. Dissecting forceps
16. Endocervical curett
12.
13.
14.
It is ideal if the vaginal speculum used has a smoke evacuator tube attached to the luminal
surface of the anterior blade so that a source of suction can be attached. If this type of speculum
is not available, a simple suction tube (preferably made of non-conductive and non-flammable
material) may be used, and the open tip should be positioned as near as possible to the cervix. A
smoke evacuation system with a high rate of flow and a means of filtering out the smoke
particles and odour is mandatory.
Local anesthesia is achieved 30 seconds after multiple injections of a total of 5ml or less of 1%
xylocaine (or a similar agent) into the stromal tissue of the ectocervix. The injections are given
in a ring pattern 1-2 mm deep (at 3, 6, 9 and 12 o’clock positions) at the periphery of
the lesion and transformation zone using a 5ml syringe and 25- to 27- gauge needle.
The aim of the LEEP procedure is to remove the lesions and the transformation zone in their
entirety and send the affected tissue to the histo-pathological laboratory for examination.
EXCISION OF AN ECTOCERVICAL LESION WITH ONE PASS
(FIGURES 7.4 AND 7.5).
The operator should use a loop that is wider than the lesion(s) and the transformation zone
to be removed.
Figure 7.4: Excision of an ectocervical lesion with one pass
60
Figure 7.5: Excision of an ectocervical lesion with one pass. Note the excised specimen in place;
the excised specimen is removed and the appearance of the cervix after the removal of the excised
specimen.
The depth of the loop should be at least 5 mm (height from the cross bar to the farthest part of
the wire arc). Often one may use a 2.0 x 0.8 cm oval loop. To maintain the ideal geometry
and depth of cut, it is desirable to orient the surface of the ectocervix at right angles to the
handle of the cutting electrode holder - that is, to keep the cross bar parallel to the ectocervix.
To begin, local anaesthesia is administered, the electrosurgical generator is set to the
appropriate power and blended cutting setting, and the smoke evacuation system is turned on.
When the loop is poised just above the starting point, but not touching the cervical surface, the
operator activates the current with a foot pedal or finger switch on the electrode holder. The
loop is introduced into the tissue 5 mm outside the outer boundary of the lesion. It is
important not to push the electrode in, but to let it cut its own way; the operator should simply
provide directional guidance. The loop is directed gradually into the cervix until the cross bar
nearly comes in contact with the epithelial surface. Then the loop is guided along parallel to the
surface (horizontally or vertically, depending on the orientation of the direction of cutting)
until the point is reached just outside the opposite border of the lesion. The loop is then
withdrawn slowly, still keeping it at right angles to the surface. The current is switched off as
soon as the loop exits the tissue. It does not matter whether the direction of excision is right to
left or vice versa. It also is acceptable to pass the loop from the posterior to the anterior.
However, it is not acceptable to pass the loop from the anterior to the posterior, since bleeding
or excised tissue curling downward may obscure the visual field.
Once the specimen has been removed and placed in formalin, the setting on the electrosurgical
generator is changed to fulguration and the appropriate power is selected. The surface of the
excisional crater is fulgurated using 3 or 5 mm ball electrode, in the coagulation mode. The
edges of the crater should also be fulgurated to preserve the squamocolumnar junction in the
visible ectocervix. If active bleeding occurs and is difficult to control using the ball electrode, a
macro-needle style electrode can be effectively used to apply the fulguration current in a much
more concentrated (higher current density) and localized fashion to a bleeding site. If
satisfactory haemostasis has been obtained, the surface of the crater is then coated with
61
Monsel’s paste and the speculum is removed. It is a general observation that an extremely
nervous patient tends to bleed more than a relaxed one - another good reason to communicate
with the patient throughout the procedure and to try to calm her fears.
If bleeding is difficult to stop despite use of the methods outlined above, the base of the
excisional crater should be liberally coated with Monsel’s paste and the vagina packed with
gauze. The woman should be asked to wait for several hours before removing the pack. This
complication appears to occur more frequently in women with cervicitis.
