A.S.YADUGIRI & G.AISHWARYA.

Colposcope Technique Rajalakshmi Engineering College II B.E Biomedical Engineering BY A.S.YADUGIRI & G.AISHWARYA.

What is Colposcopy ? • Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix and the tissues of the vagina and vulva. • The procedure was developed in 1925 by the German physician Hans Hinselmann. • During the colposcopy, the gynecologist focuses on the areas of the cervix where light does not pass through. • Abnormal cervical changes are seen as white areas -- the whiter the area, the worse the cervical dysplasia. • Abnormal vascular (blood vessel) changes are also apparent through the colposcope. Typically, the worse that the vascular changes are, the worse the dysplasia. by A.S.Yadugiri & G.Aishwarya

Goals of Colposcopy • The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early and treating them Colpocsope consists of a steroscopic binocular microscopic equipped with a centre illuminating device of high intensity. • Many premalignant lesions and malignant lesions in these areas have discernible characteristics which can be detected through the examination,which provides an enlarged view of the areas, allowing the colposcopist to visually distinguish normal from abnormal appearing tissue and take directed biopsies for further pathological examination. by A.S.Yadugiri & G.Aishwarya

IFCPC Colposcopic Classification • Normal Colposcopic findings • Abnormal Colposcopic findings • Colposcopic findings suggestive of invasive cancer • Unsatisfactory Colposcopy • Miscellaneous findings by A.S.Yadugiri & G.Aishwarya

Instrumentation • Manipulation, magnification, light intensity and the type of green filter/red filter vary slightly from one instrument to another. • Most of the colposcope have the microscope on a movable floor stand to enable easy transportation. • Also there are light source does not generate heat, hence convenient to both patient and examiner. • The main parts are binocular tube, magnification changer(or stepper) with 5x10x20xmagnification,field of vision 32nm.angle leveller- tilting 30(deg) up & downwards, objective lens-300nm,eye piece-15x,source:24-250w,halogen cold light source by A.S.Yadugiri & G.Aishwarya

Materials Required • Sponge- holders • Sigleys forceps and self retaining endo cervical speculum • Karvokian forceps, punch biopsy forceps • Endo cervical curettes of different size • Cotton tipped swabs, gloves,finger stalks,glass slides, diamond marking pencil, slide fixatives, spatulas(ayres), bottles containing 10% formalin for biopsy materials. by A.S.Yadugiri & G.Aishwarya

Materials Required SOLUTION: • Normal saline, 3% of acetic acid, lugols iodine, meta cresol sulphonic acid 5 grams of salicylic acid in 100 ml of 70% alcohol is available. • Different size of the speculum with blade curvature varying must be available to suit the individual needs very high speculum cause discomfort to the patients and may slip off. Length more than 10cm is hardly required. Cut the rubber glove insertion for speculum facilitates to keep the vaginal wall apart especially in pregnant women. Sim’s speculum is not normally used because two speculums are required and a assistant is also necessary to hold the forceps, disposable light plastic speculum are ideal and causes very light deiscomfort to the patient. COLPOSCOPY TECHNIC: • Examination of vulva and vagina must be done initially as a conventional method then a suitable sized bivalve cusco’s speculum should be inserted gently and examined. Intial examination of cervix should be made for type of mucous and bleeding. by A.S.Yadugiri & G.Aishwarya

How to Prepare ? • First - Relax, it will not be as bad as you think it will be. • Take 600-800 mg of Aleve or Advil one hour before leaving for your doctor's office. If you are allergic to ibuprofen, take two Extra-Strength Tylenol. • Make sure you have not started nor will start your period for about two weeks. • Do not use anything in the vagina for 24-48 hours before the procedure. This includes spermicides, vaginal medications, douching products or tampons. These all interfere with the accuracy of the test. • Do not have vaginal sex 24 - 48 hours before the procedure because this can also interfere with the test's accuracy. by A.S.Yadugiri & G.Aishwarya

How to Perform Colposcopy • It is performed by woman lying on her back, legs placed on stirrups and buttocks at the lower edge of the table. • The height of table should be comfortable for both patient and the doctor. • The colposcope when postioned to 6-7cm for the introitus,portio vaginalis of cervix, and the outer third of endocervical canal can be seen and examined at a magnification of 5x10x20x in stepped manner. • Working distance between the microscope objective and the patient should be minimum 300mm(1 foot) 400mm working distance objective may be required as per the examiner choice • A speculum is placed in vagina after the vulva is examined by any suspicious lesion. by A.S.Yadugiri & G.Aishwarya

