COLOR ATLAS OF

COLPOSCOPY

Cervix, Vagina & Vulva

V. Cecil Wright, MD, FACOG, FRCS(C)

COLOR ATLAS OF
COLPOSCOPY

Cervix, Vagina & Vulva

V. Cecil Wright, MD, FACOG, FRCS(C)

Professor
Department of Obstetrics and Gynaecology
The University of Western Ontario
London, Ontario Canada
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 PREFACE

The variety of images examined during cervical colposcopy is endless and sorting
them out is endlessly fascinating. Even normal metaplasia, by which glandular
epithelium is transformed into squamous epithelium, presents a multitude of
appearances. Most colposcopists can interpret blood vessel arrangements and detect
acetowhite epithelium. Most can predict the histology in squamous disease using
Adolf Stafl’s five criteria (surface contour, color tone, vessel configuration,
abruptness of demarcation and intercapillary distance). But glandular lesions are
poorly understood by many of even the most experienced colposcopists because
they are encountered so rarely and because their features are only now being
delineated. The existence of colposcopic mimics, in which completely different
histology produces similar or virtually identical colposcopic appearances, complicates
the situation. This is why a biopsy is always required on the cervix.

Colposcopic evaluation of the vagina, vulva and adjacent sites presents an entirely
different array of features to interpret. Expertise is only achieved by evaluating a
large number of cases, either in actual practice or by studying images in print, film,
video or electronic form. The author hopes that this work, and particularly the
important new material on glandular disease, will contribute to excellence in the
contemporary practice of colposcopy.

The clinical information and illustrations in this volume come from the author’s
many years devoted to colposcopy in which he has evaluated more than 25,000
newly referred patients with abnormal cytology or other lower genital tract
pathology.

The information contained in this book is not only intended to introduce new
material but also to review established concepts and supplement the knowledge of
the practicing colposcopist. This information is advisory only and is not intended
to replace sound clinical judgment. The reader is advised to constantly review
medical publications, manufacturers’ recommendations and any package
information related to the practice of colposcopy.

V. Cecil Wright, MD

i
 CONTENTS

CONTENTS

Preface ................................................................................................................... i

CHAPTERS

1. The Colposcope .......................................................................................... 1

2. Instrumentation and Clinical Set-up ............................................................ 9

3. Steps in the Basic Colposcopic Examination ............................................... 19

4. The Normal Cervix: Anatomy and Structure .............................................. 23

5. The Original or Native Squamous Cervical Epithelium .............................. 27

6. The Columnar Epithelium ......................................................................... 31

7. Metaplasia – The Normal Transformation Zone ......................................... 35

8. The Abnormal Transformation Zone and

Squamous Intraepithelial Neoplasia ............................................................ 45

9. Colposcopy of Cervical Squamous Cell Carcinoma..................................... 53

10. Grading the Squamous Colposcopic Lesion ............................................... 59

11. Colposcopy of Adenocarcinoma In Situ and

Adenocarcinoma of the Cervix ................................................................... 65

12. Correlation in Squamous and Glandular Disease ........................................ 75

13. The Colposcopic Differentiation of Glandular

Lesions from Other Cervical Lesions .......................................................... 87

14. Colposcopy of the Cervix in Pregnancy .................................................... 103

15. Colposcopy of Cervical Condylomata ...................................................... 109

16. Colposcopy of Cervical Polyps and the DES-Exposed .............................. 115

17. Colposcopy of the Cervix After Treatment for

Squamous Intraepithelial Neoplasia .......................................................... 119

18. Colposcopy of the Vagina ........................................................................ 123

19. Colposcopy of the Vulva and Adjacent Sites ............................................. 127

iii
ATLAS OF COLPOSCOPY

CHAPTER 1

The Colposcope
• A colposcope consists of one or two main objective lens or lenses, binocular
tubes containing a prism system, eye pieces (also called oculars) with diopter
adjustments, gross with or without a fine focusing mechanism, a light source and
a filter, usually green, which is used to study blood vessel patterns.
• In most scopes a magnification changer is standard equipment, although a few
are single magnification (usually 13.5X). For best colposcopy a low
magnification (3 to 5 times), a middle magnification (7–10X), and a high
magnification (15–20X), are required. Some colposcopes feature zoom
magnification adjustments which are in increments or continuous. At least one
colposcopy system uses a video camera to obtain an image that is displayed on a
TV monitor. This system has no eyepieces.
• The focal length of the main objective lens equals the working distance from lens
to target (most are 300mm).
• In some colposcopes (such as the Zeiss OPMI series) the numbers on the step-
wise-magnification changer reflect the magnification factor which is used in the
calculation of the overall magnification. These scopes have interchangeable parts.
• In other scopes the magnification changer displays the overall magnifications
(such as 3.5X, 7.5X and 15X) at each setting. In this case the oculars and main
objective lenses are not interchangeable.
• The binocular system contains a prism pair which uprights the image, shortens
the working distance between the planes of the binocular objective and eyepiece,
and provides adjustment for the interpupillary distance.
• Eyepieces are either straight (orthogonal with the main objective lens[es]) or
angled. In at least one instrument, they are not used at all.
• The higher the magnification the less is the diameter of the target that can be
viewed at one time, the less is the illumination of the target and the less is the
depth of focus.
• Dividing the overall magnification into the constant 200 gives the approximate
field of view (that is, how many millimetres of diameter of the target that is
seen) at that magnification.
• Figures 1.1 to 1.23 illustrate a variety of colposcopes.

1–1
 CHAPTER ONE

1.1 LEISEGANG MODEL 1D/1DL Colposcope. 1.2 LEISEGANG MODEL 3BDF Colposcope. (Courtesy
(Courtesy of Leisegang Medical). of Leisegang Medical).

1.3 LEISEGANG MODEL 3BDFX Colposcope. 1.4 LEISEGANG MODEL 3DX Colposcope. (Courtesy
(Courtesy of Leisegang Medical). of Leisegang Medical).

1–2
ATLAS OF COLPOSCOPY

1.5 ZEISS Colposcope Plus. (Courtesy of Carl Zeiss). 1.6 ZEISS Colposcope Plus on 0.65 m floor stand.
(Courtesy of Carl Zeiss).

1.7 ZEISS Colposcope 150 FC. 1.8 ZEISS Colposcope E.

(Courtesy of Carl Zeiss). (Courtesy of Carl Zeiss).

1–3
 CHAPTER ONE

1.9 WALLACH Video Zoom Scope and Definition Monitor. (Courtesy of Wallach Surgical Devices, Inc.).

1.10 WALLACH Colpostar 1H. (Courtesy 1.11 WALLACH ZOOM STAR Colposcope.
of Wallach Surgical Devices, Inc.). (Courtesy of Wallach Surgical Devices, Inc.).

1–4
ATLAS OF COLPOSCOPY

1.12 BEI Gyné-TechTM Colposcope – the Z45TM Zoom Scope.

(Courtesy of BEI Medical Systems).

1.13 BEI Gyné-TechTM Colposcope

– the HB 401/402TM Series
(Courtesy of BEI Medical
Systems).

1–5
 CHAPTER ONE

1.14 1.15

1.14 and 1.15 (above)

The CooperSurgical CerveillanceTM Scope (CS 2000,
CS3000). These are fully integrated digital colposcopy
systems that facilitate easy viewing, reviewing and
documentation for cervical images in full digital color.
(Courtesy of CooperSurgical).

1.16 The CooperSurgical Overhead Zoom Scope

(OZM, VOZM). (Courtesy of CooperSurgical).

1–6
ATLAS OF COLPOSCOPY

1.18 CRYOMEDICSRMM-6000 Colposcope. (Courtesy

of Circon Corporation).

1.17 CRYOMEDICSR MM-6000 Colposcope.

(Courtesy of Circon Corporation).

1.19 ZEISS Colposcope demonstrating the magnification changer stamped with the magnification index values. The latter
are used in the calculation of the overall magnification.

1–7
 CHAPTER ONE

1.21 The diopter settings on the eyepieces (oculars)

of a ZEISS Colposcope.

1.20 The overall magnification is indicated on the

magnification changer of many colposcopes (e.g.,
Leisegang).

1.23 Video Colposcopy. The WelchAllynTM Video

Colposcope and monitor.

1.22 The Video Colposcope (VideoPath Colposcope).

(Courtesy of WelchAllynTM).

1–8
ATLAS OF COLPOSCOPY

CHAPTER 2

Instrumentation and Clinical Set-up

• An adequate examination room.
• A colposcope. The colposcope should be evaluated as to the type of mount, the
optical system, the fine focus mechanism, binocular tubes (straight or inclined),
oculars, teaching attachment, photographic capability, type of lighting system
and the capability of attaching a carbon dioxide laser.
• An examining table.
• Equipment for cytology.
• Examining gloves, cotton balls, cotton swabs, 4 X 4 swabs and sponge sticks.
• Acetic acid (3–5%) and normal saline.
• Lugol’s or Schiller’s iodine solution.
• Monsel’s paste – not liquid. The liquid form is dehydrated to create the paste.
• Speculums of different sizes.
• Endocervical curettes, endocervical speculum, skin hooks, and endometrial
sampling curettes.
• Biopsy forceps.
• Vaginal wall retractors.
• Measuring instruments.
• Instrument table.
• Containers for disposables and contaminated equipment, facilities for cleaning
and sterilizing reusable equipment.
• Therapeutic equipment as required (e.g., suction, laser, electrosurgical
generator, cryotherapy units and ancillary instruments.
• Figures 2.2 to 2.33 illustrate examples of the instrumentation required.

2–9
1–9
 CHAPTER
CHAPTER TWO
ONE

2.1 Kevorkian tip punch biopsy. (Courtesy of BEI Medical Systems).

2.2 Spring handle biopsy forceps. 2.3 Baby tischler tip punch biopsy.
(Courtesy of BEI Medical Systems). (Courtesy of BEI Medical Systems).

2.4 Colposcopic picture of a Kevorkian tip 2.5 Colposcopic picture of a punch biopsy with
punch biopsy. rounded jaws (Eppendorfer type).

2–10
1–10
ATLAS OF COLPOSCOPY

2.6 An endocervical speculum.

2.7 The blades of an endocervical speculum.

(Courtesy of BEI Medical Systems).

