Role of Colposcopy in Cervical Erosion

TO STUDY THE ROLE OF
COLPOSCOPY IN CERVICAL
EROSION
A Dissertation submitted for the degree of
Diplomate of National Board Delhi
Obstetrics and Gynaecology
December 2014
By
DR. PRIYANKA T.SURYAWANSHI (M.B.B.S.)

Under the guidance of
DR. UJJWALA S. PATKI (MD)

Patki Hospital and Research Foundation,
Kolhapur: 416001
CERTIFIED BY THE CANDIDATE
I hereby declare that this dissertation/thesis entitled "To Study the

Role of Colposcopy in cervical erosion" is a bonafide and genuine research
work carried out by me under the guidance of Dr. Ujjwala S Patki, M.D,
Consultant Gynecologist , Patki Hospital and Research Foundation,
Kolhapur, Maharashtra. This dissertation has been prepared in fulfilment to
the requirement of the DNB programme in accordance with standards and
guidelines set by the National Board of Examinations.
This has not been submitted by me previously for the award of any
Diploma/Degree to any other university.
Date:
Place: Kolhapur,Maharashtra
.Dr.Priyanka T. Suryawanshi
CERTIFICATE BY THE GUIDE
This is to certify that Dr.Priyanka T.Suryawanshi

(DNB Reg. No. 125-31181-121-103940)
Has prepared this dissertation entitled "To Study the Role of Colposcopy
in cervical erosion" under my guidance and to my satisfaction, in the
fulfilment of the requirement for the DNB Programme in accordance and
guidelines set by the National Board of Examinations.
Date:
Place: Kolhapur,Maharashtra
Dr. Ujjwala S. Patki( M.D.)

Consultant Gynaecologist
Patki Hospital and Research
and Foundation, Kolhapur.
Maharshtra 416 001.
CERTIFICATE BY HEAD OF DEPARTMENT
This is to certify that the dissertation entitled "To Study the Role of
Colposcopy in cervical erosion" is bonafiede research work done by
Dr.Priyanka T.Suryawanshi in partial fulfilment of the requirement for the
DNB Programme in accordance and guidelines set by the National Board of
Examinations.
Date:
Place: Kolhapur, Maharashtra
Dr.Satish M.Patki(MD)
Head of Depatment
Patki Hospital &Research Foundation
Kolhapur.
ACKNOWLEDGEMENTS
I attribute the successful completion of my dissertation to the

guidance and support of many people to whom I am very grateful and I take
this opportunity to thank everyone who made it possible.
I take this opportunity to express my profound gratitude and
overwhelming respect to HOD Dr. Satish M Patki (MD) ,whose esteem
guidance helped me in successful completion of the study. It is indeed my
greatest fortune in my life to his student.
I am extremely grateful to Dr. Ujjwala S. Patki(MD) for her constant
supervision with great encouragement and learned guidance.
I wish to express my sincere thanks to Dr.R.S. Patil, Professor and
Head of Dept of Pathology, for his valuable help and co-operation.
I am ever grateful and indebted to my parents, sister, brother and
my In-laws for their understanding, encouragement and support.
Special thanks to my Husband Dr.Nikhil D.Raut, for his constant
support and co-operation which lead to the successful completion of my
dissertation.
Date:
Place: Kolhapur, Maharashtra
Dr.Priyanka T.suryawanshi
ABSTRACT
Background and Objective:
This was a prospective Observational study conducted from
Jan
2012-Jan
2013
at
Patki
Hospital
and
Research
Foundation, Kolhapur, Maharashtra.

