Colpos

7/10/2018 Colposcopy - UpToDate
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Colposcopy
Authors: Colleen M Feltmate, MD, Sarah Feldman, MD, MPH

Section Editor: Barbara Goff, MD
Deputy Editor: Sandy J Falk, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2018. | This topic last updated: Sep 13, 2018.
INTRODUCTION — Colposcopy is a diagnostic procedure in which a colposcope (a dissecting microscope with various magnification lenses) is used to provide an
illuminated, magnified view of the cervix, vagina, vulva, or anus (picture 1) [1]. The primary goal of colposcopy is to identify precancerous and cancerous lesions so
that they may be treated early.
Colposcopy is performed most commonly of the cervix, and is the main focus of this topic. It is used as further evaluation of abnormal cervical cancer screening
tests (cytology and/or human papillomavirus testing).
Colposcopic evaluation is based on the finding that malignant and premalignant epithelium have specific visual characteristics in terms of contour, color, and
vascular pattern that are recognizable using colposcopy. The improved visualization of epithelial surfaces with colposcopy compared with gross visual examination
enhances the colposcopist's ability to distinguish normal from abnormal areas and to obtain directed biopsies.
The techniques for colposcopy of the female lower genital tract are reviewed here. Related topics are discussed in detail separately, including:
● Cervical cancer screening (see "Screening for cervical cancer")
● Follow-up of abnormal cervical screening tests (see "Cervical cytology: Evaluation of atypical squamous cells (ASC-US and ASC-H)" and "Cervical cytology:
Evaluation of low-grade squamous intraepithelial lesions (LSIL)" and "Cervical cytology: Evaluation of high-grade squamous intraepithelial lesions (HSIL)" and
"Cervical cytology: Evaluation of atypical and malignant glandular cells")
● Anal neoplasia (see "Anal squamous intraepithelial lesions: Diagnosis, screening, prevention, and treatment")
INDICATIONS — Colposcopy is used as a follow-up test to evaluate abnormal cervical cancer screening tests (cytology and/or human papillomavirus testing
[HPV]) or abnormal findings on gross examination of the cervix, vagina, or vulva. It has not been found to be an effective screening tool for cervical cancer when
used alone [2].
The indications for cervical colposcopy based on abnormal results of cervical cytology or HPV testing are discussed in detail separately and are shown in the
algorithms (algorithm 1 and algorithm 2 and algorithm 3 and algorithm 4 and algorithm 5 and algorithm 6 and algorithm 7 and algorithm 8 and algorithm 9 and
algorithm 10) [3]. (See "Cervical and vaginal cytology: Interpretation of results (Pap test report)", section on 'Normal cytology, HPV-positive' and "Cervical cytology:
Evaluation of atypical squamous cells (ASC-US and ASC-H)" and "Cervical cytology: Evaluation of low-grade squamous intraepithelial lesions (LSIL)" and "Cervical
cytology: Evaluation of high-grade squamous intraepithelial lesions (HSIL)" and "Cervical cytology: Evaluation of atypical and malignant glandular cells".)
Additional common indications for colposcopy include [4]:
● Evaluation of a palpably or visually abnormal cervix, vagina, or vulva.
● Evaluation of a positive screening test for cervical neoplasia other than cervical cytology or HPV testing. These methods are most commonly used in low-
resource settings and include visual inspection with acetic acid or Lugol iodine, cervicography, or speculoscopy. (See "Cervical cancer screening tests: Visual
inspection methods".)
● In conjunction with treatment of cervical neoplasia with laser or other treatment modalities: to ensure that known lesions are completely removed or treated; to
detect any other lesions in surrounding areas; and for posttreatment surveillance. (See "Cervical intraepithelial neoplasia: Management of low-grade and high-
grade lesions".)
CONTRAINDICATIONS — There are no absolute contraindications to colposcopy.
It is advisable to treat active cervicitis, if present, before the examination because inflammation and infection impede accurate assessment of epithelial
abnormalities. Vaginitis due to Trichomonas vaginalis can cause cervicitis, but other vaginal infections do not affect visualization with colposcopy. However,
treatment of vaginitis before colposcopy may allow the patient to be more comfortable during the examination if the patient has vaginal discomfort or discharge.
(See "Acute cervicitis" and "Approach to women with symptoms of vaginitis".)
Anticoagulation or bleeding diatheses are not contraindications to colposcopy. Bleeding is usually minimal, even in women with these issues. (See 'Complications'
below.)
RELEVANT ANATOMY AND HISTOLOGY — The uterine cervix is a tubular fibromuscular structure that serves as the conduit between the endometrial cavity
and the vagina. The superior portion is continuous with the uterus. The cervical canal opens into the endometrial cavity at the internal os and into the vagina at the
external os.
The inferior portion of the cervix protrudes into the vagina. In some women (eg, postmenopausal, following pelvic radiation), the cervix may appear flush with the
vagina on examination rather than protruding.
The ectocervix is the surface of the cervix that protrudes into the vagina (figure 1). It is covered with squamous epithelium. The endocervix is the cervical canal,
which is lined with columnar (glandular) epithelium.
The squamocolumnar junction (SCJ) of the cervix (junction of squamous and glandular cells, generally at the external cervical os) and the transformation zone (the
transformation zone is the area between the original SCJ and the current one) are the areas at greatest risk for neoplasia (figure 2 and figure 3 and picture 2) [5].
The transformation zone is an area of squamous metaplasia that lies between the SCJ and the remainder of the squamous epithelium [6]. The transformation zone
contains embryonic cells that may be especially vulnerable to infection with human papillomavirus and to oncogenic transformation [5]. (See "Cervical and vaginal
cytology: Interpretation of results (Pap test report)", section on 'Absent EC/TZ component'.)
A comparison of normal, low-grade, and high-grade squamous lesions by cervical cytology and histology is shown in the figure (figure 4).
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The vagina is tubular and the proximal portion is the widest. The areas of the vagina that surround the protruding cervix are called the fornices. The vagina is
covered with squamous epithelium.
The vulva comprises the external female genitalia, including the labia majora, labia minora, clitoris, vulvar vestibule, external urethral meatus, and vaginal orifice.
These structures are covered with squamous epithelium.
Female pelvic anatomy is discussed in detail separately. (See "Surgical female pelvic anatomy" and "Surgical female urogenital anatomy".)
INSTRUMENTATION AND EQUIPMENT
Colposcope — The colposcope is a lighted binocular microscope that magnifies the tissue of interest (eg, cervical, vaginal, or vulvar epithelium), thereby helping
to identify features suggestive of abnormal tissue (picture 1). Specifications and set-up of the colposcope include:
● At the start of the procedure, the clinician should adjust the intraocular distance between the two eyepieces on the colposcope to ensure binocular vision.
● The colposcope should be placed approximately 30 cm from the tissue that is being visualized. Most colposcopes have a focal length (ie, working distance
between the lens and target tissue) of 30 cm. This focal length allows the colposcopist the appropriate amount of room to comfortably reach the cervix with
instruments.
● Colposcopes differ by manufacturer, and magnification can range from 3.5x to 30x. On conventional colposcopes, the head of the colposcope is moved closer
and farther from the patient, and this changes the focus, and sometimes the magnification. One type of video colposcope automatically adjusts the
magnification, depending on how close the scope is to the patient, and this is based on the focus. Fine focusing can be done by turning a knob; coarse
focusing is performed by moving the instrument toward or away from the patient.
● Low power (2x to 10x) is often used to obtain an overall impression of surface architecture and for examination of the vulva. Medium (10x to 20x) and high
(20x to 25x) powers are utilized to evaluate the vagina and cervix, with high power being particularly useful for close inspection of vascular patterns, which can
signify high-grade or invasive disease. A consistent plan for magnification (usually starting at 15x) is important so that examinations are comparable and
reproducible. In general we use a magnification of 15x for the cervix and vagina and 3.5 to 7.5x for evaluation of the vulva, as the organ is closer and thus
requires less magnification.
● The examination should begin with white light at a low-power setting for a global view of the cervix. A green filter switch is present to toggle between the two
light settings. Green filter light may help identify vascular changes.
Other supplies and instruments — Other supplies and instruments include biopsy instruments and solutions needed for the examination (eg, acetic acid) or to
control bleeding (eg, Monsel solution) (table 1). Prior to starting the examination, all necessary equipment and supplies should be readily available to the
colposcopist, and an assistant should be present throughout the procedure.
PREPROCEDURE PREPARATION
Review of history and records — A focused medical history and relevant medical records should be obtained. The biggest risk factor for cervical neoplasia is a
history of cervical neoplasia, especially recurrent or persistent abnormal results over a period of years.
The lower genital tract history and review of records should include:
● Prior cervical cytology (Pap test) and human papillomavirus tests, normal and abnormal
● Prior cervical, vulvar, and vaginal biopsy results
● History of lower genital tract cancers or precancers
● History of condyloma (genital warts)
● Treatments to the cervix, vagina, and vulva
If possible, documentation of prior abnormal results should be obtained to confirm the history. For most patients, the written reports of previous cytology and
histology are sufficient. In some cases, in our practice, we request the slides and have them reviewed by our pathology laboratory. In general, we do this when the
patient is seeing us for a second opinion or when there is a discrepancy between the cytology and biopsy result (especially when the cytology results is a high-
grade squamous epithelial lesion or adenocarcinoma in situ and we are unable to find a lesion on colposcopic examination that explains this abnormality).
In addition, a relevant medical history should be obtained, including:
● Obstetric and gynecologic history – Last menstrual period, history of sexually transmitted infections, birth control method (if appropriate), history of cervical or
pelvic surgery.
● Immunosuppression – Immunosuppression increases the risk of progression of cervical neoplasia (eg, human immunodeficiency virus infection, autoimmune
disease, history of transplant or cancer, or immunosuppressant medications).
● Smoking history – The risk of cervical neoplasia is increased in cigarette smokers.
● Factors that impact the safety of the procedure – Anticoagulation, bleeding disorders, allergy to iodine.
Informed consent and counseling — The procedure should be explained to the patient. Questions should be answered about the procedure, possible results and
prognosis, and follow-up. The discussion is documented in the medical record and a consent form is signed.
Procedural anxiety — Anxiety, pain, and compliance with follow-up after colposcopy appear to be improved by several measures, including showing an
informational video before colposcopy, playing music during colposcopy, viewing video colposcopy during the procedure, or providing a visual distraction such as a
picture on the ceiling [7-10]. Although printed information leaflets did not reduce anxiety levels, they did increase knowledge levels.
CERVICAL COLPOSCOPY — The colposcope is used to examine the entire surface for the cervix, but the most emphasis is put on examining the
squamocolumnar junction (SCJ) and transformation zone. (See 'Relevant anatomy and histology' above.)
Recommendations have been made by the American Society for Colposcopy and Cervical Pathology (ASCCP) Standards Committee to address shortcomings in
colposcopic practice. These include [11]:
● Terminology colposcopic practice – To standardize terminology for colposcopic practice and reporting of findings.
● Risk-based colposcopy practice approach – To adapt colposcopic practice based on previous level of risk or probability of finding precancer/cancer.
● Colposcopy procedures and adjuncts approach – Drafted components for comprehensive and minimum practice for colposcopy exam based on expert
opinion.
The cervical colposcopy procedure includes:
● Repeat cervical cytology (with human papillomavirus [HPV] testing, if indicated)
● Examination of vulva, vagina, and cervix under gross visualization
● Colposcopic examination of cervix and upper one-third of the vagina
● Biopsy and/or endocervical curettage, as indicated
● Documentation of findings
Abnormal colposcopic findings are used to choose the sites to biopsy. However, colposcopic findings themselves are not diagnostic of cervical neoplasia; this can
only be established definitively by pathologic examination of the biopsied tissue.