2.9 Kevorkian
endocervical
2.8 Kevorkian endocervical curette with closed basket. curette with open
(Courtesy of BEI Medical Systems). basket.

2–11
 CHAPTER TWO

2.11 A rounded tip endocervical curette.

2.12 A measuring device
for determining
linear length of CIN.

2.13 Containers for solutions.

2.10 A rounded tip
endocervical
curette.

2.15 A hook.

2.14 A tenaculum. 2.16 A vaginal wall retractor.

(Courtesy of BEI Medical
Systems).

2–12
ATLAS OF COLPOSCOPY

2.17 Monsel’s solution as a liquid. After dehydration a tan colored paste results.

2.18 Injection equipment for local anesthesia.

2.19 Syringe with a needle extender for local injection of anesthesia.

2–13
 CHAPTER TWO

2.20 The WALLACH LL100 Cryosurgical Unit. (Courtesy of Wallach Surgical Devices, Inc.).

2.21 The WALLACH 1000BTM Cryosurgical System. 2.22 The CRYO-PLUS (2402 with
(Courtesy of Wallach Surgical Devices, Inc.). double ‘E’ cylinder yoke). (Courtesy
of Wallach Surgical Devices, Inc.).

2–14
ATLAS OF COLPOSCOPY

2.23 BEI Cryosurgical System with Autoclavable tips. (Courtesy of BEI Medical Systems).

2.24 CryomedicsRMT – 700 Cryosurgical System. (Courtesy of Circon Cryomedics).

2–15
 CHAPTER TWO

2.25 The WALLACH QUANTUM 500 Electrosurgical Generator.

(Courtesy of Wallach Surgical Devices, Inc.).

2.26 The WALLACH 2000

Electrosurgical System: It
includes the Biovac Smoke
Evaculator and Integration Unit.
(Courtesy of Wallach Surgical
Devices, Inc.).

2–16
ATLAS OF COLPOSCOPY

2.27 BEI Plus IITM Electrosurgical Generator. (Courtesy of BEI Medical Systems).

2.28 BEI Bi-Safe – I

Bipolar Surgical
System. Courtesy
of BEI Medical
Systems).

2.29 Bi-Safe – I
Electrosurgical
Bipolar double
loop tissue
electrode.
(Courtesy of BEI
Medical Systems).

2–17
 CHAPTER TWO

2.30 Erbe ICC50,

ICC300, ICC200
and ICC350
constant voltage
electrosurgical
generators
(Courtesy of Erbe
USA Inc.)

2.32 WALLACH Electrosurgical Loops. (Courtesy

of Wallach Surgical Devices, Inc.).

2.31 CooperSurgical LEEP System 1000TM 2.33 LLETZ Electrodes

Workstation (KH 6098). (Courtesy of (Courtesy of Circon Cryomedics).
CooperSurgical).

2–18
ATLAS OF COLPOSCOPY

CHAPTER 3

Steps In The Basic Colposcopic Examination

• Review the patient’s history.
• Perform general physical (may not always be required).
• Place patient in lithotomy or modified lithotomy position.
• Perform digital examination.
• Carefully insert the speculum and clinically inspect the cervix.
• Perform special tests (cultures, DNA evaluation) if necessary.
• Repeat Pap test if necessary (particularly if referral cytology report is not
available).
• Apply normal saline and clear mucus with cotton ball swab carefully so as not to
produce bleeding.
• Examine the blood vessels of the cervix using a green/blue filter. Various
magnifications may be required. Start at the lowest first and determine the most
suspect area, then study it using higher magnification.
• Apply acetic acid and again examine the entire cervix.
• Colposcopically examine the upper vagina particularly that part surrounding the
cervix.
• Perform iodine staining (optional for cervix, but mandatory for vaginal disease)
in the presence of estrogenized epithelium.
• Take cervical or vaginal biopsy or [biopsies] where appropriate.
• Perform endocervical curettage (ECC) when appropriate.
• Achieve hemostasis.
• Withdraw speculum slowly while inspecting the mid and lower vagina.
• Biopsy mid and lower vagina if lesion is seen.
• Inspect the vulva, perineum and perianal skin using the colposcope.
• Use standard colposcopic evaluation of these areas. Toluidine blue staining is
optional but acetic acid is helpful.
• Biopsy any suspicious areas under local anesthesia using colposcopic guidance.
• Record the findings.
• Discuss with the patient the findings and potential future management.
• Figures 3.1 to 3.14 illustrate some basic colposcopic findings to be evaluated
during the colposcopic evaluation.

3–19
 CHAPTER THREE

3.1 Adequate cervical biopsies are important as demonstrated in this photograph. This biopsy is taken at the
squamocolumnar junction demonstrating dysplasia and normal glandular epithelium with adequate
stroma to exclude malignancy.

3.2 This endocervical curettage (ECC) shows high grade (HSIL/CIN III) disease. The ECC cannot necessarily
grade the lesion due to the frequent lack of stroma and fragmentation.

3–20
ATLAS OF COLPOSCOPY

3.3 Fine punctation under ordinary colposcopic 3.4 Fine punctation employing the blue filter and
lighting and high magnification. high magnification.

3.5 An acetowhite lesion using low magnification. 3.6 Dense acetowhite changes using high
magnification.

3.7 Coarse punctation after acetic acid 3.8 Acetowhite changes on the ectocervix with
application. Blood vessel patterns are best low magnification.
studied before its application.

3–21
 CHAPTER THREE

3.9 A large, dense white, well demarcated lesion 3.10 After Lugol’s iodine. It is necessary to biopsy
with an irregular surface. the cervix as well as the vagina to exclude a
congenital TZ.

3.11 Measuring the linear length of the CIN lesion. 3.12 Low magnification of a VIN III lesion.

3.13 Retention of toluidine blue within a VIN III 3.14 VAIN III multifocal disease after Lugol’s
lesion. iodine.

3–22
ATLAS OF COLPOSCOPY

CHAPTER 4

The Normal Cervix: Anatomy and Structure

• It is cylindrical in shape.
• Its dimensions vary considerably.
• The nulliparous cervix measures 2.5 to 3.0 centimetres in length constituting
one-half the uterine length.
• Adult parous cervix comprises one-third of the length of the uterus.
• Average diameter of nulliparous cervix measures 2.5 cm; the parous cervix is
usually larger.
• Anterior cervical lip is shorter and thicker than the posterior lip.
• Cervical canal is fusiform in shape. Its greatest diameter measures 6–8
millimetres.
• The main blood supply is from the cervical branch of the uterine artery.
• The blood supply is enhanced by anastomotic vessels between pelvic and
extrapelvic sources.
• The venous drainage parallels the arterial supply.
• The posterior cervix bleeds more after a biopsy than the anterior cervix.
• The nerve supply is from the autonomic system and contains both sympathetic
and parasympathetic divisions.
• The anterior cervix is more sensitive to painful stimuli than the posterior cervix.
• The internal os is most sensitive to pain.
• Two cell types are found on the cervix: squamous (distal) and glandular
(cephalad).
• Figures 4.1 to 4.6 illustrate the schematics and colpophotographs of the normal
cervix.

4–23
 CHAPTER FOUR

4.1 The cervix normally projects into the vagina. The lateral fornices are formed between the lateral
border of the cervix and vaginal wall. Adapted from Graham JB, Sotto LSJ, Paloucek FP.
Philadelphia: Carcinoma of the Cervix, WB Saunders, 1962.

4.2 In its normal position, the anterior cervix occupies a lower position in the vagina. The anterior and
posterior fornices are formed between the peripheral margins of the cervix and vaginal wall. Adapted
from Rioux J-E, Collins JA, Reproduction. Quebec City: Les Presses de l’Université Laval, 1973.

4–24
ATLAS OF COLPOSCOPY

4.3 Low magnification of a normal cervix. The normal squamocolumnar junction is seen. The majority of
the cervix is occupied by columnar epithelium undergoing metaplasia.

4.4 The ratio of columnar epithelium to squamous epithelium varies greatly. In this case the prominence
of columnar epithelium clinically can cause post-coital bleeding and excessive leukorrhea.

4–25
 CHAPTER FOUR

4.5 The columnar epithelium can become quite congested due to a continuous hormone
stimulation (e.g., pregnancy, contraceptive pill and Depo Provera).

4.6 A double cervix. Note the two canal openings.

4–26
ATLAS OF COLPOSCOPY

CHAPTER 5

The Original or Native Squamous Cervical

Epithelium
• Histologically there are four distinct layers (basal cells, parabasal cells,
intermediate cells and superficial cells.
• The proportion of surface involvement by squamous epithelium vs.columnar
epithelium varies greatly and changes over time due to metaplasia or because of
treatment (cryotherapy, laser surgery, electrosurgery, etc.).
• The earliest junction is referred to as the original squamocolumnar junction; it is
the site of side by side cell types before the onset of metaplasia.
• The native squamous epithelium is continuous with the vaginal epithelium.
• The native squamous epithelium has a transparent pink tinge.
• Physical factors such as contraceptive pill use, menopause, pregnancy, and
inflammation (e.g., trichomonas) can alter the color.
• The native epithelium is smooth and featureless.
• Its vascularity is described as fine, with blood vessels arranged in an orderly
branching fashion running parallel to the surface.
• The vascularity becomes altered in diseased states (e.g., trichomonas).
• The vascularity plays no role in the development of the premalignant or
malignant process.
• Figures 5.1 to 5.6 illustrate colposcopic pictures of the normal cervical native
squamous epithelium.

5–27
 CHAPTER FIVE

5.1 The normal native cervical squamous epithelium is smooth. It joins the normal rugal vaginal
epithelium peripherally. Centrally it borders on columnar epithelium, metaplastic or diseased
epithelium. In this case it is metaplastic epithelium.

5.2 High power colposcopic view of normal squamous epithelium. The color varies due to physical
factors such as hormones and inflammatory states.

5–28
ATLAS OF COLPOSCOPY

5.3 The normal cervix. The outer portion is normal squamous epithelium. The matured metaplastic
epithelial junction colposcopically appears similar except gland openings are seen in the TZ.

5.4 Colposcopy of a trichomonas infection. The darkened red areas are referred to as “flea-bitten” and/
or “strawberry” spots.

