Introduction To Colposcopy

Question 1

Colposcopy (陰道鏡)

Answer 1

• Low power microscope to magnify cervix
• Diagnostic when combined with Biopsy
• No need anaesthesia, day clinic procedure

Indications:
1. Abnormal cervical screening test
- ASCUS twice / ASCUS with high risk HPV
- LSIL / above
- AGC-NOS / above

Process:
1. Speculum insertion
2. Colposcopy
- Identify squamocolumnar junction (SCJ) + transformation zone (TZ)
- Normal saline (cleaning)
- 5% Acetic acid + Lugol’s iodine staining —> observe cervical epithelium
- Abnormal vascular pattern (e.g. mosaic, punctation) (afferent + efferent capillary trapped in dysplastic epithelium)
3. Biopsy

SE:
- Bleeding for a few days (avoid coitus)

Results of biopsy:
- Low grade lesion —> Regular surveillance (repeat smear every 6 months for 3 times)
- High grade lesion —> **LLETZ (large loop excision of transformation zone) / **LEEP (loop electrosurgical excision procedure) (LLETZ = LEEP) (can be done under LA in outpatient)

(Acetic acid (乙酸):
- Coagulate nuclear proteins
- Abnormal cells will have higher protein content in nuclei —> turn white (Acetowhite) after acetic acid addition
- 不正常:變白

Lugol’s iodine (碘液):
- **Differentiate between normal and abnormal epithelium / **Delineate SCJ
- Normal squamous: Glycogen-rich, take up iodine stain —> turn ***black / brown
- Dysplastic epithelium / Columnar epithelium: Little / No glycogen —> not stain with iodine
- 不正常: 無上色)

Question 2

Histology of cervix

Answer 2

Ectocervix: Stratified squamous epithelium
Endocervix: Columnar epithelium
—> 2 types of epithelium meet at SCJ

After exposure to estrogen
—> Glycogen from exfoliated vaginal cells is converted to lactic acid
—> Acidity stimulate columnar epithelium to be replaced by squamous epithelium (i.e. Metaplasia)
—> A new SCJ is formed (closer to external os)

Transformation zone:
- Area between old and new SCJ where there is squamous metaplasia

Question 3

LLETZ (large loop excision of transformation zone) / ***LEEP (loop electrosurgical excision procedure) (子宮頸電圈切除)

Answer 3

• Can be done under LA in outpatient
• Not affect conception
• Diagnostic: Biopsy to identify any more serious lesion
• Therapeutic: Remove dysplastic lesion

Process:
1. Speculum insertion
2. Colposcopy
- Identify squamocolumnar junction (SCJ) + transformation zone (TZ)
- Normal saline (cleaning)
- 5% Acetic acid + Lugol’s iodine staining
3. Inject LA (mixed with Adrenaline) in 4 quadrants of cervix
4. LEEP
5. Haemostasis with bore diathermy

Risk:
Short-term:
1. **Injury to surrounding structures (e.g. bladder, rectum)
2. **Bleeding (Primary / Secondary)
3. ***Infection

Long-term:
1. **Increased risk of preterm births / low birthweight babies / PROM (but no difference in baby mortality)
2. **Cervical stenosis

Recommendations after LEEP:
1. Bleeding is normal for 2-3 weeks, but should be minor (if more severe than menstrual bleeding —> go to A/E)
2. Avoid coitus for 6 weeks
3. Avoid swimming, bathing (shower ok)
4. Can go to work next day

Management after LEEP:
1. FU after 3 weeks for report + check wound
2. Cervical smear after 6 months + regular smear monitoring