The study was performed on 100 women between 20-60years
of age presenting with complaints of chronic leucorrhoea,
postcoital bleeding, intermenstrual bleeding etc.
The objective of study were to study the various pathological
findings on colposcopy , also cytological and Histopathological
observations in patients of cervical erosion under colposcopic
guidance. Also to compare and correlate the colposcopy , HPE
and cervical pap smear findings .
Study Design:
Prospective study over a period of one year from Jan 20132014Jan.
Setting:
Study was carried out in the OPD at Patki Hospital and
Research Foundation, Kolhapur, Maharashtra.
Sample size: 100 women
Methods:
All women enrolled in the study underwent Pap smear,
colposcopy and colposcopic directed biopsy. The sensitivity,
specificity, positive predictive value. Negative predictive value,

Accuracy and Strength of correlation were calculated.
Results:
Majority 70.5% CIN occurred in age group 3 0-49 years.
Incidence of CIN increases among multipara.
Women having CIN 70.5% complained of excessive
discharge.
Pap smear had sensitivity 29% and Specificity 88%,
accuracy 78%.
Colposcopy
showed
sensitivity
83%,specificity
81%.
Accuracy was found to be 82%.

Strength
of
Agreement
between
colposcopy
and
Histopathology is moderate., while strength of agreement

is Fair between colposcopy and Pap test.
Conclusion:
Colposcopy is definitely more sensitive and accurate than pap
smear. By combining pap smear, colposcopy and colposcopic
guided biopsy we can maximise the sensitivity and specificity
of cervical cancer screening.
Key words: Colposcopy, cytology, CIN, Histopatholgy
LIST OF ABBREVIATIONS USED
LSIL- Low grade squamous intraepithelial lesion

HSIL- High grade squamous intraepithelial lesion
SSC Squamous cell carcinoma
ASCUS-Atypical squamous cell of undetermined significance
CIN-Cervical intraepithelial neoplasia
CIS-Carcinoma in situ
HPV-Human papilloma virus
TZ-Transformation zone
VIA-Visual inspection with Acetic acid
LEEP Loop Electrosurgical Excision Procedure
TABLE OF CONTENTS
PARTICULARS
PAGE
1 INTRODUCTION
2 AIMS AND OBJECTIVES
3 REVIEW OF LITERATURE
4 MATERIAL AND METHOD
42
5 OBSERVATIONS AND RESULTS
50
6 DISCUSSIONS
65
7 SUMMARY
72
8 CONCLUSION
74
9 BIBLIOGRAPHY
75
10 ANNEXURE1: INFORMED CONSENT
89
11 ANNEXTURE2: PROFORMA
91
12 ANNEXTURE 3:
94
MASTER CHART
LIST OF TABLES
1.
Colposcopic Reid Index
2.
Distribution of cases according to Age
3.
Distribution of cases according to parity
4.
Distribution of cases according to symptoms
5.
Distribution of cases according to contraceptives
6.
Colposcopic findings according to age
7.
Colposcopic findings according to Parity
8.
Colposcopic findings according to Complaints
9.
Colposcopic findings according to contraceptives
10.
Pap smear findings according to Age
11.
Pap smear findings according to parity
12.
Pap smear findings according to Complaints
13.
Pap smear findings according to Contraceptives
14.
Pap smear findings
15.
Colposcopic findings
16.
HPE findings
17.
Correlation between Pap test & Biopsy
18.
Correlation between colposcopy & Biopsy
19.
Correlation between colposcopy & Pap test
LIST OF FIGURES
1. Colposcope
2. Colposcopic Examination
3. Squamocolumnar Junction
4. Normal Colposcopy
5. Acetowhite changes
6. Lugols Iodine Staining
7. Punctation
8. Polyps
INTRODUCTION
INTRODUCTION
Cervical cancer is the commonest malignancy found
amongst Indian women and third most common cancer in the
world1. Over 5,00,000 new cases of invasive cervical cancer are
diagnosed annually worldwide2.Cervical cancer is serious
health problem in India which accounts for the worlds one
sixth of the worlds population. There are approximately
130,000 new cases of cervical cancer every year and the
disease is responsible for 20% of all the female death.
As carcinoma of cervix is the most frequent of all the
genital tract cancers. it is very common for the Gynaecologist
who work in tertiary care institutes in the developing countries
to get referrals from practitioners and peripheral health centres
for patient of clinical diagnosis of an unhealthy cervix3.Cervical
cancer is a potentially preventable cancer. It is proceed by
premalignant lesion which may take 5-15 years to progress to
invasive cancer. If detected and treated timely preinvasive
disease has 100 per cent cure rate with simple surgical
procedure, while advance cancers have less than 35 per cent
survival rate.4
However
in
universal
screening
screening
method
percentage
of
developing
has not
been
(pap smear)is
countries
achieved
available
population .Cytology
programs are limited
based
like
India,
.The main
to a
small
screening
infrastructure, trained personnel and
fund.5
INTRODUCTION
A colposcopic evaluation and guided biopsy remains a