Colposcopy by an experienced colposcopist will usually detect sites of significant disease (cervical intraepithelial neoplasia [CIN] 2, 3, cancer), but some women
with a normal colposcopic examination can still have a significant histologic abnormality. For this reason, it is important to reconcile the cytologic, colposcopic, and
histologic findings in formulating a diagnosis and management plan for each woman.
To begin the procedure, the patient is placed in the dorsal lithotomy position. The vulva is examined under gross visualization for any suspicious lesions or findings
that require biopsy or colposcopic examination. A speculum is placed in the vagina; it is best to use the largest speculum that the patient can easily tolerate so that
the entire cervix and vaginal fornices may be visualized.
Colposcopy is typically well-tolerated, and anesthesia or analgesia are not usually required. A review of 19 randomized trials found no difference in pain scores in
women given an oral analgesic compared with placebo [12].
Procedure
Repeat cytology and HPV testing — Cervical cytology is repeated (with HPV testing, if indicated) (table 2). The Pap test is repeated because abnormal
cervical cytology findings (low-grade squamous intraepithelial lesion and high-grade squamous intraepithelial lesion) may resolve or progress over time. A current
cytologic result enables the colposcopist to make the most accurate correlation of cytologic, colposcopic, and histologic findings.
Traditionally, it was advised that the interval between cervical cytology tests be at least six weeks, but it appears that shorter intervals do not compromise the
adequacy of the specimen. (See "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing", section on 'Interval between
Pap tests'.)
Gross visualization — The cervix and vagina are first examined under gross visualization with a bright light, without application of solutions. If the view of the
cervix is occluded (mucus, blood, discharge, or debris), cotton soaked in saline may be used to cleanse it.
The clinician should look for and define the following features/findings:
● Erosion
● Ulceration
● Areas in which the ectocervix has an irregular surface (the surface of the ectocervix is normally smooth) – This may represent mitotically active tissue, such as
a neoplasm or condylomata
● Leukoplakia
● Pigmented lesions
● Exophytic growth
Ulcerations or erosions may be due to cervical neoplasia, but may also be due to trauma or infection. Gross inspection can often identify abnormalities. Any
abnormality that is detected should be biopsied.
Colposcopic examination
Technique — The colposcope is used to examine the entire surface for the cervix, but the most emphasis is put on examining the SCJ and transformation
zone. The SCJ (junction of squamous and glandular cells, generally at the external cervical os) and the transformation zone (the transformation zone is the area
between the original SCJ and the current one) are the areas at greatest risk for neoplasia (figure 2 and figure 3 and picture 2) [5]. (See 'Relevant anatomy and
histology' above.)
Visualization is aided by:
● Application of acetic acid – The cervix is examined first without, and then with a solution of 3 to 5 percent acetic acid. This allows improved colposcopic
visualization of abnormal areas. The acetic acid is applied generously to the cervix using a cotton swab [13]. After 30 to 60 seconds, the acidic solution
dehydrates cells so that squamous cells with relatively large or dense nuclei (eg, metaplastic cells, dysplastic cells, cells infected with HPV) reflect light and
thus appear white [14]. This is referred to as "acetowhite change." Blood vessels and columnar cells are not affected but become easier to visualize against
the white background. The acetic acid should be reapplied, as needed, after three to five minutes. If excessive acetic acid pools in the vagina, it should be
removed with dry swabs, as it can cause irritation.
● If no lesions are seen after acetic acid is applied, a dilute Lugol or Schiller solution may be applied to the cervix and vagina to aid in detection. Lugol's iodine
consists of 5 g of iodine and 10 g of potassium iodide in 100 mL distilled water [15]. Uniform uptake of stain would confirm the colposcopist's impression that
no lesion is present. Glycogen-containing cells will take up iodine and become dark brown. Nonglycogenated cells, such as normal columnar or glandular cells,
high-grade lesions, and many low-grade lesions, will not take up iodine and remain light yellow. Thus, they can be easily differentiated from normal tissue for
sampling or treatment purposes. Iodine staining should not reveal any lesions the examiner has not previously identified with saline or acetic acid.
● Differential light absorption by squamous versus glandular cells – A tissue characteristic that helps to differentiate between cell types is that squamous and
glandular cells have a differential absorption of light. The squamous cells of the ectocervix have a smooth grey-pink appearance and the glandular cells of the
endocervix have a pink-red cobblestone appearance (figure 1).
● Green or blue filter – Use of the green or blue filter on the colposcope can accentuate abnormal vasculature. Visualized through the green or blue filter, the
blood vessels appear darker and this sharpens the contrast between vessels and the surrounding epithelium.
After the cervix is examined, the upper one-third of the vagina, in particular the lateral fornices, is also examined. The transformation zone and SCJ may extend
into the upper vagina, particularly in younger patients. Abnormal vaginal findings include adenosis, polyps, cysts, diethylstilbestrol morphology, condyloma, and
changes suggestive of preinvasive or invasive disease. (See 'Vaginal colposcopy' below.)
Approach to a difficult colposcopy — In some women, it may be difficult to visualize the entire cervix or the SCJ. Guidance to address these challenges
includes:
● The SCJ is always a circumferential region around the external cervical os. However, the distance between the os and the edges of the junction varies. In
some women, the distance between the os and the edges of the junction is narrow or the SCJ is not visible because it recedes within the endocervical canal.
The location and size of the junction is altered by several factors:
• Hormonal factors – Conditions or medications that result in high serum estrogen levels (eg, pregnancy, oral contraceptives) cause the SCJ to be more
everted. If a great degree of eversion is present, the columnar epithelium is exposed to the vaginal milieu; this is referred to as ectropion. Ectropion is
common during pregnancy or in adolescents. In contrast, menopause may cause the squamocolumnar to recede into the cervical canal. (See "Congenital
cervical anomalies and benign cervical lesions", section on 'Ectropion'.)
• Prior cervical treatments – Cervical conization with removal of transformation zone may make it difficult to visualize the current SCJ.
If it is difficult to visualize the SCJ or the upper margin of a lesion, an endocervical speculum may be used or a wet cotton swab can be placed on the
ectocervix to pull the tissue aside and open the os (picture 3). The cotton swab is often less traumatic than the endocervical speculum.
● If the patient has a hypertrophied cervix or markedly redundant vagina, it is sometimes necessary to use a large cotton swab to move the cervix or attach a
single tooth tenaculum to the cervix to allow manipulation and visualization of the entire cervix and vagina.
Findings — The locations of abnormalities are noted as on the face of the clock (eg, at 2:00 or 10:00).
The type and characteristics of an abnormality may correspond with the grade of the abnormality. Thus, the colposcopist forms an impression of the severity of
disease based upon visualization. However, a colposcopic impression is not diagnostic, and biopsies must be performed to obtain histologic results. No
colposcopic findings are pathognomonic for cervical cancer. ASCCP Colposcopy Standards have been drafted that suggest both comprehensive and minimum
recommendations for documenting the colposcopic evaluation [11].
Abnormalities that should be noted during cervical colposcopy include:
● Acetowhite epithelium – Acetowhite lesions with sharp borders are more likely to be high-grade lesions, while diffuse borders suggest low-grade disease.
● Abnormal vascular patterns; these include:
• Mosaicism – Punctate (figure 5) and mosaic (figure 6) vessels (picture 3 and picture 4) in a field of acetowhite epithelium in the transformation zone are
suggestive of CIN, low-grade (picture 5A-B) or high-grade (picture 6A-C).
• Punctation – Findings consistent with punctation should be differentiated with a stippled appearance beyond the transformation zone that may be found
in patients with vaginitis (picture 7).
• Atypical vessels – Atypical vessels that have increased caliber (coarseness); display irregular and abrupt changes in direction; are widely spaced;
suddenly terminate; or have corkscrew, comma, or hairpin patterns are suggestive of microinvasive or invasive disease (picture 8).
It should be noted that inflammatory changes on the cervix can appear similar to high-grade lesions, with diffuse mosaicism and cervical friability. If the cervix
appears inflamed or if there are prior biopsies suggestive of acute inflammation, reactive changes, or follicular cervicitis, in our practice, we perform testing for
gonorrhea and chlamydia and treat the patient empirically for cervicitis with a single dose of azithromycin (oral, 1 g) prior to performing the colposcopy. If testing for
gonorrhea is positive, further treatment is required. (See "Acute cervicitis" and "Treatment of Chlamydia trachomatis infection" and "Treatment of uncomplicated
Neisseria gonorrhoeae infections".)
The 2011 International Federation of Cervical Pathology and Colposcopy colposcopic terminology of the cervix that includes the components of the examination
and the terminology to describe abnormal findings (table 3). This classification includes the following findings that are likely to correlate with abnormal histology
[16]:
● Features suggestive of low-grade disease: thin acetowhite epithelium; irregular, geographic border; fine mosaic; fine punctation (picture 5A-B).
● Features suggestive of high-grade disease: dense acetowhite epithelium, rapid appearance of acetowhitening, cuffed crypt (gland openings), coarse mosaic,
coarse punctation, sharp border, inner border sign, ridge sign (picture 6A-C).
● Features suggestive of invasive cancer: atypical vessels, fragile vessels, irregular surface, exophytic lesion, necrosis, ulceration (necrotic), tumor/gross
neoplasm (picture 8).
● Nonspecific: leukoplakia (keratosis, hyperkeratosis), erosion.
Biopsies — Cervical biopsies are obtained using long biopsy instruments that are able to reach the cervix. The Kevorkian cervical biopsy instrument (picture 9)
is most commonly used. The amount of tissue removed is approximately 1 to 2 mm. These biopsies are referred to as punch biopsies.
Local anesthesia is not routinely used for biopsies of the cervix and upper vagina, since injection of the anesthetic is probably as painful as the biopsy. Injection of
an anesthetic may also disrupt the epithelium, making visualization of the lesion more difficult. Distraction techniques (eg, visual distraction [10], music, or verbal
distraction) are as effective as local anesthetic injection, require less time, and have no risk of intravascular injection of anesthetic agents [17]. Topical and oral
analgesics are ineffective [18]. One technique is to ask the patient to cough and perform the biopsy during the cough.
Each specimen is individually labeled according to its location on the cervix as if taken from the face of a clock (eg, biopsy at 2:00 or 10:00) and each biopsy
specimen is placed in a separate, labeled container containing a permanent fixative.
There has been a shift in practice in terms of the number of biopsies performed. Traditionally, only a single biopsy was obtained from the most abnormal appearing
area of the cervix. Some of the reasons for limiting the number of biopsies were that biopsies are painful and there is a balance between biopsying every lesion and
maintaining a patient's comfort and willingness to return for care. However, it has been found that detection of CIN is enhanced by obtaining multiple biopsies [19-
22]. There appears to be no concern for harm from multiple biopsies. In a prospective study, biopsy of multiple versus single sites was not associated with an
increased likelihood of acquiring new HPV infections [19].
The best available data on this issue are from the Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesions Triage
Study, a randomized trial of evaluation of abnormal cervical cytology [22]. Observational data from this trial were used to evaluate the sensitivity of a CIN 2+
colposcopic biopsy at enrollment to detect women who were diagnosed with CIN 3+ over a two-year study period. The sensitivity of two (82 percent) or three or
more (83.3 percent) biopsies was superior to one biopsy (68 percent). ASCCP recommendations for the number and type of biopsies have been drafted based on
various strata including cytology, HPV testing, and colposcopic impression [23].
In general, in our practice, we biopsy no more than two lesions, unless there is a significant suspicion of cancer or many areas of abnormality that appear distinct
from each other. Biopsies may be taken from any part of the most abnormal appearing area or from more than one abnormal appearing area. (See 'Effectiveness'
below.)
