To further assess abnormalities detected on cervical cytological sample. To guide colposcopically directed biopsy

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2 To further assess abnormalities detected on cervical cytological sample To guide colposcopically directed biopsy To exclude invasive disease To aid in outpatient management and treatment of precancerous lesions To assist follow-up after treatment. 2

3 One cervical sample with borderline nuclear changes in squamous cells that are high-risk HPV positive mild dyskaryosis changes in squamous cells that are high-risk HPV positive mild dyskaryosis changes in squamous cells with unreliable or inadequate results for HPV test

4 One cervical sample showing borderline nuclear changes in endocervical cells moderate or severe dyskaryosis possible invasion glandular neoplasia

5 Three consecutive inadequate cervical samples Any grade of dyskaryosis following treatment for CIN before return to routine recall abnormal cervical sample of any grade over a 10year period Suspicious symptoms and abnormal cervix.

6 For centres that have not yet introduced triage with HPV DNA testing in women with borderline or lowgrade findings in cytology, the previous indications are used: Three cervical samples showing borderline nuclear changes in squamous cells. One cervical samples showing mild dyskaryosis.

7 Colposcopy is deemed satisfactory when : The entire squamocolumnar junction is visualised and the upper limit of any lesion is seen. The size and topography of the lesion should be ascertained, especially if there is any extension of the lesion into the cervical canal or onto the vagina.

8 No absolute contraindication Should be deferred until - Menstrual bleeding ceases - Acute cervicitis or vulvovaginitis treated Women who have an indication for colposcopy and are pregnant should undergo the procedure - The aim of this examination is to exclude invasive disease and postpone any cervical biopsy or treatment until the postnatal period. 8

9 Transformation zone 9

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11 Zone I: Original Squamous epithelium Zone II: The Transformation Zone Zone III: Original Columnar epithelium II III I

12 The TZ is identified on colposcopy by an area which contains 1) Gland openings 2) Islands of non transformed columnar epithelium 3) Nabothian follicles 4) Metaplastic epithelium pale aceto white

13 Gland islands Metaplasia Mature Sq E NF

14 Normal vascular patterns 27 Jan

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16 Dissolves mucus Induces intracellular dehydration Causes coagulation of protein As a result cells with increased N/C ratio Nuclear density Chromosomal aneuploidy become opaque

17 After the application of acetic acid the squamous epithelium appears dull and pale in contrast to the usual pink hue; the columnar epithelium looks less dark red, with pale acetowhitening of the villi. Squamous metaplasia may appear as a patchilly distributed glassy, pinkish-white membranes, with crypt openings, with tongue-like projections pointing towards the external os.

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19 Both the original and mature squamous metaplastic epithelium stain mahogany brown or black with Lugol s iodine solution, while columnar epithelium does not. Immature squamous metaplastic epithelium usually does not stain with iodine or may partially stain if it is partially glycogenated.

20 Schillers test 20

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22 Abnormality within the TZ is more important than the abnormality outside Abnormality within the immature TZ (closer to sharp new SCJ) is more significant than within the mature TZ(closer to indistinct old SCJ).

23 Angio-architecture abnormality: best studied immediately after applying normal saline Epithelial cell abnormality: best studied after applying 3% acetic acid Schiller s test with Lugol s iodine

24 1)Punctation - fine (CIN I) or coarse (CIN II) focal (CIN) or diffuse (Inflam) 2)Mosaic - (CIN II/III)

25 Punctations 25

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28 3)Atypical vessels - irregular branching and direction,branches may be bigger than the main vessel Types: 1) comma, cork screw: Microinvasive 2) bizarre : Invasive

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31 Epithelial Abnormality Acetowhite areas 1)Pale, transparent, indistinct border metplasia 2)Semitransparent with jagged/geographic/feathery border CIN I/HPV infection 3)Opaque, sharp border CIN II/III

32 Lugols iodine--lugol s iodine application is negative in immature squamous metaplasia, atrophy, and cervical intraepithelial neoplasia,high grade due to a lack of glycogenation of the squamous epithelium. partial iodine uptake, is associated with slight aceto-white change may be immature metaplasia or low-grade intraepithelial neoplasia Complete iodine negativity is more suggestive of high-grade neoplasia.

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34 Colposcopic prediction of histologic diagnosis using the Reid Colposcopic Index (RCI) RCI (overall score) Histology 0-2 : CIN Overlapping lesion : CIN 1 or CIN : CIN 2-3 DISADVANTAGES - subjective, is prone to intraobserver variability, and commonly produces inconclusive findings.