critical
diagnostic
step
for
women
with
squamous
intraepithelial lesion, in order to identify the women who

require treatment .Simultaneous use of cytological studies and
screening colposcopy has been shown to increase the rate of
cervical cancer detection.6
Colposcopy performs better in differentiation of low
grade disease from normal cervix.7
And Correlated with directed biopsy is described as the
reference investigation as Gold standard for the diagnosis of
cervical cancer.8
Colposcopy is close examination of vagina and cervix. It
is medical diagnostic procedure to examine an illuminated
magnified view of the cervix and tissue of the vagina and vulva.
It is low power, binocular microscope for study of surface
epithelium and underlying connective tissue stroma along with
vascular pattern.9 It provides an enlarged view of the areas,
allowing the colposcopist to visually distinguish normal from
abnormal appearing tissue and take directed biopsies for
further examination.
Hinselman
started
performing
colposcopies
in
Germany in the 1924.

Indian history is concerned in 1976.Dysplasia or
cytology clinic was started in Cama Hospital , Mumbai.
The recent technological advancement which utilize the
properties of fluorescence, reflectance and spectroscopy which
2
INTRODUCTION
are intrinsic to the in vivo tissues, have lead to development of

a useful adjunct to improve the colposcopic detection of a high
grade CIN.
The additional of the LUMATM(medispectra,Inc MA USA)cervical
imaging system to colposcopy has been shown in two
prospective, to a result in a25% or greater increase in the true
positive biopsy rate of the colposcopy for patients with atypical
squamous cell or low grade intraepithelial lesion on pap smear
examinations, with only 4% increase in the false positive rate,
versus that of colposcopy alone.10
Present study will be undertaken to evaluate the role of
colposcopy in patients having cervical erosion. The earlier
diagnosis of CIN and of invasive cervical cancer in women is a
desirable goal. Hence colposcopic evaluation of unhealthy
cervix is necessary for the earlier detection of the cervix, so
that conservative line can be chosen, especially in young
women.
AIMS AND OBJECTIVES
AIMS AND OBJECTIVES

1. To Study various Pathological finding on Colposcopy of
patients having Cervical Erosion.
2. To Study various Cytological findings of the Smear of
Patients of Cervical Erosion
3. To Study various Histological Observations of the Cervical
Biopsy in patient of cervical erosion under colposcopy
guidance
RIVIEW OF LITERATURE
REVIEW OF LITERATURE
Cervical cancer is one of the well understood human
cancers and potentially the most preventable. The anatomic
accessibility of cervix to direct examination and long preclinical stage during which 95% of precursor lesion can be
treated conservatively and successfully make cervical cancer
an ideal target for screening and treatment.
The basic purpose of screening is to sort out from large
group of healthy person those likely to have disease or at
increased risk of disease under study and to bring those who
are
apparently
abnormal
under
medical
supervision.
Screening test should be simple, minimally invasive, easy to

perform, cost effective and highly sensitive. Participation in
regular cervical screening program decreases mortality rate of
cervical cancer.
ANATOMY OF CERVIX
The cervix measures 2.5-3 cm in diameter and 3-4 cm in
length. The portion of cervix exposed to vagina is the ectocervix
or portiovaginalis. It has convex round surface with a circular
or slit like opening, the external os into the endocervical canal.
The endocervical canal about 3cms in length
and opens
proximally into the endometrial cavity at the internal os.11