5–29
 CHAPTER FIVE

5.5 After Lugol’s iodine. Abnormal appearing (pale) epithelium extends off the cervix anteriorly
(glycogen negative areas). Biopsies are required to differentiate between CIN and congenital TZ
(see Figure 3.10).

5.6 Normal cytology from normal squamous epithelium demonstrating intermediate and
superficial cells.

5–30
ATLAS OF COLPOSCOPY

CHAPTER 6

The Columnar Epithelium

• Histologically, it can be seen as a single row of columnar epithelial cells each with
a basally situated round or oval nucleus.
• The cytoplasm stains grey to blue in color.
• The cells lie over the superficial stroma and extend from the squamo columnar
junction to the histological os.
• Identical epithelium lines the cervical crypts (so-called “glands”) which are
actually involutions of the surface epithelium.
• The surface epithelium consists of villous structures which look papillary.
Columnar epithelium on the ectocervix is sometimes referred to as an ectopy or
an ectropion.
• The individual villous structures vary in dimensions; some are elongated, finger-
like, others are flattened and rounded and some are cuboidal.
• Each villous structure is surrounded by an indentation which separates it from
adjacent villi.
• A single capillary loop, which may or may not be visible colposcopically, occupies
each villous.
• The vascular network inside the transparent-to-translucent villous structure
accounts for the red appearance of the columnar epithelium.
• This villous angioarchitecture is transformed by abnormal metaplasia into the
abnormal vascularity (such as punctation and mosaicism) seen in squamous
intraepithelial neoplasia.
• In the absence of metaplasia the villous structures remain transparent after acetic
acid application.
• Figures 6.1 to 6.6 illustrate the colposcopic and histologic features of normal
columnar epithelium.

6–31
 CHAPTER SIX

6.1 The villous structures of an ectopy. In the absence of metaplasia, they remain transparent after
acetic acid application.

6.2 The villous structures are well defined. Frequently no angioarchitecture is seen. Anteriorly the villi
have been replaced by squamous metaplasia as demonstrated by the pale acetowhite epithelium
(A).

6–32
ATLAS OF COLPOSCOPY

6.3 The villous structures assume a polyp-like formation which protrudes from the endocervical canal.

6.4 A high power colposcopic picture of the normal transparent villi. They resemble sea anemone.

6–33
 CHAPTER SIX

6.5 Histologically, the individual villous structure can be seen to be lined by a single layer of columnar
cells with basally situated nuclei.

6.6 The villous structures become flattened and indistinct as a result of the metaplastic process.

6–34
ATLAS OF COLPOSCOPY

CHAPTER 7

Metaplasia – The Normal Transformation Zone

• Metaplasia is the process by which columnar epithelium is transformed into
squamous epithelium. Its catalyst is vaginal pH.
• The earliest changes occur at the tips of the glandular villi.
• Fusion occurs, the villi flatten, fade and glaze over with a “frosted glass”
translucency replacing the original transparency.
• Heterogeneous villous fusion creates islands of columnar epithelium surrounded
by pink appearing immature squamous epithelium.
• Further metamorphosis results in fused tongue-like masses.
• The end result is a mature, stable, relatively smooth and permanent surface of
normal squamous epithelium punctuated only by crypt (“gland” ) openings and
retention cysts.
• The benign-appearing angioarchitecture reflects the stage of the transition.
• Immature metaplasia produces three different blood vessel patterns: so called
“tree-like”, “root-like” and “character-writing-like” formations.
• Areas of matured squamous epithelium contain network capillaries, parallel
vessels, “hairpin-like”, regular “tree-like” and other arrangements consisting of a
central vessel with peripheral radial branching with associated anastomotic
patterns. “Staghorn-like” vessels indicate inflammation (e.g., trichomonas).
• Normal blood vessels, regardless of the stage of metaplasia, taper off from the
central trunk like the branches of a tree.
• Figures 7.1 to 7.28 illustrate the various colposcopic patterns of metaplasia.

7–35
 CHAPTER SEVEN

7.1 Metaplasia occurs at the squamocolumnar junction and over the tips of the villus structures. They
become glazed over, lose their transparency and become fused into large cords of epithelium.

7.2 A few villous structures are seen surrounded by immature metaplastic epithelium.

7–36
ATLAS OF COLPOSCOPY

7.3 Islands (“bouquet-like” formations) of white immature metaplastic epithelium overly the red columnar
epithelium.

7.4 Immature metaplastic squamous epithelium in “scallop-like” formations. A reverse mosaic blood
vessel formation is noted. In the individual villous tips single dot-like blood vessel formations are
seen.

7–37
 CHAPTER SEVEN

7.5 Glazing of the villi accompanies the fusion of the villous structures.

7.6 The metaplastic process forms flattened plains and ridges. Dense acetowhite changes occur around
the gland openings.

7–38
ATLAS OF COLPOSCOPY

7.7 In mature squamous metaplasia, “branch-like” blood vessel formations develop. This is characterized
by a large central trunk and tapering branches.

7.8 Pronounced “branch-like” angioarchitecture of immature metaplasia.

7–39

7.9 Long branching “tree-like” vessels within 7.10
matured metaplastic squamous epithelium.
A large central trunk is seen and the
branching vessels taper off in a uniform
manner.
7.11 Large normal branching blood vessels within 7.12
a matured transformation zone. A fine
network arrangement results.
CHAPTER SEVEN
Normal angioarchitecture of matured
metaplastic squamous epithelium and
retention cysts.
Long uniform tapering blood vessels within a
matured transformation zone.
7–40
ATLAS OF COLPOSCOPY

7.13 High power view of normal tapering blood vessels of a matured transformation zone.

7.14 Large tapering blood vessels coursing over a large retention cyst.

7–41
 CHAPTER SEVEN

7.15 Tapering “root-like” angioarchitecture in a matured transformation zone.

7.16 Large normal tapering blood vessels in a “tree-like” pattern crossing over a large retention cyst.

7–42
ATLAS OF COLPOSCOPY

7.17 Fusion of the villous structures. They 7.18 The metaplastic process produces islands of
become glazed and transparency is lost. columnar epithelium surrounded by
immature metaplastic epithelium.

7.19 Metaplasia with villous fusion produces 7.20 As metaplasia continues the villous
tongues of flat, faint acetowhite epithelium. structures become replaced by faint
Below are the normal villous structures. acetowhite immature squamous epithelium.

7.21 Discreet acetowhite “mound-like” formations 7.22 The metaplastic process results in fused
occur over the columnar epithelium in early “finger-like” projections.
metaplasia.

7–43
 CHAPTER SEVEN

7.23 The villous structures are replaced by faint 7.24 A matured transformation zone with normal
acetowhite squamous epithelium. Normal angioarchitecture and retention cysts.
tapering blood vessels are seen.

7.25 Normal tapering and anastomosing 7.26 Long tapering “root-like” blood vessels in a
angioarchitecture of a matured matured transformation zone.
transformation zone. A retention cyst and a
polyp are evident.

7.27 High magnification of the long “root-like” 7.28 The blood vessels taper off in a uniform
tapering blood vessels in a matured manner and anastomose with similar blood
transformation zone. vessels in this matured transformation zone.

7–44
ATLAS OF COLPOSCOPY

CHAPTER 8

The Abnormal Transformation Zone and Squamous

Intraepithelial Neoplasia
• The colposcopic features which differentiate the abnormal from the normal
transformation zone are [1] vascular patterns, [2] intercapillary distance, [3]
color tone related to adjacent normal tissue, [4] surface contour and, [5]
sharpness of the border between different areas (Stafl’s criteria).
• In “punctation”, hairpin-like capillaries are seen histologically as straight or coiled
lines, but colposcopically, in an end-on-view, they appear as points or dots in a
stippling pattern. The fineness or the coarseness of this stippling and any
irregularities in distribution are important.
• In “mosaicism” circular or rectangular shaped arrangements of capillaries
resemble a mosaic arrangement like that found in inlaid tile. The fineness,
coarseness and regularity or irregularity of the avascular surrounded spaces are
revealing.
• Atypical vessels not conforming to the punctate and mosaic patterns may be
associated with a malignant change.
• The color tone (degree of whiteness) after acetic acid application correlates with
the histologic grade. Faint white corresponds to low grade (CIN 1), metaplasia
or inflammation. Dense white usually equals high grade squamous intraepithelial
neoplasia (HSIL/CIN II-III, severe dysplasia/carcinoma in situ).
• The surface contour (smooth, uneven, granulated, papillary, nodular, etc.)
reflects the histological grade. The more bizarre the topography/surface features
the more severe the disease.
• The borderline between normal and lesional tissue (poorly defined versus well-
defined) is used to grade the lesion. Low grade lesions are poorly defined. High
grade lesions are well defined.
• These colposcopic features are used together to grade the lesion to arrive at a
colposcopic impression which, in turn, is used in the correlation process.
• Figures 8.1 to 8.28 illustrate colposcopic features of squamous cervical
intraepithelial neoplasia.

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 CHAPTER EIGHT

8.1 Coarse mosaicism reflecting a CIN III 8.2 Coarse mosaicism seen in a CIN III lesion.
(severe dysplasia/carcinoma in situ) lesion.

8.3 Dense acetowhite epithelium and coarse 8.4 Mosaic structure is becoming lost. Atypical
mosaicism in a CIN III lesion. vessels depict this microinvasive carcinoma.

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ATLAS OF COLPOSCOPY

8.5 Slight irregular punctation and mosaicism characterize this CIN III squamous intraepithelial lesion.

8.6 A CIN III lesion demonstrating coarse and irregular mosaicism.

8–47
 CHAPTER EIGHT

8.7 A dense acetowhite lesion with an irregular surface and an irregular mosaic patternin a CIN III lesion.

8.8 A dense acetowhite lesion with an irregular surface is seen on the anterior cervical lip
reflecting a CIN III lesion.

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ATLAS OF COLPOSCOPY

8.9 A well demarcated, elevated, dense white 8.10 The linear length of this CIN III lesion
CIN III lesion. measures 20 mm.

8.11 The linear length of this CIN III lesion 8.12 This CIN III lesion measures 12 mm.
measures 16 mm.

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 CHAPTER EIGHT

8.13 Fine, coarse and irregular punctation and 8.14 Metaplasia with a pseudo mosaic
mosaicism are seen in this CIN II – III angioarchitecture.
squamous lesion.

