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Colposcopy (Ancient Greek: κόλπος, translit. Kolpos, lit. “emptiness, uterus, vagina” + skopos “to look”) is a medical diagnostic procedure for examining the cervix and vaginal tissues. Many precancerous conditions and malignant lesions in these areas have prominent characteristics that can be detected on examination. The study is carried out using a colposcope – a special device that provides an increased field of view of the areas under study, allowing the colposcope to visually distinguish between normal and abnormal emerging tissue and biopsy for further pathological examination. A colposcope is an illuminated binocular microscope connected to a video monitor that magnifies the area of interest 6 to 40 times its normal size. The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early and treating them.
Historical facts
In 1924, Ginselmann asked to write a chapter based on the etiology, symptoms, and diagnosis of uterine cancer in the third edition of the Handbook of Gynecology. Ginselmann was most successful in this task. He performed gynecological examinations and often encountered early diagnosis of cervical cancer, which, in his opinion, could only be improved by optical means. He considered it necessary to “provide an intense source of light for the enlarged image without sacrificing binocular vision”.
By 1925, he reported the construction of the first colposcope. To this end, he connected a light source to Lake’s binocular biological microscope. He connected the optical system to a stand that allowed movement in every direction and also supported a small screw for fine adjustment. After the invention of the colposcope, Ginselmann was able to state that “with respect to the so-called early problems, colposcopy makes it possible to detect earlier cases.” Even the tiny, dot-sized tumor did not disappear and was visible even at the initial magnification of 7,5 times. Thus, Ginselmann discovered a completely new invention and proved its significance in the field of medicine.
Composition colposcope
Colposcopes come in two types: those with a fixed focal length lens, whose magnification can be changed by changing the power of the eyepieces, and those with a fixed focal length lens, but with multiple magnifications, where you can change the dial setting or press a button. .
Increase
Multiple magnifications starting at x5 or x7,5, x20 or x30 are preferred. The magnification commonly used for detailed examination is × 15. The modern colposcope is based on the original prototype, but differs from the original in that the magnification varies from 6 to 40 times, as opposed to the initial 7,5 times. 10x magnification is suitable for everyday use. A higher magnification allows you to recognize some minor points, but it is not at all necessary to use it for accurate diagnosis.
The most important accessories for a colposcope are photographic equipment and special parts for teaching. Also always available on the market are simple low-power devices without any accessories, as well as more complex ones with electric control, a zoom lens with fine tuning and a camera. For routine use, a simple colposcope is fine, but for training, both a camera and a viewing tube are a must. All colposcopes have objectives, eyepieces, filters, a light source and a stand.
Lens
This in turn affects the focal length and therefore the working distance. The best focal length is between 250mm and 300mm. This makes it easy to work and manipulate tools without interfering with vision.
Eyepieces
The eyepieces should have the following good characteristics: the axes of the eyepieces can be straight or inclined at an angle of 45° to the optical axis of the device, rubber cups should be installed on them, they should have independent focusing elements that adapt to human vision. Also one very important feature is the converged line of sight for fatigue-free working.
filters
Most colposcopes are equipped with green filters. They absorb red light and improve the image of blood vessels that appear black. The contrast between normal and abnormal epithelium is also enhanced.
Light source
The light source must be at least 30 lux, must be constantly in the center and must have a rheostat to change the intensity of the light. Some equipment has automatic light control depending on the magnification used. Most colposcopes are equipped with a halogen lamp with a power of 000 to 6 W and 12 to 20 W. A recent innovation is the light-emitting diode (LED), which is the best light source. They generate light by semiconductor processes rather than heating a wire filament as in a halogen lamp. The advantage of the LED light source is that its light output is five to seven times higher than that of the lamp, this light uses a different optical system, significantly improving the contrast, and with it the overall visibility improves. The service life of an LED is many times higher (up to 75 hours) than that of a halogen lamp. It lasts up to about 10 years with about 000 hours of daily use.
Indications for the use of colposcopy
The main purpose of colposcopy is to detect intraepithelial neoplasia and early neoplasia of the cervix, vagina, and vulva.