The lower order of canal, the external os, contains the
transition from squamous epithelium of the portiovaginalis to
the columnar epithelium of the endocervical canal. This occurs
5
at variable level relative to the Cervical Os and changes with

hormonal variations that occurs during a womens life .It is in
this active area of cellular transition that the cervix is most
susceptible to malignant transformation12.
The squamo-
columnar junction (SCJ) is the point at which the squamous

and columnar cells meet. It typically found between the central
ectocervix and the lower cervical canal, but location varies
throughout
womans
life,
from
fetal
development
to
menopause.
In reproductive aged women, the original SCJ moves out
into the portio of the cervix with hormonal influence. The
acidic vaginal pH plus mechanical irritation likely induces the
process of squamous metaplasia, resulting in a new SCJ. The
area between the original and new squamocolumnar junction
is now referred to as the transformation zone. Immature
squamous metaplastic cells in this transformation zone are
theoretically the most vulnerable to neoplasia.13
Lymphatic drainage: The cervix drains laterally to the
parametrial, obturator and external iliac nodes posteriorly
along the uterosacral nodes to the sacral nodes.
Nerve supply: Uterovaginal plexus, sympathetic and sensory
fibres derived from T10, L1 ; parasympathetic fibres derived
from S2 to S4.
The original squamous epithelium of vagina and ectocervix has
four layers.14
1.Basal
layer(Stratum
Germinatum): It
rests on the
basement membrane. It consist of single row of cuboidal or

columnar cells with scanty basophilic cytoplasm and centrally
placed round to oval large nucleus.
2.Parabasal or Prickle cell layer: It is above the basal layer,410 cells in thickness consisting of large polyhydral cells with
basophilic cytoplasm and centrally placed nucleus, arranged in
irregular mosaic pattern.
3.Intermediate cell layer: It forms the bulk of the epithelium.
The cells are large oval to polygonal with irregular vesicular
nuclei. The cytoplasm is rich in glycogen.
4.Superficial layer: It is made up of flattened, elongated or
polygonal cells with acidophilic cytoplasm and small pyknotic
neucli. The cell detach from surface(exfoliation).
AETIOPATHOGENESIS15
1. Sexual
factor:
Epidemiologically,
cervical
cancer
behaves like a sexually transmitted disease. It is more

common in women who have had multiple sexual
partners, whose partners are promiscuous and absent in
virgins.
2. Smoking: smoking is risk factor independent of sexual
parameters, with an overall two fold increase in risk for
the development of cervical intraepithelial neoplasia and
invasive cervical cancer.
3. Oral contraceptives:
There is significantly increased
risk of cervical cancer in patient who have used oral

contraceptives, the incidence increasing with duration of
use.
4. Infectious
agents:
Human
papilloma
virus-
HPV
infection has been demonstrated in almost 100%
of
invasive cervical carcinoma. HPV types are 6, 11, 42, 44 ,

subtype 16 and 18
are found in
62% of cervical
carcinoma. The mechanism by which HPV affects cellular

growth and differentiation is through the interaction of
viral E6 and E7 proteins with tumour suppressor genes
p53 and Rb, respectively. Inhibition of p53 prevents cell
cycle arrest and cellular apoptosis, which normally occurs
when damaged DNA is present. Whereas inhibition of Rb
disrupts transcription factorE2F,resulting in unregulated
cellular proliferation.16
5. Socioeconomic condition and parity:
There is increased incidence of cervical cancer in
women
of low socioeconomic status and multiparous women.
6. Immunosuppresion and cervical cancer: An increased
incidence of CIN has been described in patients who have
received renal transplants and patients infected with HIV.
7. Local hygiene: cancer of cervix is found to be positively
associated with lack of daily genital washing and negatively
with the use of clean sanitary napkins during menstruation.
8
Premalignant and Malignant squamous lesion of