8.15 A CIN III lesion extends into the endocervical 8.16 A large, densely acetowhite CIN III lesion is
canal. The worst disease is located located widely on the ectocervix and extends
centrally. If biopsies do not identify cancer, into the endocervical canal.
then an excisional biopsy is necessary.

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ATLAS OF COLPOSCOPY

8.17 A well demarcated acetowhite ectocervical 8.18 A large, elevated, dense acetowhite and well
CIN II squamous lesion. demarcated CIN III lesion is seen on the
ectocervix and with canal extension.

8.19 A CIN I – II squamous lesion occupies the 8.20 A very large, elevated, dense acetowhite
anterior cervix with a CIN III lesion on the and well-demarcated CIN III ectocervical
posterior cervix. lesion with canal extension.

8.21 A dense acetowhite CIN III lesion with canal 8.22 Fine punctation and mosaicism characterize
extension. the CIN I squamous lesion.

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 CHAPTER EIGHT

8.23 Irregular coarse mosaicism seen in a CIN III 8.24 Irregular and pronounced punctation in a CIN
lesion. III squamous lesion is revealed by the blue
filter.

8.25 Irregular coarse mosaicism in a CIN III lesion 8.26 A CIN III squamous lesion with irregular
viewed with the blue filter. punctation and varying intercapillary
distance.

8.27 A CIN III lesion histologically. The 8.28 Coarse and irregular mosaicism in a CIN III
incorporated angioarchitecture produces squamous lesion.
punctation.

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ATLAS OF COLPOSCOPY

CHAPTER 9

Colposcopy of Cervical Squamous Cell Carcinoma

• Always consider the possibility that an invasive cancer is present. Age of
patient and degree of cytological abnormality can cause one to suspect cancer,
but cancer can exist even though there are no cytological signs and the patient
is young.
• Identify the entire transformation zone colposcopically. This determines
whether colposcopy is satisfactory (meaning adequate) versus unsatisfactory
(inadequate) which mandates excision.
• Many cancers lie within the endocervical canal. The worst disease is always
located centrally. When the entire transformation zone is not visible, the
endocervical canal must be sampled.
• Use the endocervical speculum to evaluate the lower endocervical canal and
take an endocervical curettage (ECC).
• Routine ECC may be omitted in cases of unsatisfactory colposcopy due to
endocervical extension of the lesion or in cases which do not correlate, since
these patients will need a diagnostic excision and possibly a fractional dilation
and curettage (D & C).
• Study the color tone, surface contour, border between lesional and adjacent
normal tissue, intercapillary distances and vascular patterns.
• Colposcopically, the blood vessel patterns can be the most informative in
recognizing cancer. Examine them before acetic acid application using the
blue/green filter.
• Mosaicism and punctation indicate squamous intraepithelial neoplasia.
• “Corkscrew-like”, “waste-thread-like”, “tendril-like”, and multiple “dot-like”
blood vessel patterns are colposcopic warning signs of invasive cancer.
• Figures 9.1 to 9.20 illustrate colposcopic photographs of squamous cell
cancer, and its mimics.

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 CHAPTER NINE

9.1 Coarse, irregular punctation and mosaicism. 9.2 Atypical “corkscrew-like” vessels
In some areas this formation breaks up into characterize this squamous cell carcinoma.
atypical vessels. The latter area, on
excision, revealed a microinvasive squamous
cell carcinoma.

9.3 “Corkscrew-like” vessels in a squamous cell 9.4 Large dilated “waste-thread-like” blood
carcinoma. vessels in a squamous cell carcinoma.

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ATLAS OF COLPOSCOPY

9.5 Large, normal tapering blood vessels as seen in a matured transformation zone. The
colposcopist must be able to differentiate benign from malignant angioarchitecture.

9.6 The vessel structure of a uterine fibroid which has prolapsed through the cervix.

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 CHAPTER NINE

9.7 The “corkscrew-like” blood vessel formations of a post-irradiated cervix.

9.8 A large, uterine, atypical polypoid adenomyofibroma prolapsing through the cervix.

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ATLAS OF COLPOSCOPY

9.9 Irregular punctation and atypical “waste- 9.10 A recurrent squamous cell carcinoma in a
thread-like” branching blood vessels of a cervix that has been previously irradiated for
microinvasive squamous cell carcinoma. squamous cell carcinoma. Numerous
“corkscrew-like” blood vessels are seen.

9.11 “Corkscrew-like” and “waste-thread-like” 9.12 “Corkscrew-like” and “waste-thread-like”

blood vessels seen in a squamous cell vessel forms are seen in this squamous cell
carcinoma. carcinoma.

9.13 Mostly “corkscrew-like” blood vessels are 9.14 A high power view of atypical blood vessels
seen in this squamous cell carcinoma. seen in a squamous cell carcinoma.

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 CHAPTER NINE

9.15 The angioarchitecture after irradiation for 9.16 An ulcerated, well-demarcated and dense
cancer of the cervix. acetowhite lesion. Biopsy confirmed a
squamous cell carcinoma.

9.17 A well-defined squamous cell carcinoma 9.18 A clinical squamous cell carcinoma and its
containing many “waste-thread-like” blood associated atypical angioarchitecture.
vessels.

9.19 A large squamous cell carcinoma. 9.20 The angioarchitecture of a uterine fibroid
prolapsing through the cervix.

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ATLAS OF COLPOSCOPY

C H A P T E R 10

Grading the Squamous Colposcopic Lesion

• A scheme for classifying the atypical squamous transformation zone was
developed by Coppleson and colleagues as follows:

• Grade I
The acetowhite epithelium is usually shiny and transparent or
semitransparent. The borders are not necessarily sharp. Fine-calibre blood
vessels may or may not be present. Patterns are ill-defined. There are no
atypical blood vessels and the intercapillary distances are small.
Such findings are associated with varying patterns of metaplasia and the low
grade lesion, formerly labelled CIN 1 (cervical intraepithelial neoplasia), now
called low grade squamous intraepithelial lesion, LSIL.

• Grade II
Dense acetowhite or grey opaque epithelium has sharply demarcated
borders. There are dilated caliber, irregularly shaped or coiled vessels.
Atypical vessels and sometimes an irregular surface contour indicate either
imminent or frankly invasive cancer.
These findings are identified in cervical intraepithelial CIN II and III
(moderate to severe dysplasia carcinoma in situ), now referred to as high
grade squamous intraepithelial neoplasia, HSIL. Atypical vessels indicate
that an invasive carcinoma is present.

• Grading of the lesion can only be done when the colposcopy is

“satisfactory” (i.e., adequate). That occurs when the entire transformation
zone is visible colposcopically.

• Figures 10.1 to 10.19 illustrate grades of the squamous lesion.

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 CHAPTER TEN

10.1 This Grade II lesion shows acetowhite 10.2 An elevated, dense acetowhite, well-
epithelium that makes this lesion relatively demarcated lesion occupies the anterior
well demarcated on the anterior cervical lip. cervix. Biopsy of the Grade II lesion
Biopsy confirmed CIN II squamous disease. confirmed CIN III disease.

10.3 Biopsy of this Grade II lesion confirmed CIN 10.4 Between 11 o’clock and 2 o’clock a Grade I
III disease. lesion is seen. Biopsy confirmed CIN I. The
remainder of the well-defined acetowhite
areas reflect a Grade II lesion. Biopsy
confirmed CIN III disease.

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ATLAS OF COLPOSCOPY
10.5 A CIN II lesion demonstrating asperities
(small elevated “spicule-like” areas).
These are indicative of a human
papillomavirus infection.
10.7 A large CIN III lesion persistent after
electrosurgical desiccation which produced
atypical vessels mimicing an invasive cancer.
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10.6 A Grade II lesion colposcopically. This
elevated, densely acetowhite lesion has an
irregular surface contour. Biopsy confirmed
CIN III disease.
10.8 A Grade I lesion is noted between 12 o’clock
and 2 o’clock. Biopsy confirmed CIN I
disease. The remaining abnormal area
reflects a Grade II lesion colposcopically.
Biopsy of the latter confirmed CIN III disease.
 CHAPTER TEN

10.9 Patches of keratin (iodine negative) on the ectocervix of a post laser ablated cervix.

10.10 A CIN III squamous lesion.

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ATLAS OF COLPOSCOPY

10.11 A Grade II lesion with irregular angioarchitecture illustrating an invasive squamous cell carcinoma.

10.12 The initial mosaic vascular pattern is breaking 10.13 A squamous cell carcinoma.
up into irregular blood vessels. Biopsy
confirmed microinvasive squamous cell
cancer.

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 CHAPTER TEN

10.14 Grade I, insignificant, areas of 10.15 A well-demarcated, dense acetowhite Grade

acetowhiteness as depicted in metaplasia. II lesion. Biopsy confirmed CIN III disease.

10.16 Coarse mosaicism of a Grade II lesion. 10.17 A Grade I lesion (CIN I) is seen peripherally.
Biopsy confirmed CIN III disease. A Grade II (CIN II) lesion is seen centrally.
Note the difference in acetowhiteness.

10.18 A well-defined Grade II lesion. Biopsy 10.19 A large, very dense acetowhite lesion with
confirmed a CIN III lesion. ulceration. Biopsy confirmed a squamous
cell carcinoma.

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ATLAS OF COLPOSCOPY

C H A P T E R 11

Colposcopy of Adenocarcinoma In Situ and

Adenocarcinoma of the Cervix

• Adenocarcinoma in situ (ACIS) can be focal and easily overlooked.

• Most lesions resemble a developing normal transformation zone.
• ACIS lesions can be found under normal metaplastic and dysplastic
epithelium.
• In over 60 percent of ACIS cases a squamous lesion is also present (usually
HSIL). This is referred to as “mixed disease”.
• Cytology may not be reflective of the glandular lesion when a squamous
component is also present.
• Glandular lesions are suspect in the following circumstances: isolated lesion(s)
overlying columnar epithelium and not in contact with the squamous border;
single or fused villous structures which assume a faint white color after acetic
acid application; when a developing transformation zone is seen; papillary
lesions; patchy (variegated) red and white lesions; large gland openings in
association with an abnormal transformation zone; lesions demonstrating
atypical blood vessel formations such as “waste-thread-like”, “character-
writing-like”, “tendril-like”, “root-like”, and single and multiple “dot-like”.
• The linear length of the ACIS lesion is usually less than 15 mm. The shortest
length occurs in women less than 35 years of age (less than 10 mm).
• The underlying cervical crypt involvement by ACIS usually does not exceed 4
mm and never more than 7 mm.
• The radial linear length and depth of crypt involvement increases with patients
ages.
• If a colposcopically directed biopsy indicates ACIS, it is recommended that the
patient be colposcoped again prior to excision. Frequently lesion location and
size can be determined and the excision can be designed to remove it entirely,
preserving in most instances a functional cervix.
• When a biopsy indicates ACIS some method of excision is always necessary to
exclude adenocarcinoma. The excised specimen must have negative margins.
If margins are involved, a repeat excision must be carried out to produce
them.
• Figures 11.1 to 11.32 illustrate some of the colposcopic features of glandular
disease.

