Brief History | The Colposcope & Instrumentation | Indications | Colposcopic Exam | Benign Lesions |
Low-Grade Lesions | High-Grade Lesions | Malignant Lesions |

Brief History of Colposcopy

Colposcopy was introduced by Hans Hinselmann in 1925 in Germany. He theorized that it might be possible to detect cervical cancer at an early stage by properly illuminating and magnifying the cervix. Although the technique was widely accepted in Europe, it did not gain popularity in the U.S. or the United Kingdom primarily because of a cumbersome terminology that was difficult to translate into English.

In 1928 Shiller introduced the concept of placing iodine on the cervix to identify non-glycogen-containing areas for biopsy. This became popular in the U.S. and further delayed the acceptance of the colposcope.

In 1941 Papanicolaou and Traut published their report on the use of vaginal pool cytology for detecting cervical cancer. In 1949 Ayre developed the wooden cervical spatula, and it became possible to obtain abrasive cervical smears rather than exfoliative cytologic samples, which improved the detection of cervical neoplasia. The Pap smear, thus, became the accepted method of screening for cervical neoplasia. Cytology is an effective screening method, and colposcopy is the appropriate clinical diagnostic technique for evaluation of an abnormal pap smear.

*From the Modern Colposcopy Textbook and Atlas, Second Edition. American Society for Colposcopy and Cervical Pathology. Kendall-Hunt Publishing Co., Dubuque, 2004. Chapter 1.

The Colposcope & Instrumentation

The purpose of colposcopy is the examination of the uterine cervix and lower genital tract epithelium under magnification, identification of potentially dysplastic or cancerous areas, and performance of directed biopsies of abnormal areas to provide a histological diagnosis. Dr. Hans Hinselmann performed the first colposcopic examination by mounting lenses on a pile of books and placing an ordinary lamp above his head. The first true colposcope he developed was a fixed binocular instrument that was mounted on a tripod and equipped with a light source, with a mirror to direct the light. Since that time, a wide variety of advances have been made that improve the functioning and capabilities of the colposcope.

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Indications

Colposcopy is indicated whenever a magnified examination of cervical topography and epithelial character are needed. Common indications include:

• Grossly visible or palpable abnormality of the cervix
• Abnormal cervical cytology
• Positive screening test for cervical neoplasia such as spectroscopy, cervicography, speculoscopy or persistently positive assay for oncogenic HPV.
• Persistent unsatisfactory cervical cytology
• History of in-utero diethylstilbestrol (DES) exposure
• Unexplained cervico-vaginal discharge
• Unexplained abnormal lower genital tract bleeding
• Surveillance for lower genital tract neoplasia (cervical, vaginal, vulvar)
• Post-treatment surveillance

Basic Components of the Colposcopic Exam

Disclaimer: The following is an introduction to the basic colposcopic examination. The actual performance of colposcopy should be done only after comprehensive didactic and clinical instruction under the supervision of an experienced and well-trained colposcopist. See ASCCP Mentorship Requirements.

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Colposcopic Appearance of Benign Lesions

The International Federation for Cervical Pathology and Colposcopy classification system categorizes the findings of keratosis, erosion, inflammation, atrophy, deciduosis, and polyps under the miscellaneous category. An appreciation of these benign colposcopic findings is essential.

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Colposcopic Appearance of Low-Grade Lesions

Features that are useful to distinguish and characterize any lesion are gross appearance, aceto-whitening, vascular changes, internal and external boundaries, and iodine uptake. Low-grade lesions exhibit typical changes in most or all of these characteristics. Gross visual inspection of the cervix is an essential first step in evaluation.

The vast majority of low-grade lesions are flat with a smooth surface. The exceptions are acuminate and flat condylomas. Condylomas may arise within the transformation zone or as skip lesions within the mature squamous epithelium. Papillary spike-like projections are macroscopically apparent on the surface of acuminate warts and are visible as regular projections (asperites) on the surface of flat condylomas with colposcopic magnification.

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Colposcopic Appearance of High-Grade Lesions

A high-grade squamous intraepithelial lesion (HSIL) is a cytologic or histologic abnormality that encompasses nuclear and other cellular changes indicative of pre-invasive squamous neoplasia of a moderate to severe nature. This terminology came into use in 1988 with the creation of the Bethesda System, which standardized the nomenclature used for cervical cytology classification. “HSIL” is also used for histologic interpretations. In terms of previously accepted nomenclatures, HSIL encompasses the disease spectrum from moderate dysplasia / cervical intraepithelial neoplasia grade 2 (CIN2) to severe dysplasia / cervical intraepithelial neoplasia grade 3 (CIN3) and carcinoma-in-situ (CIS).

Cervical squamous intraepithelial lesions constitute a spectrum of disease. The divisions between CIN2, CIN3, and CIS are arbitrary and subjective. The distinction between these grades of disease on cytology or histology specimens is characterized by low inter- and intra-observer reproducibility. The use of the HSIL terminology clearly communicates an abnormality at the more severe end of the disease spectrum and is a more reliable, reproducible way to classify lesions with malignant potential.

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Colposcopic Appearance of Malignant Lesions

The most important goal of the colposcopist is to rule out the presence invasive disease. More advanced disease is often accompanied by a history of menorrhagia or other types of abnormal bleeding. Early invasive disease is commonly asymptomatic, and colposcopy allows diagnostic at a potentially curable stage.

SQUAMOUS LESIONS

Early squamous cancer of the cervix usually presents as very thick white epithelium (either acetowhite or leukoplakia) with uneven density, giving the appearance of piling of thick keratotic layers upon each other. The surface is, therefore, irregular but the borders tend to be sharply defined. In some cases, subtle ulceration can be the only feature present, and may be missed by the inexperienced examiner. Invasive cancer should be suspected in the presence of multiquadrant, high grade disease with extension into the endocervical canal. Areas of coarse punctuation and mosaicism are usually visible in the periphery of the thick, white, “mountain range”-like epithelium. Atypical vessels, which are highly variable in caliber and form, are the hallmark of invasive neovascularization. Not infrequently, hemorrhagic changes and easy contact bleeding are found. Later stages of cervical cancer defy the need for colposcopy, as large, ulcerated lesions are visible without magnification. A punch biopsy of the periphery of the lesion rather than any ulcerated portion becomes instrumental for pathological diagnosis.

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1. Early Invasive Squamous Cell Carcinoma
2. Advanced Squamous Cancer
3. Microinvasive Cancer
4. Invasive Cervical Cancer

GLANDULAR LESIONS

Adenocarcinoma in situ

The diagnosis of adenocarcinoma in situ or early invasive adenocarcinoma of the cervix is one of the most challenging aspects of colposcopy. The colposcopic findings are often subtle and nonspecific for entities that are clinically infrequent. The stark acetowhiteness of fused, irregular heaps of glandular villi can be seen in the transformation zone and maybe surrounded by completely normal glandular epithelia. Glandular neoplasia is often accompanied by high grade squamous dysplastic lesions. The vascular patterns are usually less striking than in squamous dysplasia or early cancer. Some describe the vascular changes associated with glandular dyplasias as “tendril-like”.

» Cervical Cancer Screening and Colposcopy During Pregnancy