cervix
1.Low Grade Squamous intraepithelial lesion(LSIL) (CIN 1
and HPV changes )In CIN 1 or LSIL , only the lower third of epithelium is involved
and above this the mucosa shows maturation to a normal
surface layer.17 The cumulative rate of progression of mild
dysplasia to moderate and severe dysplasia at 2,5,and 10 years
were 11.1%, 20.4% , and 28.8% respectively, and for
progression to severe dysplasia, rates of progression at 2,
5,and 10 years were 2.1%, 5.5%, 9.9% respectively.18
2. High Grade Squamous intraepithelial lesion HSIL(CIN 2
and CIN 3)
In CIN 2, two third of mucosa is involved, and CIN 3, it is
totally replaced. HSIL includes CIN 2 and CIN 3.16 It is
estimated that 43% of CIN 2 lesion would regress if it left
untreated, however , 22% may progress to CIS or invasive
cancer.
Pathogenesis of CIN19
In most cases, CIN is believed to originate as a single
focus in TZ at the advancing SCJ. The anterior lip of cervix is
twice as likely to develop CIN as the posterior lip and CIN
rarely originates in the lateral wall.
Ones CIN occurs, it can progress horizontally to involve
the entire TZ but usually does not replace the original
9
squamous epithelium. Proximally CIN involves the cervical

clefts and this area tends to have more severe lesions.
CIN is most likely to begin either during menarche or
after first pregnancy when metaplasia is more active.
Conversely a woman who has reached menopause without
developing CIN has little metaplasia and is at a lower risk.
CIN Terminology
Richart recommended use of the term cervical neoplasia
(CIN) to replace dysplasia and carcinoma in situ. CIN is
classified into grades 1, 2 and 3 in which the artificial
distinction between severe dysplasia and carcinoma in situ is
avoided by including them both in CIN 3.20
The Bethesda System
The 1988 Bethesda system for reporting cervical/vaginal
cytologic diagnosis was published by a workshop of North
American Experts convened by the Division of cancer
Prevention and Control of the National cancer Institute. At
present 2001 Bethesda system of reporting Pap smear is
used.21
Abridged table of terminology for reporting cervical cytology.22
10
I.Negative for Intra epithelial lesion or malignancy

II.Epithelial cell abnormalities
a) Squamous cells
i)
Atypical squamous cells of undermined significance

cannot exclude high grade squamous intraepithelial
lesions. (HSIL).
ii)
Low grade squamous intra epithelial lesions

(encompassing human papilloma virus/mild
dysplasia/ cervical intraepithelial neoplasia )
iii)
HSIL ( moderate and dysplasia, carcinoma in situ, CIN

2,and CIN 3.)
iv)
Squamous cell carcinoma.
b) Glandular cells
i)
Atypical glandular cells (specify endocervical,

endometrial or not otherwise specified)
ii)
Atypical glandular cells, favour neoplastic (specify

endocervical or not otherwise specified)
iii)
Endocervical adenocarcinoma in situ
iv)
Adenocarcinoma
III) Others , e.g.endometrial cells in woman >40 years of

age
Cervical cancer has long precancerous phase with
cytological changes that progress through different grades
definable cytologically (dyskaryosis) or histologically
(dysplasia ).Hence screening assumes important role in
reducing the disease burden.23
11
Screening Techniques
Screening techniques for cervical cancer include
i)
24
Conventional exfoliative cervicovaginal cytology ,that is

cervical PAP smear
ii)
Fluid sampling techniques with automated thin layer

preparation (Liquid based cytology)
iii)
Automated cervical screening techniques
v)
Neuromedical systems
vi)
HPV -DNA testing
vii)
Polar probe
viii) Laser induced Fluorescence

xi)
Visual inspection of cervix after applying lugols iodine
under
colposcopy
ix)
Speculoscopy
x)
cervicography
12
Cytology
Papanicolaou
and
Traut
first
reported
the
use
of
exfoliative cervical cytology for the diagnosis of cervical cancer

and precancer. They obtained cellular material from vaginal
pool. Ayre reported the use of wooden spatula to scrap cellular
material directly from cervical transformation zone. Centre of
cytology in Vancouver, British Columbia published data which
confirmed that cytological screening leads to a reduction in the
rate of invasive cancer of uterine cervix.25
The indigenous
technique of collecting exfoliated cells from the cervix, placing

them on a glass slide and examining under a microscope
remained largely unchanged for more than 50 years.26
Advantage of cytology are ideal for mass screening, high
specificity, easy to perform, less time taken to obtain the
diagnosis and detection of lesion in endocervical canal.
Disadvantage of cytology are low sensitivity, need for
laboratory with high human expertise, not possible to locate
the lesion and high cost.27
Liquid based cytology
Liquid based cytology is now the preferred method of
sample collection where a cervical brush
used to collect the
specimen which provides almost twice as many epithelial cells.