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 CHAPTER ELEVEN

11.1 Adenocarcinoma in situ (ACIS) has many colposcopic mimics. ACIS lies from 6 o’clock to 12 o’clock
(A). A metaplastic process extends from 12 o’clock to 6 o’clock (B).

11.2 A higher magnification of Figure 11.1. The line separating ACIS and squamous metaplasia is very
subtle.

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11.3 ACIS lesions can occur as isolated acetowhite lesions overlying columnar epithelium and not
necessarily in contact with the squamous border. In contrast, high grade squamous intraepithelial
lesions are dense white from border to border and the periphery is in contact with the normal
squamous border (see Figure 8.9).

B
A
B

11.4 An ACIS lesion (A) is located between two low grade squamous lesions (B).

11–67
 CHAPTER ELEVEN

A B

11.5 An elevated, dense acetowhite lesion with atypical blood vessels and papillary features extends from
5 o’clock to 9 o’clock (A). From 2 o’clock to 5 o’clock and 9 o’clock to 12 o’clock (B) different
acetowhite lesions are seen. Excision revealed ACIS at site A and CIN III at sites B.

11.6 A higher magnification of the ACIS lesion as shown in Figure 11.5. Small “root-like” and “waste-
thread-like” blood vessels are seen.

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ATLAS OF COLPOSCOPY

A B
B

11.7 A well defined CIN III squamous lesion is easily seen from 6 o’clock to 10 o’clock (A). A variegated
red (dark blood vessels) and white lesion occupies the endocervical canal (B). Excision revealed CIN
III at site A and ACIS at sites B.

11.8 A higher magnification of the ACIS lesion as 11.9 A patchy red (dark areas) and white lesion
depicted in Figure 11.7. Numerous “root- occupies the cervix from 9 o’clock to 12
like” blood vessel formations are seen. o’clock. Excision revealed ACIS.

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 CHAPTER ELEVEN

11.10 The angioarchitecture of a large ACIS lesion involving the entire ectocervix.

11.11 A higher magnification of Figure 11.10

demonstrating long “root-like” (A) and
“waste-thread-like” (B) blood vessels. (inked
in)

11.12 Another high magnification view of Figure

11.10. In this area “tendril-like” and
“character-writing-like” vessels are evident.
(inked in)

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ATLAS OF COLPOSCOPY

A
B

11.13 An ACIS lesion (A) is separated by a small band of columnar epithelium from a large microinvasive
squamous cell carcinoma (B).

11.14 A patchy red and white papillary lesion is seen overlying the site of columnar epithelium within the
endocervical canal. Biopsy confirmed a cervical adenocarcinoma.

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11.15 A well-defined, dense acetowhite lesion is
located between 7 o’clock and 8 o’clock and
lies over columnar epithelium not in contact
with the squamous border. Excision
revealed ACIS.
11.17 A higher magnification of Figure 11.16.
Large gland openings are noted. The upper
limit is seen. The linear length of the lesion
is less than 15 mm.
11.19 ACIS resembling a transformation zone. A
multiple “dot-like” angioarchitecture is seen.
CHAPTER ELEVEN
11.16 A variegated (patchy red and white)
transformation zone-like lesion occupies the
endocervical canal. Excision revealed ACIS.
11.18 An ACIS lesion demonstrating
acetowhiteness and papillary projections. It
appears similar to immature metaplasia (see
Figure 7.4).
11.20 Extensive ACIS involvement of the
ectocervix. Some areas are patchy red and
white after acetic acid application.
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ATLAS OF COLPOSCOPY
11.21 Adenocarcinoma between the 3 o’clock and
7 o’clock resembling metaplasia.
11.23 An ACIS lesion resembling metaplasia.
11.25 Another example of dilated and engorged
blood vessels (called “root-like”) of an
adenocarcinoma.
11–73
11.22 A squamous intraepithelial lesion is seen
between 9 o’clock and 12 o’clock. Adjacent
to it and lying between 12 o’clock and 3
o’clock is a transformation zone-like area.
Excision of the latter revealed ACIS disease.
11.24 An adenocarcinoma of the posterior cervix
containing dilated and engorged blood
vessels termed “root-like”. The vascular
distribution is characteristic of
adenocarcinoma.
11.26 A papillary cervical adenocarcinoma.
 CHAPTER ELEVEN

11.27 A papillary cervical adenocarcinoma. 11.28 An ACIS lesion in the endocervical canal. It
Numerous villous-like excrescences are has a variegated red and white appearance.
seen. These appear similar to the villous
structures of an ectopy.

11.29 Patchy (variegated) red and white areas are 11.30 A well-defined acetowhite CIN III lesion is
scattered over the columnar epithelium noted peripherally. Centrally is an
mimicking a transformation zone. Excision adenocarcinoma with many “waste-thread-
confirmed a cervical adenocarcinoma. like” vascular formations.

11.31 A large cervical adenocarcinoma. It is very 11.32 An acetowhite CIN II lesion overlies
dense acetowhite with fused papillary columnar epithelium. Classic punctation is
excrescences. seen in CIN and not in glandular disease.

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ATLAS OF COLPOSCOPY

C H A P T E R 12

Correlation in Squamous and Glandular Disease

• At least one adequate Pap test must be obtained and fulfill the criteria of the
Bethesda System for reporting cervical/vaginal cytology.
• Satisfactory colposcopy must be achieved in that the entire transformation zone
(TZ) must be seen on the ectocervix and be colposcopically interpreted.
• The colposcopic biopsy must be adequate to permit interpretation.
• If satisfactory cytology, colposcopy and histology are achieved, ablative
procedures may be considered when:
1) diagnoses are consistent within one grade among the three parameters;
2) the colposcopist determines from the qualitative assessment of the TZ that no
adenocarcinoma in situ, microinvasive or invasive cancer is present; and
3) the patient is not pregnant.
• Excisional procedures are required when:
1) discrepancies exist between cytology, colposcopy and histology;
2) lesions are located in whole or in part of the endocervical canal;
3) cytology or colposcopy suggest possible invasive carcinoma which has not
been proven by colposcopically directed biopsy;
4) colposcopic biopsy indicates microinvasive carcinoma;
5) colposcopic biopsy indicated adenocarcinoma in situ of the cervix;
6) cytology indicates a glandular lesion (ACIS or cervical adenocarcinoma) and
biopsies and colposcopy fail to identify the lesion; or
7) when colposcopy is unsatisfactory.
• The correlative process for abnormal squamous cytology is not applicable for
abnormal glandular cytology.
• Figures 12.1 to 12.36 illustrate examples of correlation and non-correlation.

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12.1 Cytology of herpes simplex virus type II.
Increased granularity of the nucleus is noted
with multiple nucleation.
12.3 Cytology of a chlamydia infection.
Intraepithelial cytoplasmic cystic spaces
contain tiny “dot-like” aggregates. However
immunocytochemical staining with
monoclonal antibody anti-chlamydia
trachomatous is required to confirm it.
CHAPTER TWELVE




12.2 A trichomonad is seen (small arrow).
Inflammatory cells are seen. A cell showing
a sharp nuclear border and an increase in
the nuclear chromatin illustrates a response
to the infestation (large arrow).
12.4 Cytology of post-radiation demonstrating
cytoplasmic vacuolation, cellular swelling,
anuclear cells and bizarre cell shapes.
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ATLAS OF COLPOSCOPY

12.5 Cytology of coccoid bacteria. 12.6 Cytology of the filaments of candida.

12.7 Cytology of clue cells seen in bacterial 12.8 Cytology of koilocytes demonstrating well-
vaginosis. demarcated clear perinuclear halo
surrounded by a dense cytoplasmic zone.
Multinucleation is seen.

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 CHAPTER TWELVE

12.9 An atrophic, inflammatory cytological smear.

12.10 The smear from the same patient (Figure 12.9) after oral estrogen. Numerous normal superficial and
intermediate cells are seen.

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ATLAS OF COLPOSCOPY
12.11 Dysplastic cytology. Hyperchromasia and
irregularity of chromatin is noted with
alteration of the cytoplasmic-nuclear ratio.
12.13 Cytology of a tadpole cell. A large
hyperchromatic nucleus is noted and the
cytoplasm of the cell extends into a long tail.
Such cytology can be indicative of a
squamous cell carcinoma.
12–79
12.12 High grade cytology (CIN III). Active,
hyperchromatic enlarged nuclei with a
slightly indented periphery and a clear
nuclear and cytoplasmic border are noted.
12.14 Atypical glandular cells reflecting a glandular
lesion from the cervix. Nuclear atypia,
overlapping of the cells with peripheral
featuring is noted.
 CHAPTER TWELVE

12.15 Fragments of normal columnar epithelium 12.16 Dysplastic epithelium from an ECC. Due to
from an endocervical curettage (ECC). the absence of stroma and fraying of the
epithelium grading of the lesion may not be
possible.

12.17 An abundance of tissue from an ECC. Most

of the fragments are without stroma.
Histology indicates at least a CIN III lesion.
12.18 An adequate cervical biopsy demonstrating a
CIN III squamous lesion with sufficient
stroma.

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ATLAS OF COLPOSCOPY

12.19 High grade squamous cytology reflecting CIN
III disease.
12.20 The colposcopy done for Figure 12.19 reveals
an elevated, well demarcated, and dense
acetowhite lesion with no canal involvement
indicating satisfactory colposcopy. The
colposcopic diagnosis is CIN III.