EXCISION OF AN ECTOCERVICAL LESION WITH MULTIPLE
PASSES (FIGURE 7.6)
If the diameter of a lesion exceeds the width of the largest loop (usually 2 cm), the lesion must be
removed with multiple passes using one or more sizes of loop. Using the basic method described
above (Figure 7.3), the central part of the lesion usually is removed first. The remaining parts of
the lesion in the periphery are then removed by one or more separate passes. All specimens
are preserved for pathological examination.
Cancer 7.6: Excision of an ectocervical lesion with multiple passes
62
EXCISION OF ECTOCERVICAL PLUS ENDOCERVICAL LESIONS
(FIGURES 7.7 AND 7 .8)
If a lesion involves the endocervical canal and is not likely to be removed with the depth of
the usual single-layer pass as described above and shown in figures 7.4 and 7.5, a two-layer
excisional method can be used. When lesions involve the canal, most of them extend for a
linear length of 1 cm or less into the endocervical canal. Older women and women with CIN 3
are likely to have longer lesions and require a second layer - composed wholly of the
endocervical canal - to be excised.
Usually the ectocervical portion of this type of lesion that extends into the canal can be excised
by one pass of a large oval (2.0 x 0.8 cm) loop. The remaining tissue in the endocervical canal can
be excised using a smaller loop - usually a square loop with a 1.0 x 1.0 cm configuration - but
care must be taken not to go any deeper than is necessary to completely excise the lesion and a
margin of normal tissue. This type of excision can reach a maximum of 1.6 cm into the
endocervical canal (Figure 7.7). Excision of this depth should be attempted only when absolutely
necessary, due to increased risk of bleeding and stenosis as the depth of excision increases. LEEP
should not be used if the distal or upper extent of the lesion in the canal cannot be seen and if
the distal end of the lesion extends more than 1 cm into the canal. Such patients should undergo
cold-knife conization. Since this two- step method requires adequate performance of the basic
LEEP procedure, it is recommended that it should not be attempted until the operator is
comfortable and competent with the basic LEEP. Women with lesions that extend further up into
the canal need cold-knife conization to properly assess the endocervical canal.
FIGURE 7.7: Excision of ectocervical plus endocervical lesions
63
FIGURE 7.8: Excision of an ectocervical lesion extending into the endocervical canal by
a two-layer excisional method; (a) appearance of the CIN 3 lesion after 5% acetic acid
application; (b) appearance after Lugol’s iodine application; (c) excision of the ectocervical
lesion in progress; (d) ectocervical cut completed; (e) endocervical cut completed and
the specimen in place (narrow arrows); ( f ) endocervical cut specimen removed and the
bleeding points in the floor of the crater are being fulgurated to achieve haemostasis
LESIONS WITH VAGINAL EXTENSION
If the lesion extends onto the vagina, it is preferable to use the ball electrode for electrofulguration on the peripheral, vaginal part of the lesion and LEEP on the central, cervical part of
the lesion. The treatment of these vaginal lesions is beyond the scope of this manual and the
LEEP treatment referred to here deals only with the type of lesions shown in Figures 7.4, 7.6, 7.7
and 7.8 and described above. Interested readers may refer to standard text books (Wright et al.,
1992; Wright et al., 1995).
FOLLOW-UP CARE AFTER LEEP
Women should receive instructions on self-care and what symptoms to expect after
treatment. If appropriate, written instructions should be provided. Women should be advised
that they will have a brown or black discharge lasting between a few days and two weeks. They
should be advised to promptly report back if the discharge persists for more than two weeks, if
64
discharge becomes malodorous and/or is associated with lower abdominal pain or if profuse
bleeding develops. Women should be advised not to use a vaginal douche or tampons, or to have
sexual intercourse for one month. The appearance of cervix three months and one year after
LEEP is shown in Figures 7.9 and 7.10.
The effect of LEEP treatment on the potential transmissibility of HIV (to or from women)
during the healing phase is not known. HIV-1 shedding in the vaginal secretions after treatment
of CIN in HIV-positive women has been demonstrated (Wright et al., 2001). Therefore, the
authors suggest advising all women that LEEP treatment may increase the transmissibility of HIV
and that using condoms is an effective means of prevention. Condoms should be used for period
of 6-8 weeks. Ideally, a supply of condoms should be available, free of charge, at colposcopy
clinics in settings where HIV infection is endemic.