The samples are collected directly in a preservative solution
and slides are prepared meticulously avoiding any uneven
manual smearing and thus reducing human error.
13
LBC has higher sensitivity and specificity than Pap smear

as a cellular structure is better because cells are fixed
immediately.28
HPV-DNA Testing
The association between high risk oncogenic types of HPV and
the development of cervical cancers and its precursor lesions is
well established.29
The Hybrid Capture II is the most useful technique for HPVDNA test. This utilizes non radioactive Riboneucleic acid(RNA)
tprobes in a modified enzyme Linked Immunosorbent assay
(ELISA) procedure to report the presence or absence of 13
strains of high risk HPV-DNA.
The ASCUS /Low grade squamous Intraepithelial Lesion triage
study-The alTS trial followed up 3488 women and reported
that HPV-DNA testing demonstrated a sensitivity of over 96%
for severe CIN. Referring 54% women for colposcopy. In this
study HPV-DNA testing for women with ASCUS abnormalities
was more sensitive, cost effective and resulted in significantly
fewer colposcopy referrals. HPV-DNA testing thus appears to
be most useful in determining the appropriate triage of women
with ASCUS abnormalities.30
Visual Inspection with Acetic acid and Lugols iodine
Examination of cervix after application of 3-5% acetic acid is
done. The cervix is inspected after one minute .Lesions with
acetowhite are regarded as positive for VIA.
14
Changes in cervix after application of acetic acid(3-5%)

1. It coagulate the cytoplasmic and nuclear protein of the cells.
The abnormal epithelium has increased nuclear
:cytoplasmic ratio leading to an increased amount of
protein in the cells, which are coagulated and thereby
hinders light transmission. The lesion appear white. This
coagulation is progressive, superficial, reversible and
reproducible.
2. It dissolves the mucous.
3. It causes intracellular dehydration due to osmotic changes.
4. It causes swelling of the individual villi of the columnar
epithelium.
Intensity of whiteness, speed of appearance, duration of stay
and speed of disappearance are directly related to severity of
the abnormality. The contour, colour and border of each
lesion is noted. Acetowhite epithelium may be due to-CIN
-Human Papilloma virus
-Immature squamous metaplasia
-Healing/regenerating epithelium
-congenital transformation zone
After application of acetic acid cervix is painted with aqueous
solution of Iodine. The normal squamous epithelium is rich in
glycogen and takes up a dark brown stain with iodine rapidly.
Proliferating cells utilize all glycogen and hence are deficient in
glycogen. They remain unstained. Hence, iodine negative areas
are considered abnormal.31
15
Cervicography
Developed by Adolf Stafl . Cervicography involve taking
photographs of the cervix with a specially designed camera
called cervicoscope following the application of 5%acetic acid.
The photographs are then developed, projected and viewed by
an expert colposcopist.32
Six hundred and fifty three women attending a family
planning clinic in Kenya underwent four concurrent methods
; pap smear, visual inspection with acetic acid, PCR for high
risk HPV and cervicography. The pap smear had the highest
specificity and HPV testing had highest sensitivity. The visual
methods and cervicography were similar and showed an
accuracy in between the former two tests.33
Polar probe(Truscan)
Portable optical electronic instrument that detects the
existence of precancer or cervical cancer by measuring voltage
decay and the scattering of various wavelengths of light. 99%
of invasive CA, 90% of high grade CIN , 85% of low grade CIN
were detected by polar probe. Normal finding of squamous
epithelium were correctly diagnosed in 94% of patients.
16
Speculoscopy
Speculoscopy involves inspection of cervix following application
of 5% acetic acid with Chemiluminiscent and a low power
magnification.
In a prospective study, a total 1000 patients were subjected to
cytology and speculoscopy examinations. Among these women,
10 had abnormal pap smear findings whereas 144 had an
abnormal speculoscopic pattern. Only three of 59 patients with
a histological diagnosis of cervical intraepithelial neoplasia
grade I (CIN 1)/HPV and only three of seven patients with CIN
2/CIN 3 had a positive Pap test. This concludes that
speculoscopy combined with a Pap test can significantly
increase the detection of cervical lesion when included in a
screening programme.34
Colposcopy
History:
Colposcopy originated in Germany. Hans Hinselmann, a
gynaecologist, believed that cervical cancer must originate as a
small dot invisible to naked eye. He devised a series of
magnifying lenses which would make the dot visible and this
originated the clinical investigation called colposcopy. The
second World War was great setback to its development. When
cytology screening programs were taken up all over the world
in 1950s and 1960s many cases with abnormal cytology by
detected and all these cases had to be further investigated by
colposcopy. Hence 1970s saw the Renaissance of colposcopy
17
and its popularity increased. This was further aided by the