12.21 Biopsy of the lesion depicted in Figure 12.20 confirms CIN III disease establishing correlation
between cytology, colposcopy and histology with no evidence of malignancy.

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 CHAPTER TWELVE

12.22 High grade squamous cytology indicating a
CIN III lesion.
12.23 Colposcopy done for the patient shown in
Figure 12.22 reveals a large, dense
acetowhite lesion with coarse mosaicism and
canal extension reflecting CIN III disease
colposcopically.

12.24 Biopsy of the lesion as shown in Figure 12.23 confirms CIN III disease with crypt
extension. Although correlation indicates CIN III disease, colposcopy is
unsatisfactory. Excision revealed a microinvasive squamous cancer in the
endocervical canal.

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ATLAS OF COLPOSCOPY

12.25 High grade squamous cytology with evidence 12.26 Colposcopy done for the abnormal cytology
of HPV infection suggesting a CIN II lesion. as depicted in Figure 12.25 indicates a CIN
III lesion with canal extension.

12.27 Histology of the lesion depicted in Figure 12.26 reveals CIN II disease. Although correlation exists,
the colposcopy is unsatisfactory due to canal extension and the possibility of malignancy has not
been excluded. Thus some method of excision is required to exclude the latter.

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 CHAPTER TWELVE

12.28 High grade squamous cytology suggesting a 12.29 Colposcopy done for the cytology as shown
CIN III lesion. in Figure 12.28 reveals a CIN II – III lesion
with canal involvement.

12.30 Biopsy of the lesion as shown in Figure 12.29 reveals CIN III disease. Due to canal extension
excision is required to exclude malignancy.

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ATLAS OF COLPOSCOPY

12.32 Colposcopy done on Figure 12.31 reveals a

flat acetowhite lesion suggesting a CIN I
lesion on the ectocervix.

12.31 Cytology showing a low grade lesion with

koilocytes.

12.33 Biopsy of the lesion as shown in Figure 12.32 shows minimal dysplasia with koilocytes.
Correlation exists and colposcopy is satisfactory.

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 CHAPTER TWELVE

12.34 Cytology reflects high grade 12.35 Colposcopy done for the cytology as shown in Figure
squamous disease (CIN III). 12.34 reveals a carcinoma.

12.36 Biopsy of the lesion demonstrated in Figure 12.35 is CIN III with crypt extension. Correlation is
lacking since colposcopy indicated a cancer. Excision of the lesion revealed a squamous cell
carcinoma.

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ATLAS OF COLPOSCOPY

C H A P T E R 13

THE COLPOSCOPIC DIFFERENTIATION OF

GLANDULAR LESIONS FROM OTHER
CERVICAL LESIONS
The glandular lesions are most effectively differentiated from colposcopic mimics by
studying surface characteristics, lesion locations and blood vessel patterns.

Table 1
Surface Topography and Blood Vessel Patterns in Different Cervical Diseases
Metaplasia Condylomata CIN ACIS Invasive Invasive MGH*
/SIL Adeno Squamous
SURFACE CHARACTERISTICS
Lesions overlying columnar
epithelium and not contiguous • • • • •
with the squamocolumnar
junction

Lesions with very large

gland openings • •

Papillary-like lesions • • • • • •

Epithelial budding • • •

Patchy red and white lesions

(transformation zone-like) • • •

BLOOD VESSEL PATTERNS

Punctation •

Mosaicism •

Corkscrew-like •

Waste-thread-like • • • •

Tendril-like • • • •

Root-like • • •

Character-writing-like • • • •

Single and multiple dot-like

formations • • • • •

*Microglandular Hyperplasia

Figures 13.1 to 13.39 illustrate some of these colposcopic differences.

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 CHAPTER THIRTEEN

13.1 Spherical and cylindrical formations of immature acetowhite metaplastic tissue overlying
columnar epithelium.

13.2 The papillary configuration of a condylomata overlying columnar epithelium.

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ATLAS OF COLPOSCOPY

13.3 Adenocarcinoma in situ (ACIS) extends from the 11 o’clock to the 5 o’clock position (A) and overlies
columnar epithelium. The area is faintly acetowhite and has a villous appearance resembling early
metaplasia.

13.4 Patches of microglandular hyperplasia (MGH) overlie columnar epithelium. This appearance
resembles metaplasia and ACIS. MGH can shed atypical glandular cells of undetermined
significance (AGUS).

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 CHAPTER THIRTEEN

13.5 An elevated, dense acetowhite and papillary 13.6 ACIS (patchy red and white area) overlies
lesion overlies columnar epithelium and is columnar epithelium. The lesion appears
not in contact with the squamous border. villous-like.
Biopsy confirmed adenocarcinoma.

13.7 The villous structures of an ectopy can 13.8 The papillary configurations of cervical
appear papillary. condylomata.

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ATLAS OF COLPOSCOPY

13.9 The papillary and budding excrescences of an adenocarcinoma in situ of the cervix.

13.10 The papillary excrescences of this adenocarcinoma mimic the villous structures of an ectopy. An
afferent and efferent looped vessel can be seen in some villi viewed from the side and small dots
created by the vessels appear in the tips of some excrescences viewed from the top.

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 CHAPTER THIRTEEN

13.11 This microinvasive squamous cell carcinoma demonstrates papillary excrescences.

13.12 The papillary fused excrescences of microglandular hyperplasia (A). These areas have a yellow hue
similar to the color of chicken fat.

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ATLAS OF COLPOSCOPY

13.13 Small papillary excrescences and epithelial budding are formed during the development of
immature metaplastic epithelium.

13.14 The epithelial budding structures and papillary excrescences of cervical condylomata.

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 CHAPTER THIRTEEN

13.15 Patchy red and white areas of an adenocarcinoma in situ. The red areas are due to the “root-
like” angioarchitecture. The posterior cervix resembles a matured TZ.

13.16 The villous structures of an ectopy can mimic glandular disease.

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ATLAS OF COLPOSCOPY
13.17 Punctation is seen in squamous intraepithelial
neoplasia and is not seen in glandular
disease. Its characteristics are used to grade
the severity of the squamous lesion.
13.19 “Corkscrew-like” vessels are seen in
squamous cell carcinoma. They are not
seen in glandular disease.
13–95
13.18 Mosaicism is associated with squamous
intraepithelial neoplasia and is not seen in
glandular disease. Its features are used to
grade the severity of the squamous
intraepithelial lesion.
13.20 “Waste-thread-like” blood vessels of cervical
condylomata.
 CHAPTER THIRTEEN

B
A
13.21 “Waste-thread-like” (A) and “tendril-like”(B) blood vessels of a squamous cell carcinoma.

13.22 “Waste-thread-like” and “tendril-like” blood vessels of a squamous cell carcinoma.

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13.23 Fine “waste-thread-like” and “character-writing-like” blood vessels seen in this adenocarcinoma.

13.24 Fine “waste-thread-like” and “character writing-like” angioarchetecture (inked-in) of the tumor
depicted in Figure 13.23

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13.25 “Waste-thread-like” and “tendril-like” blood 13.26 “Root-like” blood vessel formations in a
vessels in cervical condylomata. mature transformation zone.

13.27 Dilated “root-like” blood vessels in cervical 13.28 “Character-writing-like” blood vessel
adenocarcinoma. formations (inked in) as seen in metaplasia.

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13.29 “Character-writing-like” blood vessels within the papillary excrescences of cervical condylomata.

13.30 High magnification view of Figure 13.29 of 13.31 “Character-writing-like” and “root-like”
“character-writing-like” blood vessels seen in angioarchitecture (inked in) as seen in
cervical condylomata. adenocarcinoma in situ.

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13.32 “Character-writing-like” blood vessels in cervical adenocarcinoma (inked in).

13.33 Numerous “character-writing-like” blood vessels in cervical adenocarcinoma.

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13.34 Papillary excrescences of a cervical adenocarcinoma in situ (A) separating two acetowhite CIN III
lesions on the posterior cervix (Bs). The CIN III lesions should be contiguous and not divided.

13.35 Small “dot-like” blood vessel formations are 13.36 “Dot-like” vascular architecture within the
seen in the tips of the normal papillary papillary excrescences of cervical
excrescences of metaplasia. condylomata.

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13.37 Single and multiple “dot-like” blood vessel
formations in cervical condylomata.
13.38 The afferent and efferent blood vessel
patterns seen in cervical condylomata.
These produce single and multiple “dot-like”
blood vessel formations in the tips of the
excrescences.

13.39 Single “dot-like” blood vessel formations in the tips of the papillary excrescences of cervical
adenocarcinoma. Long vessel loops are also apparent.

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C H A P T E R 14

Colposcopy of the Cervix in Pregnancy

• Physiological alterations are induced by the profound hormone changes.
• There is an eversion of the endocervical canal which reveals epithelium in the
lower endocervical segment. This results in satisfactory colposcopy in most
patients during pregnancy.
• The most dynamic phase of metaplasia occurs during the first pregnancy.
• Hypertrophy and dilation of the endocervical canal occur.
• Formation of cervical decidual tissue and microglandular hyperplastic tissue and
their associated angioarchitecture can mimic invasive cancer.
• There is an exaggeration of colposcopic patterns.
• The edema and glandular proliferation increases the size of the cervix which in
turn increases the size of the pathologic lesion. Measurements and limits
established for non-pregnant patients do not apply.
• The vaginal walls collapse with increasing gestation which may interfere with the
colposcopic assessment.
• There is increased vascularity so that the cervix bleeds easily with even the
slightest trauma.
• An excessive amount of mucus is produced with may interfere with the
colposcopic assessment. Its removal can initiate bleeding.
• Endocervical curettage is to be avoided.
• Bleeding may be increased after biopsy.
• A decision must be made whether correlation can be achieved between cytology
and colposcopy alone in contrast to the “traditional” correlation between
cytology, colposcopy and histology.
• A consultation with an experienced colposcopist may be necessary to establish an
accurate diagnosis due to the physical changes and technical difficulties
attributable to pregnancy.
• Treatment of cervical intraepithelial neoplasia of any grade in the presence of
satisfactory colposcopy is not required in the pregnant state.
• The patient is reassessed postpartum.
• Figures 14.1 to 14.18 illustrate various colposcopic features seen in the pregnant
state.

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14.1 In late pregnancy the bulging vaginal side walls can interfere with exposure of the cervix.

