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COLPOSCOPE – AN EMERGING

BIOMEDICAL INSTRUMENTATION

TECHNIQUE TOWARDS WOMEN’S

HEALTH

 A.S.Yadugiri, G.Aishwarya.

II B.E. (BiomedicalEngineering)

Dept. of Biomedical Engineering

Rajalakshmi Engineering College,

Thandalam, Chennai – 602105

E-mail: sweetrose_pinky@rediffmail.com

 

ABSTRACT:

The proposed paper discusses an emerging biomedical

instrumentation technique towards achieving women health.

This technique is known as Colposcopy. Colposcopy is the

"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. Colposcopymay include a biopsy of lesions with characteristics of 

malignancy and premalignancy, such as acetowhite changes,

abnormal vascular patterns, and failure to uptake iodine stain.

Endocervical sampling may accompany colposcopy,

  particularly in the evaluation of nonpregnant women with

cytology results of atypical glandular cells and

adenocarcinoma in situ. Satisfactory colposcopy requires

visualization of the entire squamocolumnar junction and

margins of any visible lesions. While most midwives do not

  perform colposcopy, they will provide the pre- and

  postprocedure education, counseling, and evaluation of 

  patients undergoing the procedure. This paper discusses in

detail the Colposcope instrument, its technical features,

accessories, and various applications where it can be

effectively used. The paper also discusses 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.

 Keywords — cervical cancer, pap smear, biopsy

Introduction

 

Colposcopy is a medical diagnostic procedure to

examine an illuminated, magnified view of the cervix and the

tissues of the  vagina  and  vulva.Colposcope consists of 

stereoscopic binocular microscope euipped xit an central

illuminating device of high intensity which is used to inspect

cervix,vagina and vulva. Many premalignant lesions and

malignant  lesions in these areas have discernible

characteristics which can be detected through the examination.

It is done using a  colposcope, 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. The

main goal of colposcopy is to prevent cervical  cancer   by

detecting precancerous lesions early and treating them.

Reliance on papanicolausmear for a cervical neoplasia

detection delayed acceptance of coloposcopy in North

America. More than 20 years passed before colposcope

technique could play a significant role in evaluation and

treatment of cervical neoplasia.The procedure was developed

in 1925 by the German physician Hans Hinselmann.

One of the most frightening times in a woman's life is when

the gynecologist calls and says her Pap smear results areabnormal. Although you might think an abnormal Pap smear 

means you have cervical cancer, the fact is that the majority of 

abnormal Pap smears are not caused by cervical cancer. The

more likely cause of abnormal Pap smear results is

inflammation or a vaginal infection. Because the Pap smear is

a screening tool and not a diagnostic tool, your gynecologist

may want to take a closer look at your cervix to determine the

cause of your abnormal Pap smear results. He will perform an

examination called a colposcopy. Your doctor may order this

 procedure if you have Pap smear results which: 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, theworse 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.

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2.INSTRUMENTATION:

Manipulation, magnification, light intensity and

the type of green filter/red filter vary slightly from oneinstrument 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.

3.MATERIALS REQUIRED:

• Bi-valved cuscos speculum of different size either metal

or plastic disposable

• 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.

3.1.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.

3.2.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.

4.HOW TO PREPARE YOU FOR COLPOSCOPY:

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 teh test's accuracy.

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5.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.

6.INDICATIONS AND USES:

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.

• If a patient has a serious abnormality (CIN II or 

worse)

7.PROCEDURE:

Colposcope

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 toidentify 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.

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 dorsal lithotomy 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

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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.

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 havea thin coffee-ground like discharge for up to several days after 

the procedure.

1) After the Procedure:

Following the colposcopy, you should wear a sanitary pad.

Small amounts of bleeding may occur for 3-5 days. You may

see on the pad dark fluidlike material, sometimes green,

resembling coffee grounds. The fluid is normal because you

are expelling the solutions used during the exam. However,

you should avoid douching, sexual intercourse, vaginal

medications, or tampons until the bleeding stops.

8.SIGNIFICANCE OF COLPOSCOPY FINDING IN

NON NEOPLASTIC LESIONS

Some colposcopic findings that often the signal aneo-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

GRADING COLPOSCOPIC FINDINGS 

Grade I Flat, white epithelium with or without a

regular pattern of fine calibre vessels

fine caliber vessels

 

Grade I Flat, white epithelium with or without a

irregular pattern of coarse caliber vessels

 

Grade III Very white epithelium with or without a

irregular pattern of Coarse caliber coiled or 

bizarre branching BVS usuall Wide

intercapillary distance an a irregular surfacecontour.

 

 Histological correlation

GRADING COLPOSCOPIC FINDINGS 

Grade I Normal to CIN- I

Grade II CIN –II

Grade III CIN-III-early invasion to Frank 

Carcinoma.

It is possible for Colposacopist with vast experience to

differentiate various forms of cervical intra epithelial

neoplasia from each other and from early invasive cancer on

  basis of Colposcopy alone . This temptation to make a

histological diagnosis should be resisted and any abnormal

area must be biopsied and confirmed by histology.

CIN – III AND MICRO INVASIVE CARCINOMA.

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The CIN III lesions which generally progress to early invasive

carcinoma or frank carcinoma are characterized by

abnormally thickened acetowhite epithelium atypical blood

vessels, increased intercapillary distance, coarse and irregular 

 punctuation and mosaic and irregular surface contour. As

malignancy advances these changes becomes more and more

 pronounced

9.UNSATISFACTORY COLPOSCOPY

There are certain situations where Colposcopic examinations

remains unsatisfactory. They are

1. Atrophy (postmenopausal)

2. Following conization or Hysterectomy.

3. Following Cryotherapy.

4. 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.

10.POINTS TO REMEMBER.

1. 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.

2. To perform a Colposcopy , it is essential to

•

Devote time for careful and methodicalexaminations .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.

3. Person should be properly and adequately trained

  before he starts interpreting the Colposcopic findings.

Doctors has attempted to classify the three levels of 

expertise.

i) Ability to recognize the lesion , which in

his opinion

3-4 months of staining .

ii) the ability to sample by directly biopsy of 

most advancedarea of the lesion which requires a year of 

training.

iii) 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.

11.COMPLICATIONS:

Significant complications from a colposcopy are not common,

  but may include bleeding, infection at the biopsy site or 

endometrium, and failure to identify the lesion. Monsel's

solution and silver nitrate interfere with interpretation of 

 biopsy specimen, so these substances should not be applied

until all biopsies have been taken. Most patients experience

some degree of pain during the curettage, and almost all

experience pain during the biopsy.

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CONCLUSION:

ACKNOWLEDGEMENTS

The authors wish to thank the Chairperson andPrincipal, 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.

R EFERENCES

Dr. Lakshmi Dhandapandian (gyn)

Sundaram Medical Foundation

Chennai

Mr.Subash (Biomedical engineer)

Sundaram Medical FoundationChennai