Colposcopy is used for the following purposes:
- is an integral part of every gynecological examination in combination with cytology;
- used to display the localization of lesions;
- to clarify the nature of clinically suspect pathologies;
- used as part of the investigation of sexual violence in a forensic medical examination;
- for the diagnosis of diseases caused by papillomavirus infection;
- with changes associated with immunosuppression, such as the human immunodeficiency virus (HIV) or a transplant patient.
Indications for the mandatory use of extended colposcopy are:
- the presence of condylomas of the vagina and vulva during examination;
- pathological changes according to the results of a cytological smear;
- pathological conditions, noticeable on the mucous membrane of the cervix;
- preoperative periods and before cervical biopsy;
- scheduled examinations after treatment of diseases of the cervix.
This manipulation allows the gynecologist to diagnose such pathological processes as cervicitis – inflammation of the cervix, the presence of condylomas, papillomas, polyps, genital warts, erosion, dysplasia, cancer of the cervix and vulva, leukoplakia, erythroplakia, possible progression of precancerous and cancerous changes.
Differences between simple and extended colposcopy
An extended examination of the cervix and vagina differs from a simple procedure using certain other drugs and medical tests. In an extended study, doctors most often use:
- Three percent acetic acid. This acid tends to constrict intact blood vessels, thus all doctors must use it. The acid causes a short-term swelling of the epithelium, the blood supply to the mucosa decreases, the cells of the spinous layer swell and the subepithelial vessels contract. This allows you to accurately determine the presence of pathological conditions, types of epithelium (stratified squamous, cylindrical), assess the state of blood vessels (typical and atypical).
- Schiller’s test. This is a test with Lugol’s solution, in which iodine is present. Its property is the release of glycogen into the epithelium, staining a healthy mucosa in a dark brown color. If the cells of the stratified squamous or cylindrical epithelium are pathological, then this area will not stain. It will look like whitish spots on a dark background.
- Chrobak’s test. A method by which a doctor can recognize cancer of the vaginal part of the cervix. It is carried out by light pressure with a thin probe on suspicious areas of the mucosa. A sign of cancer is the appearance of bloody fluid.
- Color colposcopy – chromocolposcopy. This procedure is performed by gynecologists much less often. It is carried out by applying special solutions that stain the stratified squamous epithelium in blue shades, without staining the cylindrical epithelium. For example, these are solutions of hematoxylin, toluidine blue, gentian violet, methyl violet.
A simple colposcopy can be said to be a preliminary manipulation before an extended study. The cervix is opened with a vaginal speculum, any discharge on the surface is removed with swabs, and then the doctor examines the vaginal part of the cervix using a colposcope.
Preparation for the survey
There is no special preparation for patients. However, the patient may be more comfortable if she cleans her bladder and bowels before the procedure. It is also desirable to exclude sexual contact a day before the proposed manipulation, do not place any objects in the vagina, lubrication and douching are not recommended. It is necessary to inform the doctor about pregnancy or if there is such a possibility.
Method of conducting
At the initial visit of the patient to her gynecologist, the doctor collects an anamnesis, namely the number of previous pregnancies and childbirth, the course of pregnancy, previous diseases, information about the menstrual cycle, the use of contraceptives, previous smear results, the presence of allergic reactions, medication, whether there are harmful habits and other related issues.
The colposcope is used to identify visible signs that indicate abnormal tissue. It works like an illuminated binocular or monocular microscope to magnify the view of the cervix, especially the vaginal part and the vagina as a whole. Low magnification (2×6×) can be used to obtain a general view of the mucosal surface. Magnification from 8x to 25x is already used for a full assessment of the vagina and cervix. High magnification along with a green filter is often used to identify certain vascular structures that may indicate the presence of more complex precancerous or cancerous lesions. An acetic acid solution and an iodine solution are applied to the surface to improve visualization of abnormal areas.