14.2 A 36 week pregnancy. Prominent gland openings are seen.

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14.3 The bulging vaginal side walls are seen. Dynamic metaplasia occurs particularly during the first
pregnancy as evidenced by scattered areas of faint white epithelium.

14.4 The cervix becomes larger in pregnancy. Gland openings are prominent. Colposcopic patterns
become exaggerated. Biopsy confirmed CIN II disease.

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14.5 Note the bulging vaginal side walls. An elevated, well-demarcated, dense acetowhite lesion is seen
on the ectocervix with slight canal extension. Biopsy and correlation confirmed CIN III disease.

A
B

14.6 Pregnancy at 37 weeks gestation. Decidual changes (A and B) are seen as well as a large decidual
polyp (C).

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14.7 Metaplasia during pregnancy. The fused villi 14.8 Faint yellow polypoid masses of
appear edematous and glazed with loss of microglandular hyperplasia in a cervix at
transparency. 36 weeks gestation.

14.9 Large, normal, pronounced blood vessels 14.10 Dynamic metaplasia in pregnancy. Clumps
and metaplasia in pregnancy. of glazed metaplastic tissue overlie columnar
epithelium.

14.11 Linear measurements are exaggerated with 14.12 Figure 14.11 under higher magnification.
pregnancy. This CIN III lesion measures The CIN III lesion is elevated, well
over 20 mm due to increase in size of the demarcated with an associated irregular
cervix. mosaic and punctate pattern.

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14.13 Heaped up decidual tissue on the posterior 14.14 Decidual changes of the posterior cervical
cervical lip in a pregnant patient. lip. The decidual angioarchitecture is classic.

14.15 An invasive squamous cell cancer. It mimics 14.16 A large decidual polyp in pregnancy.
decidual tissue (see Figure 14.13).

14.17 A very large, fleshy polyp in pregnancy. 14.18 Cervical and vaginal condylomata in
pregnancy.

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C H A P T E R 15

Colposcopy of Cervical Condylomata

• The colposcopic features of cervical condylomata are diverse.
• The condylomata may appear white due to their hyperkeratosis even before the
application of acetic acid.
• Surface contours produced by epithelial excrescences are varied. Some
proliferations are described as “epithelial budding”, others as individual or fused
papillary masses or brain-like formations.
• There are many different blood vessel arrangements produced by the human
papillomavirus. They become incorporated within the areas of epithelial
proliferation and associated hyperkeratosis. Single and multiple dots can be seen
in the tips of the excrescences when viewed head-on; afferent and efferent looped
capillaries (“hairpin-like”) are noted when viewed from the side; “waste-thread-
like” and “tendril-like” arrangements also appear.
• The lesions may or may not be in contact with the squamous border.
• The lesions may overlie only columnar epithelium, squamous epithelium or both.
• The condylomata can be confluent or scattered.
• An associated intraepithelial or malignant lesion might also be present.
• Cervical condylomata have many colposcopic mimics. The villous structures of
columnar epithelium, microglandular hyperplasia, glandular disease (in situ and
adenocarcinoma) and papillary squamous cell carcinoma can all resemble cervical
condylomata.
• Biopsy of the lesion is always necessary.
• Figures 15.1 to 15.14 illustrate the various colposcopic features of cervical
condylomata.

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15.1 Small papillary-like projections of cervical condylomata.

15.2 Condylomata overlying columnar epithelium. After acetic acid application, the lesion appears
dense white due to hyperkeratosis. Small “dot-like” blood vessel formations are seen.

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15.3 Cervical condylomata assuming a “brain-like” formation.

15.4 Varying sized papillary excrescences of cervical condylomata. Single and multiple “dot-like”
angioarchitecture is seen within the tips of some of the excrescences.

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15.5 A very large and densely acetowhite cervical condylomata.

15.6 Excessive hyperkeratosis seen in a cervical condylomata.

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15.7 Papillary and epithelial budding formations seen in cervical condylomata.

15.8 Cervical condylomata with small “dot-like” angioarchitecture.

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 CHAPTER FIFTEEN

15.9 A cervical condylomata between 12 o’clock 15.10 A large florid cervical condylomata.
and 6 o’clock and a CIN II lesion between 6
o’clock and 12 o’clock.

15.11 Cervical condylomata with “waste-thread- 15.12 “Waste-thread-like” and “tendril-like” blood
like” and “tendril-like” blood vessels. vessels of cervical condylomata.

15.13 Florid condylomata of the cervix and vagina. 15.14 “Character-writing-like” blood vessels of
cervical condylomata.

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C H A P T E R 16

Colposcopy of Cervical Polyps and the

DES-Exposed
• Cervical polyps are usually benign and asymptomatic.
• They are composed of endocervical-type epithelium overlying a thin
fibrovascular stalk.
• Their removal, including the base of the stalk, will enable the pathologist to
distinguish between endometrial and endocervical polyps.
• The exposed columnar surface responds to the same environmental factors as
the columnar epithelium on the exposed surface of the cervix.
• Hence cervical polyps can exhibit inflammation, metaplasia, intraepithelial
neoplasia, squamous cell carcinoma and glandular disease (in situ and
adenocarcinoma).
• Abnormalities of the fibromuscular tissue in the diethylstilbestrol-exposed
women produces abnormalities of the cervix such as hoods, collars,
cockscomb-like protuberances and cervical hypoplasia. Columnar
epithelium-like areas can also be seen involving the vagina.
• Figures 16.1 to 16.11 illustrate colposcopic pictures of the diethylstilbestrol-
exposed and various configurations of cervical polyps.

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16.1 “Cockscomb-like” formation of a DES cervix. 16.2 Shortened cervix with a “cockscomb-like”
formation.

16.3 Cervical “hood-like” formation in the 16.4 A diethylstilbestrol shortened cervix with a
diethylstilbestrol exposed cervix. complete cervical collar.

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16.5 Multiple cervical polyps. 16.6 A large fleshy polyp with metaplastic
changes.

16.7 Polypoid masses of normal endocervical 16.8 A large fleshy polyp in pregnancy.
columnar epithelium.

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 CHAPTER SIXTEEN

16.9 A large cervical polyp in pregnancy with 16.10 A large cervical polyp which demonstrated
metaplastic changes. areas for ACIS.

16.11 A large cylindrical fibroepithelial polyp. Note 16.12 A benign fibroepithelial endocervical polyp.
the unusual shape.

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C H A P T E R 17

Colposcopy of the Cervix After Treatment for

Squamous Intraepithelial Neoplasia
• Regardless of the grade of the squamous cervical intraepithelial lesion (CIN/
SIL), the method chosen to treat it must account for the distribution of disease
(linear length and underlying crypt/gland involvement).
• The technique chosen should enable the cervix to restore its original volume
whenever possible.
• Preserving the peripheral ectocervical rim when excising usually results in
restoration of the original cervical volume.
• A cervix which loses its portio length will not regenerate to its pre-treatment
length.
• An irregular (lacerated) cervix may have the same deformity post-treatment.
• A post-treatment healed cervix can demonstrate uniform blood vessels radiating
in a “spoke-like” fashion regardless of the method of treatment.
• Incomplete removal of disease will result in persistent disease in most instances.
• Complete removal of disease does not guarantee a normal follow-up. Insult of
the cervix induces the metaplastic process and can activate latent HPV causing
condylomata and/or some grade of intraepithelial lesion to develop in unique
patterns. Usually a symmetrical lesion will surround the external os covering the
entire area that was ablated or excised.
• Figures 17.1 to 17.10 illustrate some of the colposcopic patterns of the post-
treated cervix by different methods.

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17.1 A cervix after electrosurgical loop excision. 17.2 A cervix after an electrosurgical pass of a
loop electrode followed by another, smaller
central excision producing a cowboy hat-like
surgical defect.

17.3 A cervix after laser ablation. 17.4 A cervix after laser cylindrical excision and
peripheral ablation producing a cowboy hat-
like configuration.

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17.5 A cervix 3 months post laser ablation for CIN 17.6 Multiple cervical condylomata after
III. During the healing process the HPV electocervical excision for CIN III.
becomes incorporated into the regenerating
tissue and results in a persistent lesion.

17.7 Keratin on the ectocervix following laser ablation for CIN II.

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 CHAPTER SEVENTEEN

17.8 Patchy areas of HPV (LSIL) after cryosurgery 17.9 Persistent CIN after a laser ablation. HPV
for CIN I. Note the symmetrical distribution. becomes incorporated into the newly forming
tissue producing a “white-walled tire”
appearance.

17.10 A normal cervix after laser ablation.

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C H A P T E R 18

Colposcopy of the Vagina

• Lubricants should not be used since they can interfere with good visualization.
• Careful insertion of the speculum is necessary to prevent trauma to the vaginal
mucosa.
• A repeat Pap smear may be necessary.
• The vaginal mucosa must be estrogenized. In post-menopausal women who are
not on hormonal replacement, a three week course of vaginal or oral replacement
is required. The interpretation of the iodine staining is based upon the fact that
intraepithelial lesions are devoid of glycogen. Estrogen is required to ensure the
presence of glycogen in normal tissues.
• Iodine staining (Lugol’s or Schiller’s) is mandatory for vaginal colposcopy.
• The entire vagina (and cervix if present) must be examined.
• Any mucus in the vagina should be carefully removed.
• A blue/green filter is used to detect blood vessel patterns.
• Acetic acid is applied. It may be necessary to apply the acetic acid every 2 or 3
minutes to enhance the colposcopic features during the colposcopic examination.
• The entire vagina is then stained with an iodine solution.
• Biopsies are taken from the suspected diseased areas (e.g., for vaginal dysplasia,
those areas not taking up the iodine stain).
• Monsel’s paste can be applied by a cotton-tip applicator to control any bleeding
if necessary.
• A bimanual pelvic examination may be performed after the colposcopic
examination.
• A review of colposcopic findings and probable histology of the lesion(s) is
presented to the patient.
• The various methods of management are discussed with the patient.
• Figures 18.1 to 18.14 demonstrates some diseases and miscellaneous conditions
of the vagina.

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 CHAPTER EIGHTEEN

18.1 Small papillary excrescences of vaginal vault 18.2 Florid condylomata of the right lateral vagina
condylomata. adjacent to the cervix.