A follow-up appointment should be made for review at 9-12 months after treatment.
Management of women who have persistent disease at the follow-up visit(s) is discussed in the
next section.
FIGURE 7.9: Appearance of the cervix three
months after LEEP; note the parallel blood
vessels in the healed cervix (arrow)
FIGURE 7.10: Appearance of the cervix one
year after LEEP
65
ADVERSE EFFECTS, COMPLICATIONS, AND LONG – TERM
SEQUELAE OF LEEP
Most women experience some transitory pain from the injection of local anaesthetic into the
cervix. Severe perioperative bleeding occurs after 2% or less of LEEP procedures. Women should
be advised to contact the clinic if they have any concerns during the post- operative period. It is
advisable to give written post-operative instructions that outline the following points. Few
women complain of post-operative pain. If post-operative pain occurs, it usually is similar to
cramps; women should be instructed to use oral analgesics such as acetaminophen or ibuprofen,
if necessary. A blood-tinged, dark brown (from the Monsel’s paste) mucus discharge usually
lasts for one or two weeks after treatment. Severe and moderate post- operative bleeding occurs
in a few women, who should be seen promptly. Healing after LEEP usually takes place within a
month.
When post-operative bleeding occurs, it usually appears 4-6 days after treatment and often
from the posterior lip of cervix. This bleeding can usually be controlled by fulguration, applying
Monsel’s paste, or using a silver nitrate applicator stick. Rarely, placement of a suture at the
bleeding site is necessary. The risk of post-operative infection is very small and can probably be
reduced even more by delaying surgical treatment until any woman with a likely
diagnosis of PID, cervicitis, vaginal trichomoniasis or bacterial vaginosis has been adequately
treated and recovered. If a woman presents post-operatively with a malodorous discharge, it
should be cultured if possible and empirical treatment prescribed with antibiotics that are
effective for PID (see Table 11.1). In developing countries, it may be preferable to institute
routine presumptive treatment with antibiotics after LEEP (doxycycline 100 mg orally, two times
a day, for seven days and metronidazole 400 mg orally, three times a day, for seven days).
The squamocolumnar junction is in the endocervical canal at the follow-up evaluation in
approximately 2% of women. This presents a challenge for adequate colposcopic examination
and cytological sampling. Women should be warned that cervical stenosis, partial or complete, is
rarely encountered (probably less than 1%), but is more common in menopausal women.
Management of women with persistent lesions at follow-up
All women, regardless of whether or not the pathology report states that the excisional margins
are clear, should be followed up at 9 - 12 months from treatment to evaluate regression or
persistence of lesions and complications. Treatment failures (persistent lesion(s) at follow-up) are
detected in less than 10% of women when they are checked at the follow-up appointment. It is
advisable to biopsy all persistent lesions to rule out the presence of unsuspected invasive
carcinoma. Persistent lesions should be re-treated with cryotherapy or LEEP or cold-knife
conization, as appropriate.
66
Chap 8: Cleaning of Instruments and Materials Used for Early
Detection and Treatment of Cervical Neoplasia
A guide to the processing instruments and materials used for early detection
and treatment of cervical neoplasia
Instrument / material
Suggested procedures
Vaginal speculam, vaginal retractors, biopsy Autoclaving or disinfection with boiling water
forceps, endocervical curette, endocervical
speculum, needle holder, toothed forceps,
insulated speculum and vaginal side-wall
retractor
Gloves
Autoclaving as wrapped packs
Cryoprobes
Disinfection with 0.1% chlorine or 2% glutaral
dehyde or 6% hydrogen peroxide
Colposcope head, Stand LEEP equipment, Wipe with 60-90% ethyl, isopropyl alcohol
cryogen and regulator, cryo gas cylinder,
examination table, hand lens, aviscope, torch
lights, halogen lamp, instrument trolley, trays
The instruments should not be left in dilute bleach for more than 10 minutes and should be
cleaned in boilewater immediately after decontamination to prevent discolouration and
corrosion of metal.
