- Is diagnosis correct? ***
- Is patient pregnant? bCHG ***
- Ensure equipment is set-up ***
- Remember: what you see as your impression is only ~50% sensitive for CIN2+, Bx may be only ~50% sensitive! Target Biopsy and consider Bx in non-lesion quadrant. Consider ECC even in adequate colposcopy. (4 Bx + ECC) ***
- Inspect cervix after speculum placed
- Apply normal saline to wipe away debris, observe vasculature location***
- Determine Adequacy *** Yes - entire Transformation Zone present from cervical crypts of original SCJ to new SCJ. No-cant see 360 of the SJC
- Apply acetic acid (Vinegar) *** and allow 60 seconds for changes to appear. Observe acetowhite staining pattern and re-apply after 2-3 minutes if more time needed
- Apply Lugols Iodine solution *** - Severe areas will appear yellow
- Integrate the saline, acetic acid, and iodine views to determine biopsy areas
- Perform Biopsy *** of most severe appearing lesions and consider 2-4 quadrant biopsy on SJC to increase sensitivity *** Have patient cough as the cervical punch biopsy is held firmly against the desired area. Use a quick motion to obtain the biopsy during the cough
- Perform Endocervical Curettage for any of 3 reasons - 1) If ectocervix doesn't reveal an obvious lesion 2) If ANY glandular findings on cytology 3) If colposcopy is deemed unsatisfactory or inadequate because the entire TZ isn't visible May consider doing on every patient, or every patient over 40 to increase sensitivity for CIN2 or >
- Apply Monsels paste & pressure to stop bleeding
- Inspect any area that has acetowhite staining on withdrawal of the speculum and ensure no trauma on other vaginal areas.
Colposcopic Diagnosis Relies on 4 Features
- colour tone and intensity of acetowhitening (well demarcated, dense, opaque, acetowhite area closer to or abutting the SCJ in the TZ after application of 5% acetic acid is critical.)
- margins and surface contour of acetowhite areas,
- CIN 2/3 - Well demarcated, regular borders, sometimes raised & rolled out; can be thick, dense chalk-like, may extend into canal and often both lips sometimes obliterating the Os)
- vascular pattern (Prior to Acetic Acid, use blue light filter & look for punctation, mosaics and atypical vessels)
- Fine Puntation & Mosaic suggest CIN 1
- Coarse Punctation & Mosaic Suggest CIN 2/ 3
- iodine staining Displastic tissue doesn't stain and stays yellow/saffron. CIN may fall off 2/2 Mechanical Force and cause ulceration.
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.
Cane be graded 2 ways
- Modified Reid Colposcopic Index
- Graded Findings Using 2 categories
- J Low Genit Tract Dis. 2011 Jul;15(3):180-8. doi: 10.1097/LGT.0b013e3181fb4547. Regardless of skill, performing more biopsies increases the sensitivity of colposcopy.
- Obstet Gynecol. 2007 Aug;110(2 Pt 1):288-95.Diagnostic utility of ECC in women undergoing colposcopy for equivocal or LGSIL. Solomon et al
- Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of CIN2 or > Pretorius et al