The order of taking the biopsies should be from posterior to anterior; this is the best order to avoid bleeding that blocks visualization of the other biopsy sites. Ferric
subsulfate (Monsel's solution) is applied with either small or large cotton swabs to the biopsied areas to control bleeding. In case of significant bleeding, having
surgical and/or vaginal packs available is advisable.
For patients at an increased risk of bleeding, care should be taken to obtain very small biopsies and limit the number of biopsies obtained. Patients with risk factors
for complications should be referred to an experienced clinician for colposcopy, if available. Factors that increase the risk of bleeding from cervical biopsies include:
● Anticoagulants or bleeding disorders. Consider having Monsel's solution close by with larger Scopettes (Q-tips).
● Pregnant women.
● Biopsy of an invasive lesion can lead to severe bleeding. If a lesion that is suspicious for cancer is found, the patient should be referred to an experienced
clinician and the biopsy performed in a setting that is well equipped to deal with bleeding if it occurs, including access to vaginal packing, transfusion, an
operating room, and radiation therapy.
Endocervical curettage — Endocervical curettage (ECC) allows sampling of the endocervical canal.
In our practice, we perform ECC at colposcopy in all nonpregnant patients. Approximately 5 to 15 percent of patients with high-grade CIN are diagnosed solely
based on the ECC specimen [22,24-27]. Some data suggest that ECC increases the sensitivity of the examination, particularly in older women [24,25]. In addition,
ECC may sample cells from "skip lesions" (noncontiguous lesions) that are typical of glandular neoplasia [28].
Some clinicians do not perform ECC in all patients. If selective use of ECC is performed, the indications are:
● Atypical squamous cells, cannot rule out high-grade squamous intraepithelial lesion (ASC-H).
● High-grade squamous intraepithelial lesion (HSIL).
● Atypical glandular cells; adenocarcinoma in situ.
● ECC is not performed routinely in women with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous epithelial lesion (LSIL).
It is performed in women with these findings if:
• No lesion is visualized during the colposcopic examination
• Colposcopy is inadequate
• Ablative treatment is contemplated
● Transformation zone is not clearly visible.
● It is essential as well in women for whom ablative therapy is being considered, and when a lesion has not been found (regardless of preceding Pap).
ECC is NOT performed in pregnant women. (See 'Pregnant women' below.)
To perform an ECC, a long straight curette is inserted into the endocervical canal and used to scrape the four quadrants of the canal. An endocervical brush is then
inserted and rotated to remove any exfoliated tissue. These specimens should be collected and labeled as a specimen separate from other specimens obtained (ie,
biopsies). A drop of mucus and blood is often seen at the os after ECC, and this should be included in the specimen.
ECC samples are intended to be from the endocervical canal but may be contaminated by cells from the ectocervix (figure 1). This is particularly likely in women in
whom the transformation zone has receded into the cervical canal (eg, postmenopausal women, women with a prior cone biopsy or ablative therapy). The
specimen should be sent even if contamination is suspected. However, if neoplasia is found, it may be unclear whether the neoplasia is present on the ectocervix
or endocervix. Thus, the clinician must use their judgement and their level of suspicion that the sample was contaminated. In such cases, positive results may not
have the same implications; for example, the clinician might be more willing to follow rather than treat a patient. In our practice, if the cervical cytology was HSIL
and the ECC is positive, even if there is suspicion of contamination, we treat with excisional biopsy. If the cytology was LSIL, continued follow-up without excisional
surgery is reasonable.
An ECC that does not show endocervical tissue is an inadequate result and cannot be construed as a negative result. In such cases, if the result may impact
management, repeat sampling should be performed.
Documentation — Colposcopic examinations should be documented in a consistent and reproducible way.
Documentation should include:
● Visualization of the cervix with visualization of the SCJ. Whether the SCJ was fully or not fully visualized has been referred to previously as "adequate" or
"inadequate" examination. In the new ASCCP guidelines, "adequacy" has been replaced by documentation of the extent of SCJ visualized.
● Size and location of abnormalities.
● Whether the vagina or vulva were evaluated. This should be clearly noted. For all patients undergoing cervical colposcopy, at minimum, evaluation of the
upper fornices should be performed.
Colposcopic evaluations have classically been classified as adequate or inadequate. The standards committee of the ASCCP has recently made
recommendations to change this terminology, breaking it down into components. That is, whether or not the SCJ can be fully visualized and specifics regarding any
abnormal colposcopic findings.
● The entire SCJ and transformation zone are visualized circumferentially around the external os (figure 3 and picture 2) (see 'Relevant anatomy and histology'
above). In addition, the margins of any visible lesions must be fully identified for an adequate examination. In addition, to be an adequate examination, the
histologic results from biopsies of the lesions should explain the abnormal cytology (ie, if the cytology was high-grade and all biopsies are normal, then the
examination was not adequate).
The locations of abnormalities are noted as on the face of the clock (eg, at 2:00 or 10:00). The approximate size is documented in millimeters.
The format of documentation will vary by practice of institution, depending on whether a paper chart or electronic health record (EHR) is used. Some EHRs have
diagrams that can be drawn on. Some allow photographs or videos. This technology is particularly useful in educational settings. The clinician should be aware of
potential medicolegal issues as future retrospective review of images may identify areas of abnormality that were initially missed. An advantage, however, is that
the images may be stored as part of an EHR so that changes may be followed over time. Alternatively, the examination findings can be described in a note. An
example of a paper form is shown in the figure (form 1).
Follow-up — We ask patients to avoid vaginal intercourse for 48 hours after cervical biopsies are taken to minimize trauma to the cervix, which may result in
bleeding. Patients should be given both verbal and written instructions about how and when they will receive their results.
The provider should review the cytology and histology results and his/her colposcopic findings with consideration of the patient's age, medical conditions, and prior
cervical cytology and histology history before establishing a diagnosis and management plan.
For women with cytology that is either suggestive of possible malignancy or shows frankly malignant cells, the colposcopic examination will not be considered
adequate unless a biopsy is done that confirms the presence of cancer. In this situation, if invasive disease is not found, and a lesser lesion such as CIN 3 is
detected, repeat colposcopy by a more experienced colposcopist and review of the referring cytology slide is appropriate before considering more invasive
intervention.
Management recommendations are discussed separately [3]. (See "Cervical and vaginal cytology: Interpretation of results (Pap test report)" and "Cervical
intraepithelial neoplasia: Management of low-grade and high-grade lesions".)
Complications — Potential complications include bleeding or infection at the biopsy site.
Significant bleeding and infection are rare. For bleeding, the first measure is typically to apply ferric subsulfate (Monsel's solution) with either small or large cotton
swabs to the biopsied areas. If necessary, sustained pressure with a cotton swab or silver nitrate sticks may also be used. In rare cases of significant bleeding, the
vagina can be packed to apply pressure to the cervix. Ferric subsulfate solution and silver nitrate interfere with interpretation of biopsy specimen, so these
substances should not be applied until after all biopsies have been taken.
Infection may present as postprocedure pelvic pain, purulent discharge, or abnormal bleeding or spotting. The patient should be evaluated for cervicitis with a
pelvic examination and cervical testing for infection. In our practice, we treat these patients in the same manner as nonspecific cervicitis (eg, doxycycline
monotherapy or a combined regimen of levofloxacin and metronidazole). (See "Acute cervicitis", section on 'Physical examination' and "Acute cervicitis", section on
'Empiric therapy'.)
Effectiveness — Colposcopy is a diagnostic test used as a follow-up for women with abnormal cervical cytologic results. It has not been found to be an effective
screening tool for cervical cancer when used alone [2].
The efficacy of colposcopy to detect CIN and cervical cancer depends upon the experience and training of the colposcopist. An important factor is the ability of the
colposcopist to interpret the colposcopic findings and obtain properly directed biopsies. Among experienced colposcopists, there is good interobserver agreement
for normal epithelium, CIN 2, 3, and invasive cancer [29]. There is more interobserver variation in diagnosis of CIN1 [30]. However, this lack of agreement is also
true for histopathologic diagnosis of these entities.
Colposcopy using the 2011 International Federation of Cervical Pathology and Colposcopy criteria was able to distinguish normal cervix from CIN/carcinoma with a
sensitivity of 86 percent and specificity of 30 percent, and to distinguish normal cervix/low-grade lesions (CIN 1) from high-grade lesions (CIN 2,3 or carcinoma)
with sensitivity of 61 percent and specificity of 94 percent [16].
One explanation for limitations of the specificity of colposcopy is that acetowhite epithelium is often observed on the anterior and posterior ectocervix, even in the
absence of CIN; this may lead to unnecessary biopsies, particular in these areas [31]. However, CIN appears to be similarly distributed in all four quadrants.
The diagnostic performance of colposcopy for detection of cervical neoplasia was evaluated in a meta-analysis of 32 studies including almost 8000 colposcopic
punch biopsies; all patients subsequently underwent excisional biopsy (cone biopsy or loop electrosurgical excision procedure) and the results of excisional biopsy
were used as the reference standard. To detect CIN 2 or higher in the excisional biopsy, a colposcopic punch biopsy of CIN 1 or higher had a sensitivity of 91
percent and a specificity of 25 percent and a punch biopsy result of CIN 2 or higher had a sensitivity of 80 percent and a specificity of 63 percent [32].
Performing two or more biopsies appears to increase sensitivity [22,24]. Options include performing additional biopsies from another part of the most abnormal-
appearing lesion, from more than one abnormal-appearing area, or randomly from normal-appearing quadrants [22]. The best approach has not been studied, but
at this time random biopsies from normal-appearing cervix do not appear warranted, since this would lead to biopsy of very large numbers of women without
disease and in the absence of information about the additional cost and risks of this approach [33].
The recommendations of the ASCCP are meant to address specific needs of and provide further guidance to United States providers performing colposcopy in a
wide variety of circumstances. The 2011 international terminology still provides a standardized framework for colposcopy and does not include a "colposcopic
impression." The specific impact of the 2017 ASCCP recommendations will need to be evaluated over time.
VAGINAL COLPOSCOPY — Colposcopy of the vagina is very similar to that of the cervix, but the natural rugae and folds make the procedure more time-
consuming and difficult. A systematic approach, beginning in one quadrant and gradually working to cover all four quadrants, involves applying acetic acid
repeatedly, and noting areas of abnormal staining. Adenosis, pigmented lesions, and cysts are usually seen without the need of special stains. It is necessary to
rotate the speculum to allow the anterior and posterior vagina to be visualized. Lugol's staining is helpful in delineating lesions, and in ensuring that all abnormal
areas have been identified.
Opening the speculum as much as is feasible pulls the vaginal tissue taught so the rugated surface appears nearly flat and facilitates colposcopy; however, when
biopsy is attempted, it is helpful to partially close the speculum to allow the vagina to fold in on itself. Keeping the vagina taut makes biopsy difficult. Cysts and
adenosis are usually easy to sample. The site of the lesion is documented using the vaginal apex, urethra, and fourchette as landmarks. Appropriate terminology
should be used similar to cervical colposcopy (table 4) [34].
Practice varies regarding whether anesthesia is used for vaginal biopsies. Some clinicians use local anesthesia for all vaginal biopsies, while others use it for only
distal vaginal biopsies (the distal vagina has somatic innervation, so biopsies may be more painful; the proximal vagina has autonomic innervation).
Ferric subsulfate solution and pressure are usually all that are required for hemostasis.
VULVAR COLPOSCOPY — Vulvar colposcopy is indicated in women with:
● Visible abnormalities of the vulva