DECONTAMINATION OF THE FLOOR OF THE SCREENING CLINIC
Procedure tables, trolleys, equipment (Colposcope, cryosurgical equipment, electrosurgical
generator, smoke evacuator, halogen lamp, etc.) in the screening clinic may be contaminated
with body fluids such as vaginal secretions, purulent discharge, blood, etc. While the surface of
the procedure table should be decontaminated after each patient procedure, the other
surfaces should be decontaminated on a daily basis by wiping with 0.5% chlorine solution, 6090% ethyl or isopropyl alcohol or other chemical disinfectants such as iodophors. The floor of
the screening clinic should also be decontaminated on a daily basis.
67
Reid
Feature
0 points
1 point
2 points
Colour of
acetowhite
(AW) area
Low-intensity acetowhitening; snow-white, Grey-white AW with
shiny AW; indistinct AW; transparent AW;
shiny surface
AW beyond the transformation zone
Dull, oyster-white;
Grey
AW lesion with
margin and
surface
configuaration
Feathered margins; angular, jagged
Regular lesion
lesions, flat lesions with indistinct margins; smooth, straight
micro condylomatous or micropapillary
outlines
surface
Rolled, peeling
edges; internal
demarcations (a
central area of
high- grade change
and peripheral area
of low- grade
change)
Vessels
Fine/uniform vessels; poorly formed
patterns of fine punctuations and/or fine
mosaic; vessels beyond the margin of
transformation zone; fine vessels within
microcondylomatous or micropapillary
lesions
Positive iodine uptake giving mahogany
brown colour; negative uptake of lesions
scoring 3 points or less on above three
categories
Absent vessels
Well defined coarse
punctation or
coarse mosaic
Partial iodine up-take
by a lesion scoring 4
or more points on
above three
categories –
variegated, speckled
appearance
Negative iodine
uptake by a lesion
scoring 4 or more
points on the
above three criteria
Iodine staining
Colposcopic grading performed with 5% aqueous acid and Lugol's iodine solution.
1. Microexophytic surface contour indicative of colposcopically overt cancer is not included in this
scheme.
2. Epithelial edges tend to detach from underlying stroma and curl back on themselves. Note:
Prominent low-grade lesions often are over-interpreted, while subtle avascular patches of HSIL can
easily be overlooked.
3. Score zero even if part ofthe peripheral margin does have a straight course.
4. At times, mosaic patterns containing central vessels are characteristic of low-grade histological
abnormalities. These low-grade-lesion capillary patterns can be quite pronounced. Until the
physician can differentiate fine vascular patterns from coarse, overdiagnosis is the rule.
5. Branching atypical vessels indicative of colposcopically overt cancer are not included in this
scheme.
6. Generally, the more microcondylomatous the lesion, the I_ower the score. However, cancer also
can present as a condyloma, although this is a rare occurrence.
7. Parakeratosis: a superficial zone of cornified cells with retained nuclei.
68
Colposcopic prediction of histologic diagnosis using the Reid Colposcopic Index (RCI)
Overall RCI = Histology
0 to 2 points = Likely to be CIN 1;
3 to 4 points = Overlapping lesion: likely to be CIN 1 - 2;
5 to 8 points = Likely to be CIN 2 - 3 lesions.
Grading abnormal colposcopic findings using two categories
Grade
1. Insignificant
2. Significant
Findings
The acetowhite epithelium is usually shiny or semitransparent. The
borders are not sharp, with or without fine-calibre vessels (fine
punctation and/or fine mosaic), which have ill-defined patterns and
short intercapillary distances. There is an absence of atypical vessels.
Dense acetowhite or grey opaque epithelium is sharply bordered.
There are dilated calibre, irregular shaped or coiled vessels (coarse
punctation and/or mosaic). Atypical vessels and sometimes irregular
surface contour indicate either imminent or invasive cancer.
Adapted from Coppleson et al., 1993 b
69
Jan Swasthya Sahyog
Village & Post – Ganiyari
Dist – Bilaspur (C.G)
Phone : 07753-244819,
E-mail : [email protected]
Web : www.jssbilaspur.org
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