Colposcopy is performed by a woman lying on her back on a gynecological chair. Simon’s or Cuzco’s speculum is placed in the vagina and the doctor performs a gynecological examination. Then, twenty centimeters from the area under study, the doctor sets the colposcope and adjusts its clarity. Now the cervix is illuminated by a bright beam of light. A simple colposcopy is performed, and then an extended one. Three percent acetic acid is applied to the cervix using cotton swabs. Areas of aceticity correlate with higher density. The “transformation zone” is a critical area on the cervix where precancerous and cancerous lesions are most likely to occur. Areas of the cervix that turn white after application of acetic acid or have an abnormal vascular pattern are often taken for biopsy. If no lesions are still visible, apply iodine to the cervix to help highlight abnormal areas.
After a complete examination, the gynecologist determines the areas with the highest degree of visible pathology and decides whether a biopsy is necessary. Most physicians and patients consider biopsy anesthesia unnecessary, however, some now recommend and use a local anesthetic such as lidocaine to reduce patient discomfort, especially if multiple samples are taken. The procedure without a biopsy takes up to a maximum of thirty minutes.
Complications after extended colposcopy
Colposcopy is a fairly safe diagnostic method, which rarely gives complications, if they occur in very rare cases, then they are not of a general nature. They may include bleeding from the genital tract during the first three to five days of a dark brown color, the color of Lugol’s solution, an increase in body temperature to low-grade numbers, increased menstruation. Rarely, but there are cases of infection at the biopsy site or on the endometrium after manipulation after some time.
If a biopsy was performed, then for two to three days there may be slight discomfort in the lower abdomen, which is not a reason for panic.
Contraindications for the study
It is contraindicated to carry out diagnostics within one month after an abortion, in the first two months after childbirth, after cryodestruction or after surgery on the uterus. Tests should not be performed if the patient is allergic to iodine or acetic acid.
Temporarily contraindicated colposcopy with bleeding from the uterus and menstruation, severe inflammatory processes.
Colposcopy and pregnancy
The test is done in pregnant women to determine if invasive cervical cancer exists. Since the procedure is more difficult in a pregnant woman due to several factors such as increased mucus and uterus production.
If the initial test is questionable, it should be repeated again every six to twelve weeks or 20 weeks later. Because the pregnant cervix tends to bleed excessively, a biopsy is usually avoided for fear of harming the unborn baby. Typically, a biopsy is performed on a pregnant woman if all evidence points to a huge risk of developing cancer or dysplasia. Done correctly, a colposcopy will never harm a patient if she is pregnant, and it will not harm her fetus in any way.
Research protocol
Each woman who underwent this diagnostic method is given a protocol with the results of the examination. It must be completed by the doctor who examined the patient. The list of results includes the following items: type of cervix (cylindrical, conical, hypertrophied, deformed), type of external uterine os (rounded, slit-like, lunate), rupture (yes, no, post-traumatic deformity), ectropion (yes, no), ectopia columnar epithelium (yes, no). Normal transformation zone: open glands or closed (nabothian cysts), keratinized glands. Atypical transformation zone: acetable, iodine-negative epithelium, punctuation (punctuation – tender, rough), mosaic – tender, rough. The presence of blood vessels (yes, no, the correct type, strengthening, atypical), leukoplakia (yes, no), the relief of the cervix (smooth, uneven, elevated), the presence of cicatricial changes, the syndrome of coagulated cervix, endometriosis, polyps, exophytic condylomas, inflammation (diffuse and local), atrophy, ulcers (true erosions), punctate ulcerations.
The norm of the mucous membrane of the cervix
The mucosa of the vaginal part of the cervix is covered with stratified squamous epithelium, upon examination it has a pale pink color, shines. It has a cyanotic tint in the second half of the menstrual cycle in women. The drawing of the vessels of the correct type, evenly spaced, the relief of the cervix is even. Any other pathology is a signal for further research and treatment.
It can be concluded that this research technique is absolutely safe and painless, it allows you to do both diagnostic and therapeutic measures, for example, with the help of it, polyps and condylomas are removed, a biopsy of a suspicious area is performed. The study allows you to identify inflammatory diseases, conduct differential diagnostics, identify serious pathologies in the early stages with the possibility of early treatment.