● No abnormalities of the cervix or vagina that can account for the abnormal cervical cytology
● Focal vulvar itch, pain, or burning, without a clear etiology
Vulvar colposcopy is performed in a similar manner to cervical and vaginal colposcopy. Three to 5 percent acetic acid is applied to the external genitalia. It may
take from three to five minutes for the solution to permeate the cells and for the lesion to appear white. Particular attention should be paid to periurethral and
perianal areas.
If clearly delineated lesions are noted, a vulvar biopsy is performed under local anesthesia using a 3 to 5 mm punch biopsy and silver nitrate sticks for hemostasis.
Alternately, a lesion may be excised with a scalpel and sutures placed. This may allow a lesion to be removed in entirety.
Specimens are individually labeled according to their location on the vulva (eg, numbered and diagrammed in the patient's record) and placed in separate
specimen containers. With the shift to electronic medical records, we recommend that a picture be taken and placed in the patient's medical record if possible.
PREGNANT WOMEN — If there is any possibility of pregnancy, a pregnancy test should be obtained. If pregnancy is possible and pregnancy status is uncertain,
the patient should be treated as if she is pregnant.
If colposcopy is indicated during pregnancy, in terms of timing, we prefer to see these patients early in the second trimester (12 to 15 weeks of gestation).
In general, biopsies of the ectocervix may bleed more during pregnancy. In our practice, we perform a biopsy in pregnant patients only if there are colposcopic
features of high-grade or invasive disease. Endocervical curettage is NOT performed in pregnant women because of potential trauma to the gestational sac and
heavy bleeding.
The indications for colposcopy during pregnancy are discussed in detail separately. (See "Cervical cytology: Evaluation of atypical squamous cells (ASC-US and
ASC-H)", section on 'Pregnant women' and "Cervical cytology: Evaluation of low-grade squamous intraepithelial lesions (LSIL)", section on 'Pregnant women' and
"Cervical cytology: Evaluation of high-grade squamous intraepithelial lesions (HSIL)", section on 'Pregnant women' and "Cervical cytology: Evaluation of atypical
and malignant glandular cells".)
ALTERNATIVES — Colposcopy is the "gold standard" diagnostic tool in the United States for diagnosing cervical intraepithelial neoplasia following abnormal
cervical cytology [35]; however, it is resource-intensive. The cervix can also be evaluated by other modalities. These may be divided into visualization techniques
utilizing broad-band light (eg, direct visualization, speculoscopy, cervicography, and colposcopy) and technologies utilizing electronic detection methods (eg,
Polarprobe and in-vivo spectroscopy). Four-quadrant biopsy of the squamocolumnar junction is also an acceptable alternative where equipment and experienced
personnel to perform colposcopy are not available, but pathology evaluation of the specimens is available [24,31].
● Visualization techniques — Visual inspection techniques have lower specificity than cytology and are generally used in low-resource settings where cervical
cytology and colposcopy are not feasible [36]. Visual inspection of the cervix is discussed in detail separately. (See "Cervical cancer screening tests: Visual
inspection methods".)
● Electronic screening techniques
• Polarprobe and TruScan – These devices are not widely used. They utilize the principle that both normal and abnormal cervical tissue have characteristic
electrical and optical properties which can be measured using a combination of various light and electronic frequencies. The probe is placed onto the
surface of the cervix and signals are transmitted between the cervix and the portable console. The emitted tissue "signals" are then compared
algorithmically with known signals stored in a databank of cervical tissue types.
• Spectroscopy – Spectroscopy relies on the principle of differential light emission by various tissue types. The targeted tissues have an "optical signature"
determined by the amount of light they absorb and emit. Biochemical and structural changes that underlie properties of various tissue types permit
detection of the differences between normal and abnormal cervical tissues using a specialized fluorescent probe. In comparative trials of fluorescence
spectroscopy versus colposcopy [37] and other diagnostic techniques, spectroscopy performed better. However, because these approaches add cost but
do not provide a pathologic diagnosis, their use in clinical practice is limited.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Cervical cancer screening and prevention".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education
pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education
pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-
depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)" and "Patient education:
Follow-up of low-grade abnormal Pap tests (Beyond the Basics)" and "Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond
the Basics)")
SUMMARY AND RECOMMENDATIONS
● Colposcopy is a diagnostic procedure in which a colposcope is used to provide an illuminated, magnified view of the cervix, vagina, and vulva to look for
malignant and premalignant epithelium. Malignant and premalignant epithelium have specific macroscopic characteristics relating to contour, color, and
vascular pattern that can be identified by the colposcopist for directed biopsy. (See 'Introduction' above.)
● Indications for colposcopy include further assessment of cervical cytologic abnormalities or abnormal human papillomavirus tests, women exposed to
diethylstilbestrol in utero, women with gross abnormalities of the lower genital tract, and as an adjunct to surgery of the cervix, vagina, and vulva. (See
'Indications' above.)
● The cervix and vagina are examined with a bright light and then with the colposcope, using saline if necessary. Pigmented areas and obvious lesions are
noted. Three to 5 percent acetic acid is applied to the cervix and the cervix is reexamined. A green-filter examination is subsequently performed to accentuate
abnormal vasculature. (See 'Procedure' above.)
● The colposcopic examination is considered adequate if the entire squamocolumnar junction (SCJ) is visible circumferentially around the os. Updated
recommendations by the American Society for Colposcopy and Cervical Pathology have suggested that "adequacy" be replaced by the actual description of
the SCJ as being fully visualized or not and careful documentation regarding the size and specific qualities of any abnormalities seen. We feel that this
recommendation may improve documentation of the colposcopic exam. In addition, the borders of all lesions should be completely visualized and biopsies of
the lesions should explain the abnormal cytology. (See 'Colposcopic examination' above.)
● Metaplastic cells, dysplastic cells, and cells infected with human papillomavirus (HPV) reflect light and thus appear white. Areas of white epithelium are further
evaluated for abnormal vascular patterns, such as punctation, mosaicism, or abnormal appearing vessels. (See 'Colposcopic examination' above.)
● The most abnormally appearing areas are biopsied. Biopsies are relatively contraindicated in patients on anticoagulation medication, who have a known
bleeding disorder, or who are pregnant. (See 'Biopsies' above.)
● Endocervical curettage or sampling is performed in patients with atypical squamous cells (ASC-H), high-grade squamous intraepithelial lesion (HSIL), atypical
glandular cells, adenocarcinoma in situ, and low-grade squamous intraepithelial lesion (LSIL) but no visible lesion; if ablative treatment is contemplated; and in
those with an unsatisfactory colposcopic examination. (See 'Endocervical curettage' above.)
● Colposcopy by an experienced colposcopist will usually detect patients with significant disease (HSIL, cancer), but some women with a normal colposcopic
examination can still have a significant histologic abnormality. For this reason, it is important to reconcile the cytologic, colposcopic, and histologic findings in
formulating a diagnosis and management plan for each woman and following these women closely. (See 'Effectiveness' above.)
● Patients with persistent abnormalities of cervical cytology over time or who repeatedly test positive for high-risk HPV, and whose initial colposcopy fails to
reveal a significant lesion, should have multiple colposcopies and biopsies over time to rule out a high-grade lesion. (See 'Effectiveness' above and 'Follow-up'
above.)
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Topic 3260 Version 16.0
GRAPHICS
Colposcope on a rolling stand
Reproduced with permission from: Apgar BS, Rubin MM, Brotzman GL. Principles and
technique of the colposcopic examination. In: Colposcopy Principles and Practice,
Apgar BS, Brotzman GL, Spitzer M (Eds), W.B. Saunders Company, Philadelphia
2002. p. 115. Copyright © 2002 Elsevier Science.
Graphic 80392 Version 2.0
Management of Women ≥ Age 30, who are Cytology Negative, but HPV Positive
Reprinted from: The Journal of Lower Genital Tract Disease Volume 17, Number 5, with the permission of ASCCP © American Society
for Colposcopy and Cervical Pathology 2013. No copies of the algorithms may be made without the prior consent of ASCCP.
Management of Women with Atypical Squamous Cells of Undetermined Significance (ASC-