Indications For Colposcopy • Most women undergo a colposcopic examination to further investigate a cytological abnormality on their pap smears. Other indications for a woman to have a colposcopy include: • The Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test) is a screening test used in gynecology to detect premalignant and malignant (cancerous) processes in the ectocervix. Significant changes can be treated, thus preventing cervical cancer. The test was invented by and named after the prominent Greek doctor Georgios Papanikolaou. An anal Pap smear is an adaptation of the procedure to screen and detect anal cancers. • assessment of diethylstilbestrol (DES) exposure in utero Diethylstilbestrol (DES) is a drug, an orally active synthetic nonsteroidal estrogen that was first synthesized in 1938. In 1971 it was found to be a teratogen when given to pregnant women. by A.S.Yadugiri & G.Aishwarya

Colposcopic examination with biopsy is indicated for the following reasons: Persistent minimal abnormality on Pap smear Major abnormality on Pap smear Lesion noted on routine gynaecologic examination In utero exposure to diethylstilbestrol(DES) or drugs. Criteria for colposcopic examination in a woman with abnormal papsmear followed by the hospital of the university of Pennsylvania If the mild dysplasia (CIN I ) persist on 2-3 or more pap smears over a 6-12 month period, the patient should undergo colposcopic evaluation If hyperkeratosis or parakeratosis persist for more than one year colposcopic examination is valuable to rule out a potentially serious lesions. Indications and Uses by A.S.Yadugiri & G.Aishwarya

Procedure • During the initial evaluation, a medical history is obtained, including gravidity (number of prior pregnancies), parity (number of prior deliveries), last menstrual period, contraception use, prior abnormal pap smear results, allergies, significant past medical history, other medications, prior cervical procedures, and smoking history. In some cases, a pregnancy test may be performed before the procedure. The procedure is fully described to the patient, questions are asked and answered, and she then signs a consent form. • A colposcope is used to identify visible clues suggestive of abnormal tissue. It functions as a lighted binocular microscope to magnify the view of the cervix, vagina, and vulvar surface. Low power (2× to 6×) may be used to obtain a general impression of the surface architecture. Medium (8× to 15×) and high (15× to 25×) powers are utilized to evaluate the vagina and cervix. The higher powers are often necessary to identify certain vascular patterns that may indicate the presence of more advanced precancerous or cancerous lesions. Various light filters are available to highlight different aspects of the surface of the cervix. Acetic acid solution and iodine solution (Lugol's or Schiller's) are applied to the surface to improve visualization of abnormal areas. by A.S.Yadugiri & G.Aishwarya

Procedure • Colposcopy is performed with the woman lying on her back, legs in stirrups, and buttocks at the lower edge of the table (a position known as the dorsallithotomy position). A speculum is placed in the vagina after the vulva is examined for any suspicious lesions. • Three percent acetic acid is applied to the cervix using cotton swabs. The transformation zone is a critical area on the cervix where many precancerous and cancerous lesions most often arise. The ability to see the transformation zone and the entire extent of any lesion visualized determines whether an adequate colposcopic examination is attainable. • Areas of the cervix which turn white after the application of acetic acid or have an abnormal vascular pattern are often considered for biopsy. If no lesions are visible, an iodine solution may be applied to the cervix to help highlight areas of abnormality by A.S.Yadugiri & G.Aishwarya

Procedure • After a complete examination, the colposcopist determines the areas with the highest degree of visible abnormality and may obtain biopsies from these areas using a long biopsy instrument. Some doctors consider anesthesia unnecessary, however, many colposcopists now recommend and use a topical anesthetic such as lidocaine or a cervical block to diminish patient discomfort, particularly if many biopsy samples are taken. • Following any biopsies, an endocervical curettage (ECC) is often done. The ECC utilizes a long straight curette to scrape the inside of the cervical canal. The ECC should never be done on a pregnant woman. Monsel's solution is applied with large cotton swabs to the surface of the cervix to control bleeding. This solution looks like mustard and becomes black in color when exposed to blood. After the procedure this material will be expelled naturally: women can expect to have a thin coffee-ground like discharge for up to several days after the procedure. • Experience some degree of pain during the curettage, and almost all experience pain during the biopsy. by A.S.Yadugiri & G.Aishwarya