18.3 Multiple florid condylomata of the cervix and 18.4 Extensive cervical and vaginal condylomata
vagina in pregnancy. in pregnancy.

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18.5 A large area of severe dysplasia/carcinoma 18.6 A large VAIN lesion after acetic acid
in situ (VAIN III) of the vaginal vault after application.
Lugol’s iodine. The lesion is refractory to the
iodine.

18.7 Multifocal VAIN III (non-staining areas) after 18.8 Extensive VAIN III of the vaginal vault (non-
Lugol’s iodine. staining areas) after Lugol’s iodine staining.

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 CHAPTER EIGHTEEN

18.9 A vaginal epithelium allergic response to a 18.10 Figure 18.9 after Lugol’s iodine - the so
topical vaginal cream. Similar lesions are called “reverse leopard spot” look.
noted after any contact allergic response
(e.g., latex condoms).

18.11 Multiple small hemangiomas of the vagina. 18.12 Granulation tissue of the vaginal vault after
hysterectomy for benign disease. The
angioarchitecture is classic in distribution and
formation.

18.13 VAIN III after Lugol’s iodine staining. 18.14 Invasive carcinoma of the lower one third of
the vagina. Numerous “corkscrew-like” blood
vessels are seen.

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C H A P T E R 19

Colposcopy of the Vulva and Adjacent Sites

• 5% acetic acid and 1% toluidine blue (optional) are the best enhancing
solutions.
• Careful inspection of the entire vulva, anus, perianal skin and anal canal
under magnification is recommended.
• Accurate mapping and recording (colposcopic photographs, macro
photographs or drawings) are recommended.
• Tissue sampling may be accomplished using Keyes dermatological punch
(4 – 6 mm), scalpel, cervical punch or electrosurgical excision with a
tissue electrode under local or general anesthesia.
• Usually painless local anesthesia can be achieved using topical Lidocaine-
Prilocaine/EMLA (Eutectic Mixture of Local Anesthetics) applied to the
suspect area(s) for 30 minutes, and then injecting anesthetic solution
(e.g., 1% lidocaine without epinephrine – pH 6.49). Mixing 1%
lidocaine and sodium bicarbonate (1 mEq/ml) at a ratio of 10:1, i.e., 10
cc of 1% lidocaine and 1.0 cc sodium bicarbonate, yields a pH of 7.38.
This alkaline pH appears to cause less discomfort upon injection than an
acid pH.
• Vulvar colposcopy including the adjacent sites provides a surface
evaluation only. It cannot predict which lesions are benign, which
extend into the sebaceous ducts and glands or involve the sweat glands.
• Figures 19.1 to 19.86 demonstrate some of the disease conditions seen
on the vulva and adjacent sites.

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 CHAPTER NINETEEN

19.1 An elevated lesion on the patient’s left 19.2 Acetowhite areas of VIN III occupying both
interlabial fold. Excision revealed severe the hairy and non-hairy areas of the vulva.
dysplasia/carcinoma in situ (VIN III).

19.3 VIN III over the upper labia minora and 19.4 Warty appearing VIN III over the upper labia
clitoral hood after acetic acid application. minora and clitoral hood.
The areas appear white and hyperkeratotic.

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ATLAS OF COLPOSCOPY

19.5 A large area of VIN III occupies the patient’s 19.6 After acetic acid application multifocal
inner right vulvar vestibule. acetowhite areas of VIN III involve the lower
labia minora and perineum.

19.7 A large, acetowhite elevated and well- 19.8 Multifocal acetowhite areas of VIN III.
demarcated VIN III lesion over a hairy area.
The lesion demonstrates hyperkeratosis.

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 CHAPTER NINETEEN

19.9 Pigmented areas of VIN III over the labia 19.10 VIN III occupying the right vestibule.
minora and clitoral hood.

19.11 A well-demarcated lesion on the perineum. 19.12 An elevated lesion on the left interlabial fold.
Excision revealed a squamous cell Excision revealed VIN III.
carcinoma with invasion
of 0.4 mm.

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ATLAS OF COLPOSCOPY

19.13 Carcinoma in situ involving the perianal skin between 3 o’clock and 6 o’clock.

19.14 An ulcerated, invasive perianal squamous cell carcinoma.

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 CHAPTER NINETEEN

19.15 Mosaicism within an area of VIN III. 19.16 Atypical vessels within a vestibular
squamous cell carcinoma.

19.17 A squamous cell carcinoma surrounded by 19.18 A large ulcerating basal cell cancer of the
areas of lichen sclerosus. vulva, perineum and perianal skin.

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ATLAS OF COLPOSCOPY

19.19 VAIN III and vestibular VIN III demonstrating 19.20 VIN III over the clitoral prepuce.
a mosaic pattern.

19.21 Carcinoma in situ over the mucosal surface 19.22 VIN III after 1% toluidine blue staining and
of an external hemorrhoid. acetic acid. The VIN III lesion retains the
dye.

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 CHAPTER NINETEEN

19.23 Acetowhite epithelium occupies the lower vagina and vulvar vestibule. Biopsy confirmed VAIN III and
VIN III.

19.24 Carcinoma in situ of the perianal mucosa and perianal skin.

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ATLAS OF COLPOSCOPY

19.25 A pigmented area of VIN III involving the upper two-thirds of the right labia minora.

19.26 A large area of VIN III involves the right vestibule (non-hairy area) and extends to the
cutaneous skin (hairy area). The latter is more elevated and well demarcated.

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 CHAPTER NINETEEN

19.27 VIN III involving the right lower one-third of the vulva and upper perineum.

19.28 VIN III involving the upper two-thirds of the right vestibule.

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ATLAS OF COLPOSCOPY

19.29 VIN III involving the right inner vestibule (acetowhite and flat) and extending to the cutaneous skin.
Note the greater elevation and demarcation of the cutaneous part (a hairy area).

19.30 An invasive squamous cell carcinoma of the vulva with surface ulceration.

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 CHAPTER NINETEEN

19.31 A melanoma of the right upper one-third of the vulva.

19.32 Epidermoid cysts of the vulva. Previously called sebaceous cysts.

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ATLAS OF COLPOSCOPY

19.33 Condylomata of the lower anal canal.

19.34 Vulvar papillomatosis of the vestibule. These fibroepithelial excrescences are benign and often
confused with condylomata to the naked eye. Colposcopy is very helpful for the differential
diagnosis.

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 CHAPTER NINETEEN

19.35 Long standing condylomata of the vulva.

19.36 Confluent extensive condylomata of the vulva in an immune-suppressed patient.

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ATLAS OF COLPOSCOPY

19.37 Confluent, extensive condylomata of the vulva in a diabetic patient.

19.38 Extensive condylomata of the perineum in a pregnant patient.

19–141
 CHAPTER NINETEEN

19.39 Perianal condylomata in an adolescent.

19.40 Confluent vulvar condylomata in a pregnant patient.

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ATLAS OF COLPOSCOPY

19.41 Florid perianal condylomata. 19.42 A large verrucous carcinoma involving the
vulva, perineum and anal canal.

19.43 Vulvar papillomatosis. These fibroepithelial 19.44 Condylomata of the female urethra.
excrescences are benign. (Courtesy Paul D.
Indman, M.D.)

19–143
 CHAPTER NINETEEN

19.45 Condylomata of the lower one-third of the 19.46 Florid perianal condylomata.
vulva and introitus.

19.47 Condyloma planum of the vulva. 19.48 Large florid condylomata of the right
vestibule and introitus.

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ATLAS OF COLPOSCOPY

19.49 Condylomata of the penis. 19.50 Extensive florid and confluent condylomata
of the vulva.

19.51 Giant condylomata of the vulva and perianal 19.52 Multiple condylomata of the perianal mucosa
skin of 20 years duration. and cutaneous skin.

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 CHAPTER NINETEEN

19.53 A squamous cell carcinoma of the urethra.

19.54 A large condylomata of the vulva which mimics a carcinoma. Excision was necessary to confirm its
benign nature.

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ATLAS OF COLPOSCOPY

19.55 Squamous cell hyperplasia of the vulva. The area is white even without acetic acid application. A
fissured area is seen which is uncommon.

19.56 Squamous hyperplasia of the vulva. Area is white and thickened with absence of fissuring.

19–147
 CHAPTER NINETEEN

19.57 Lichen sclerosus of the vulva. Note the vulvar atrophy.

19.58 Lichen sclerosus of the vulva. Considerable fissuring is seen.

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ATLAS OF COLPOSCOPY

19.59 Lichen sclerosus of the vulva. Note the 19.60 Benign vulvar intradermal nevus.
vulvar atrophy and narrowing of the vaginal
introitus. There is fusion of the labia minora
over the clitoris.

19.61 Benign mucous cyst. 19.62 Candida (yeast) infection. Note areas of
erythema and pseudo-ulceration.

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 CHAPTER NINETEEN

19.63 Molluscum contagiosum. Note dome-shaped 19.64 Pedunculated acrochordon (skin tag).
elevations and umbilicated centers.

19.65 Vulvar hidradenoma papilliferum. 19.66 Cherry angiomas of the vulva.

19.67 Lichen planus of the vestibule (red area). 19.68 Vestibular drug reaction.

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ATLAS OF COLPOSCOPY

19.69 Paget’s disease of the vulva. Note the 19.70 Lichen sclerosus of the vulva and the
velvety red and white areas. associated atrophy.

19.71 Lichen sclerosus. Note the wrinkled skin. 19.72 Herpes simplex virus (HSV II) ulcer.

19.73 Bruising and vulvar atrophy. 19.74 Multiple vulvar condylomata.

19–151
 CHAPTER NINETEEN

19.75 Condyloma planum of the vulva. 19.76 Basal cell carcinoma of the vulva.

19.77 VIN III of lower vestibule and posterior 19.78 Unifocal area of VIN III (dense acetowhite).
introitus.

19.79 Carcinoma in situ of the perineum. 19.80 Carcinoma in situ of the perianal skin.

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ATLAS OF COLPOSCOPY

19.81 Hyperkeratosis of the labia minora and 19.82 Invasive squamous cell cancer of the right
clitoral hood. labium minorum.

19.83 Invasive cancer of the vulva. 19.84 Mosaicism in a VIN III lesion.

19.85 Mosaicism in a unifocal VIN III lesion. 19.86 A squamous cell cancer within a field of VIN
III.

19–153