US) on Cytology
Management of Women Ages 21-24 years with either Atypical Squamous Cells of
Undetermined Significance (ASC-US) or Low-grade Squamous Intraepithelial Lesion
(LSIL)
Management of Women with Atypical Squamous Cells: Cannot Exclude High-grade SIL
(ASC-H)
Management of Women Ages 21-24 yrs with Atypical Squamous Cells, Cannot Rule Out
High Grade SIL (ASC-H) and High-grade Squamous Intraepithelial Lesion (HSIL)
Management of Women with Low-grade Squamous Intraepithelial Lesions (LSIL)
Management of Pregnant Women with Low-grade Squamous Intraepithelial Lesion (LSIL)
Management of Women with High-grade Squamous Intraepithelial Lesions (HSIL)
Initial Workup of Women with Atypical Glandular Cells (AGC)
Subsequent Management of Women with Atypical Glandular Cells (AGC)
Uterine cervix anatomy and histology
Cell types comprising the transformation zone. The endocervix is lined by columnar epithelium. The ectocervix is lined with
stratified squamous epithelium. The squamocolumnar junction marks the merging point of these two epithelial cell types.
Asset provided by Anatomical Chart Company. Reproduced with permission from: Altered cells and tissue. In: Applied Pathophysiology:
A Conceptual Approach to the Mechanisms of Disease, 3rd Edition, Braun CA, Anderson CM (eds), Philadelphia: Lippincott Williams &
Wilkins, 2017. Wolters Copyright © 2017 Wolters Kluwer Health. www.lww.com.
Cervical transformation zone histology
The active T-zone has immature metaplasia at the squamocolumnar junction as the squamous cells migrate over the villi. When
they form glycogen, they become mature and are resistant to human papillomavirus infection.
Reproduced with permission from Kenneth Hatch, MD, University of Arizona, Department of Obstetrics and Gynecology. Copyright © 2016.
Cervical squamocolumnar junction and transformation zone
SCJ: squamocolumnar junction.
Cervical transformation zone at colposcopy
A cervical transformation zone with mature metaplasia and active immature metaplasia.
Reproduced with permission from Kenneth Hatch, MD, University of Arizona, Department of Obstetrics and Gynecology. Copyright ©
2016.
Terminology and histology of cervical intraepithelial neoplasia
Terminology regarding cytologic and histologic precancerous changes of the uterine cervix. The
corresponding terminology from the previous classification systems is shown. Images of the histologic
correlates for each category are also shown.
LAST: lower anogenital squamous terminology; LSIL: low-grade squamous intraepithelial lesions; HSIL: high-grade
squamous intraepithelial lesions; CIN: cervical intraepithelial neoplasia.
* CIN 2 that is p16-positive is classified as HSIL. CIN 2 that is p16-negative is classified as LSIL.
References:
1. Darragh TM, Colgan TJ, Thomas Cox J, et al. The Lower Anogenital Squamous Terminology Standardization
project for HPV-associated lesions: background and consensus recommendations from the College of
American Pathologists and the American Society for Colposcopy and Cervical Pathology. Int J Gynecol Pathol
2013; 32:76.
2. Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of
cervical cytology. JAMA 2002; 287:2114.
Colposcopy equipment and supplies
General colposcopy equipment Supplies