Significance of Colposcopy finding in Non NeoPlastic Lesions Some colposcopic findings that often the signal a neo-plastic change may occur in non-neoplastic condition such as • Normal metaplasia • Infection • Infiammation • Regeneration and repair following trauma • Cautery and Cryo Surgery • The presence of an a typical TZ though highly suggestive does not prove that neoplasia exists there are three grades by A.S.Yadugiri & G.Aishwarya

Significance of Colposcopy finding in Non NeoPlastic Lesions by A.S.Yadugiri & G.Aishwarya

Unsatisfactory Colposcopy There are certain situations where Colposcopic examinations remains unsatisfactory. They are • Atrophy (postmenopausal) • Following conization or Hysterectomy. • Following Cryotherapy. • Following laser therapy. • ATROPHY: In post menopausal woman the squamo-columnar junction is not seen on Colposcopy while mucosa is found to be thin with fine branching blood vessels. Pretreatment with estrogen may help. An endocervical curettage is mandatory. • CONIZATION: Squamo-columnar junction is not seen adequately; rather it is distosted due to scarring .Endocervical curettage is important. Diagram of intial lesion is useful for localization of likely source of reccurrence. • HYTERECTOMY: Aceto-white epithelium in vagina ,vascular appearance of puncatations , schiller’s testing may be helpful • CRYO – THERAPY :Following this squamo-columnar junction is not seen in 15-20% cases. Further treatment depends on cytology. If normal no problem. • LASER THERAPY :Squamu-columnar junction is easily visible – with large areas of acetowhite epithelium. It is narmal. It sheds immature cells. • Following local therapy cytology remains abnormal for atleast 3-4 months. Cells shed from original lesions or reparative cells. So initial correct diagnosis isrequired. Other situations when Colposcopy is unsatisfactory is when lesion extent into the endocervical canal.Husbond and wife both must be investigated for papillomatous lesion .Real solution is long term follow-up. by A.S.Yadugiri & G.Aishwarya

Points to Remember • Before starting Colposcopy one should have in hand detailed history examination and cervical smear report. If smear report is abnormal one should thoroughly search the ectocervix, endocervix and vagina. • To perform a Colposcopy , it is essential to • Devote time for careful and methodical examinations .rapid Colposcopy is useless. Largest • size cusco’s speculum should be used. • Diagrammatic documentation should be precise and accurate, even if Colpophotographs are • taken. • To take biopsy whenever any unexpected lesion is found and its appearance cannot be • explained. • Beginner should take many more biopsies. • A through knowledge of Colposcopy and histopathological findings. • Endocervical curettage should be done, when Colposcopy is unsatisfactory. • Person should be properly and adequately trained before he starts interpreting the Colposcopic findings. Doctors has attempted to classify the three levels of expertise. • Ability to recognize the lesion , which in his opinion 3-4 months of staining . • The ability to sample by directly biopsy of most advanced area of the lesion which requires a year of training. • The ability to predict histopathology from colposcopic Pattern a skill which may take several years respective of time taken, the requirement for adequate training cannot be over emphasized to forestall the un fortunate consequences. by A.S.Yadugiri & G.Aishwarya

Conclusion Colposcopy is regarded as "gold standard" tool for diagnosing cervical abnormalities after an abnormal pap smear. Colposcopy is used to evaluate women with genital tract abnormalities and abnormal cervical cytology. It is an office-based procedure during which the cervix is examined under illumination and magnification before and after application of dilute acetic acid.This paper has discussed in detail the Colposcope instrument, its technical features, accessories, and various applications where it can be effectively used. The paper also discussed newer visualization techniques like direct visualization, speculoscopy, cervicography, and colposcopy and electronic detection methods , which are less expensive and can be performed with significantly less training. by A.S.Yadugiri & G.Aishwarya

Acknowledgements • The authors wish to thank the Chairperson and Principal, for all the facilities provided and all the staff members of the department of Biomedical Engineering who have rendered their support, guidance and encouragement to us in the making of this paper. by A.S.Yadugiri & G.Aishwarya

References Dr. Lakshmi Dhandapandian (gynaecologist) Sundaram Medical Foundation Chennai Mr.Subash (Biomedical engineer) Sundaram Medical Foundation Chennai Dr.Revathi Ananth BASCO Chennai. by A.S.Yadugiri & G.Aishwarya

A.S.YADUGIRI & G.AISHWARYA.