Colposcope Pap test supplies (liquid based cytology or glass slide
and fixative, spatula, cytobrush)
Speculums (variable sizes)
3 to 5 percent acetic acid
Cervical punch biopsy instruments
Schiller's solution
Endocervical curettes
Large and small cotton swabs
Tenaculum
Silver nitrate sticks
Endometrial sampling devices
Monsel's solution
Additional equipment and supplies
Small histology jars with permanent fixative and
Ring or sponge forceps labels
Needle holder Povidone-iodine
Long Debakey forceps 1 percent lidocaine (with and without epinephrine)
Anoscope, clear plastic 22-gauge spinal needle and 10-cc syringe
Vulvar biopsy supplies (consent form, povidone-iodine, 1 percent lidocaine, small syringe with 27-gauge needle, 3 to 5 Pantiliners
mm punch biopsy instruments, suture removal kit, silver nitrate sticks)
Suture material
Written material
Chux pads
Consent forms
Documentation forms
Post-biopsy instructions
Educational materials
Cervical cancer screening recommendations from United States professional organizations*
Recommended screening test

Age to Post-
Age to initiate and frequency
Organization discontinue hysterectomy for HPV vaccination
(years) Age 21 to 29 Age ≥30
(years) benign disease
(years) (years)
ACS/ASCCP/ASCP 21 ¶ 65 Δ Pap test every three One of these methods: Not indicated ◊ Same
(2012) years (preferred) Co-testing (pap recommendations as
test and HPV unvaccinated women
testing) every
five years
(preferred)
Pap test every
three years
ASCCP/SGO (2015 21 N/A Can consider primary Can consider primary N/A N/A
interim guidelines) HPV testing every HPV testing every
three years for women three years
age ≥25
USPSTF (2018) 21 65 § Pap test every three One of these methods: Not indicated ¥ Same
years Pap test every recommendations as
three years unvaccinated women
hrHPV testing
alone every five
years
Co-testing (pap
test and HPV
testing) every
five years
ACOG (2016) 21 65 ‡ One of these methods: One of these methods: Not indicated † Same
Pap test every Co-testing (pap recommendations as
three years test and HPV unvaccinated women
Can consider testing) every
primary HPV five years
testing every (preferred)
three years for Pap test every
women age ≥25 three years
Can consider
primary HPV
testing every
three years for
women age ≥25
ACP (2015) 21 65 § Pap test every three One of these methods: Not indicated ¥ N/A
years Pap test every
three years
Alternative: Co-
testing (pap test
and HPV testing)
every five years
HPV: human papillomavirus; ACS: American Cancer Society; ASCCP: American Society for Colposcopy and Cervical Pathology; ASCP: American Society for Clinical Pathology; SGO:
Society of Gynecologic Oncology; USPSTF: United States Preventive Services Task Force; ACOG: American College of Obstetricians and Gynecologists; ACP: American College of
Physicians; hrHPV: high-risk human papillomavirus; DES: diethylstilbestrol; HIV: human immunodeficiency virus; CIN: cervical intraepithelial neoplasia.
* These guidelines are intended for the general population and are not intended for women who have a history of cervical cancer, high-grade cervical precancers, DES in utero exposure,
or who are immunocompromised, as with HIV infection.
¶ Regardless of the age of sexual initiation or other risk factors.
Δ For women with evidence of adequate negative prior screening (three consecutive negative cytology results or two consecutive negative co-tests within the previous 10 years, with the
most recent test within the previous five years) and no history of CIN 2 or greater within the last 20 years. Screening should not be resumed for any reason, even if a woman has a new
sexual partner.
◊ For women who have had a benign hysterectomy with removal of the cervix who do not have a history of CIN 2, CIN 3 in the past 20 years, or a history of cervical cancer ever.
Evidence of adequate negative prior screening not required.
§ For women with evidence of adequate negative prior screening, specified as three consecutive negative cytology results or two consecutive negative co-tests within the previous 10
years, with the most recent test within the previous five years.
¥ For women who have had a benign hysterectomy with removal of the cervix who do not have a history of CIN 2 or higher.
‡ For women with no history of CIN 2 or higher with evidence of prior adequate screening (three or more negative cytology test results in a row or two consecutive negative co-tests in
the past 10 years, with the most recent within the past five years).
† For women who have had a benign hysterectomy with removal of the cervix who do not have a history of CIN 2, CIN 3, or cervical cancer. Women in whom a negative history cannot
be documented should continue to be screened.
Reference:
1. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology
screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin 2012; 62:147.Curry SJ. Screening for cervical cancer: United States Preventive
Services Task Force recommendation statement. JAMA 2018; 320:674.
2. Cervical cytology screening. ACOG Practice Bulletin No. 157. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 127:e1
3. Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol 2015; 136:178.
http://dx.doi.org/10.1016/j.ygyno.2014.12.022.
4. Sawaya GF, Kulasingam S, Denberg TD, et al. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American
College of Physicians. Ann Intern Med 2015; 162:851.
Colposcopy of the cervix: Punctation and mosaicism with swab technique to evert
transformation zone
Cotton swab is used to avert the anterior lip of the cervix to see the entire lesion. With complete visualization of the
transformation zone, examination is adequate.
2016.
Colposcopy of the cervix: Punctation histology
Punctation occurs when the columnar villi blood vessels are recruited to feed the neoplastic tissue.
Colposcopy of the cervix: Mosaicism histology
Mosaic is formed when the neoplasia replaces glands and the vascular network forms a circle.
CIN: cervical intraepithelial neoplasia.
Colposcopy of the cervix: Ridge sign and mosaicism
(A) Large transformation zone before application of acetic acid.

(B) After application of acetic acid, showing ridge sign.
(C) After acetic acid has faded, showing mosaicism.
Low grade cervical intraepithelial lesion
This lesion represents a geographic map-like, low-grade dysplasia. The lesion

itself is irregular, and it extends to the posterior cervical portio.
Reproduced with permission from: Rubin MM, Barbo DM. Colposcopic assessment
system. In: Colposcopy Principles and Practice, Apgar BS, Brotzman GL, Spitzer M
(Eds), W.B. Saunders Company, Philadelphia 2002. p. 216. Copyright © 2002
Elsevier.
Colposcopy of the cervix: Cervical intraepithelial neoplasia, low-grade
CIN 1 transformation zone completely seen.
2016.
High grade cervical intraepithelial lesion
Coarse punctation is seen on the anterior lip of the cervix.
Reproduced with permission from: Brotzman GL, Apgar BS. Abnormal transformation
zone. In: Colposcopy Principles and Practice, Apgar BS, Brotzman GL, Spitzer M
(Eds), W.B. Saunders Company, Philadelphia 2002. p.186. Copyright © 2002
Elsevier.
Colposcopy of the cervix: Cervical intraepithelial lesion, high-grade
CIN 2. The outer border is smooth and distinct.
2016.
Colposcopy of the cervix: Cervical intraepithelial neoplasia, high-grade with abnormal vessels
Cervical intraepithelial neoplasia, grade 3.
Colposcopy of the cervix: Vaginitis
(A) Low-power view of cervix in a patient with high-grade cervical intraepithelial neoplasia (CIN3) and trichomonas vaginitis.
(B) Cervical intraepithelial lesion, grade 3. Cuffed gland sign, sometimes seen in high-grade cervical neoplasia. Stippled appearance consistent with trichomonas vaginitis and
cervicitis.
Colposcopy of the cervix: Invasive cervical carcinoma
(A) Invasive cervical cancer, abnormal branching blood vessels.

(B) Invasive cervical cancer, abnormal loop blood vessels.
HPV: human papillomavirus.
2011 IFCPC cervical colposcopy nomenclature
General assessment Adequate/inadequate for the reason (ie, cervix obscured by inflammation, bleeding, scar)
Squamocolumnar junction visibility: completely visible, partially visible, not visible
Transformation zone types 1, 2, 3
Normal colposcopic findings Original squamous epithelium

Mature
Atrophic
Columnar epithelium
Ectopy
Metaplastic squamous epithelium
Nabothian cysts
Crypt (gland) openings
Deciduosis in pregnancy
Abnormal colposcopic General principles Location of the lesion: inside or outside the T-zone, location of the lesion by clock position
findings Size of the lesion: number of cervical quadrants the lesion covers, size of the lesion in percentage of cervix
Grade 1 (minor) Thin acetowhite epithelium Fine mosaic

Irregular, geographic border Fine punctuation
Grade 2 (major) Dense acetowhite epithelium Coarse mosaic

Rapid appearance of acetowhitening Coarse punctuation
Cuffed crypt (gland) openings Sharp border
Inner border sign
Ridge sign
Non-specific Leukoplakia (keratosis, hyperkeratosis), erosion

Lugol's staining (Schiller's test): stained/non-stained
Suspicious for invasion Atypical vessels

Additional signs: fragile vessels, irregular surface, exophytic lesion, necrosis, ulceration (necrotic), tumor/gross neoplasm
Miscellaneous finding Congenital transformation zone Stenosis

Condyloma Congenital anomaly
Polyp (ectocervical/endocervical) Post-treatment consequence
Inflammation Endometriosis
IFCPC: International Federation for Cervical Pathology and Colposcopy.
From: Bornstein J, Bentley J, Bosze P, et al. 2011 Colposcopic Terminology of the International Federation for Cervical Pathology and Colposcopy. Obstet Gynecol 2012; 120:166. DOI:
10.1097/AOG.0b013e318254f90c. Copyright © 2012 American College of Obstetricians and Gynecologists. Reproduced with permission from Lippincott Williams & Wilkins. Unauthorized
reproduction of this material is prohibited.
Kevorkian cervical biopsy forceps
Reproduced with permission from: Abu-Rustum NR, Ungar L, Alektiar K, Chi DS. Cancer of the cervix. In: TeLinde's
Operative Gynecology, 11th ed, Jones HW, Rock JA (eds), Lippincott Williams & Wilkins, 2015. Copyright © 2015
Lippincott Williams & Wilkins (www.lww.com). Unauthorized reproduction of this material is prohibited.
Colposcopy form
2011 International Federation of Cervical Pathology and Colposcopy colposcopic terminology
Section Pattern
General assessment Adequate or inadequate for the reason (eg, cervix obscured by inflammation, bleeding, scar)
Squamocolumnar junction visibility: completely visible, partially visible, not visible
Transformation zone types 1, 2, 3
Normal colposcopic Original squamous epithelium: mature, atrophic

findings
Columnar epithelium, ectopy/ectropion
Metaplastic squamous epithelium, nabothian cysts, crypt (gland) openings
Deciduosis in pregnancy
Abnormal colposcopic General principles

findings
Location of the lesion: inside or outside the transformation zone, location of the lesion by clock position
Size of the lesion: number of cervical quadrants the lesion covers
Size of the lesion as percentage of cervix
Grade 1 (minor): fine mosaic; fine punctation; thin acetowhite epithelium; irregular, geographic border
Grade 2 (major): sharp border, inner border sign, ridge sign, dense acetowhite epithelium, coarse mosaic, coarse punctation, rapid appearance of
acetowhitening, cuffed crypt (gland) openings
Nonspecific: leukoplakia (keratosis, hyperkeratosis), erosion
Lugol's staining (Schiller's test): stained or nonstained
Suspicious for invasion Atypical vessels
Additional signs: fragile vessels, irregular surface, exophytic lesion, necrosis, ulceration (necrotic), tumor or gross neoplasm
Miscellaneous findings Congenital transformation zone, condyloma, polyp (ectocervical or endocervical), inflammation, stenosis, congenital anomaly, posttreatment
consequence, endometriosis
Reproduced with permission from: Bornstein J, Bentley J, Bosze P, et al. 2011 Colposcopic Terminology of the International Federation for Cervical Pathology and Colposcopy. Obstet
Gynecol 2012; 120:166. Copyright © 2012 Lippincott Williams & Wilkins.

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7/10/2018 Colposcopy - UpToDate

Official reprint from UpToDate®

Authors: Colleen M Feltmate, MD, Sarah Feldman, MD, MPH

● Cervical cancer screening (see "Screening for cervical cancer")

Additional common indications for colposcopy include [4]:

● Evaluation of a palpably or visually abnormal cervix, vagina, or vulva.

CONTRAINDICATIONS — There are no absolute contraindications to colposcopy.

INSTRUMENTATION AND EQUIPMENT

● Prior cervical, vulvar, and vaginal biopsy results

● History of lower genital tract cancers or precancers

● History of condyloma (genital warts)

● Treatments to the cervix, vagina, and vulva

In addition, a relevant medical history should be obtained, including:

● Smoking history – The risk of cervical neoplasia is increased in cigarette smokers.

The cervical colposcopy procedure includes:

● Repeat cervical cytology (with human papillomavirus [HPV] testing, if indicated)

● Examination of vulva, vagina, and cervix under gross visualization

● Colposcopic examination of cervix and upper one-third of the vagina

● Biopsy and/or endocervical curettage, as indicated

Visualization is aided by:

Abnormalities that should be noted during cervical colposcopy include:

● Abnormal vascular patterns; these include:

● Nonspecific: leukoplakia (keratosis, hyperkeratosis), erosion.

● High-grade squamous intraepithelial lesion (HSIL).

● Atypical glandular cells; adenocarcinoma in situ.

• No lesion is visualized during the colposcopic examination

• Ablative treatment is contemplated

● Transformation zone is not clearly visible.

ECC is NOT performed in pregnant women. (See 'Pregnant women' below.)

Documentation — Colposcopic examinations should be documented in a consistent and reproducible way.

Documentation should include:

● Size and location of abnormalities.

Complications — Potential complications include bleeding or infection at the biopsy site.

VULVAR COLPOSCOPY — Vulvar colposcopy is indicated in women with:

● Visible abnormalities of the vulva

● Focal vulvar itch, pain, or burning, without a clear etiology

● Electronic screening techniques

SUMMARY AND RECOMMENDATIONS

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Colposcope on a rolling stand

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Management of Women with Atypical Squamous Cells of Undetermined Significance (ASC-

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Management of Women with Low-grade Squamous Intraepithelial Lesions (LSIL)

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Management of Pregnant Women with Low-grade Squamous Intraepithelial Lesion (LSIL)

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Management of Women with High-grade Squamous Intraepithelial Lesions (HSIL)

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Initial Workup of Women with Atypical Glandular Cells (AGC)

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Subsequent Management of Women with Atypical Glandular Cells (AGC)

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Uterine cervix anatomy and histology

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Cervical transformation zone histology

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Cervical squamocolumnar junction and transformation zone