manufacture of this instrument in all parts of world.35
Colposcopy introduced by Prof. Hinselmann (1925) is an
optical method for visualizing the lower female genital tract
with bright illumination using stereoscopic vision, at a
magnification between 4 and 40 fold. It has many advantages
over cytology. it permits the topographical study of lesion
during clinical examination. It is an important tool which
complements cytology and histopathology in early detection
various cervical lesions.
Thus, colposcopy is the traditional method for evaluation of
abnormal Pap smears and today colposcopy has a central role
in the cervical screening programs. Initially, colposcopy was
used to identify asymptomatic early invasive disease, thereby
improving patient survival. Subsequently, it helped in
diagnosing pre-invasive lesions, with resultant reduction in the
incidence of cervical cancer and significant drop in the number
of diagnostic conisation.
In 1990, De pale (Italy) published a manual on colposcopy and
treatment of lower genital tract.
Mitchel et al in 1998, did a meta analysis in the role of
colposcopy for the diagnosis of CR4 and found that average
weighted sensitivity of diagnostic colposcopy.36
Olaniyan B. explained the validity of colposcopy in diagnosis of
early cervical cancer and concluded that colposcopy is a valid
18
tool for the diagnosis of CIN. Its integral role in the

management of early cervical cancer was justified.37
Basics of colposcopy
Colposcopy is a clinical method which evaluates changes in the
terminal vascular network of cervix that reflects the
biochemical and metabolic changes in the tissue. It consist of
examination of connective tissue of the cervix, across the
mucosa using stereoscopic vision.
The following factors are assessed38.
1. Colour, tone and opacity of the mucosa
2. Surface contour
3. Transformation zone must be seen clearly as most
cancers originate there
4. Presence or absence of abnormal vessels on the surface
5. Acetic acid application
INSTRUMENTATION
Colposcope consist of the following components:
1) Optics39
A colposcope is a low power , stereoscopic, binocular, field
microscope with a powerful variable intensity light source
that illuminate the area being examined.
The head of the colposcope, also called the optics carrier
contains the objective lens, a light source, green filters to be
interposed between the light source and the objective lens, a
19
knob to introduced the filter, a knob to change the

magnification of the objective lens ,if the colposcope has
multiple magnification facility and a fine focusing handle.
The filter is used to remove red light, to facilitate the
visualization of blood vessels by making them appear dark.
Modern colposcope usually permit adjustable .
Magnification commonly 6x to 40x usually in steps .It may
have electrical zoom capability to alter the magnification.
Most simple colposcope have a single field magnification
level such as 6x,9x,10x,12x or15x.Lower magnification
yields a wider view and greater depth of field for examination
of cervix.
Modern light source usually either on tungsten or halogen
lamp or fibre optic cable. Halogen bulbs are usually
preferred, as they produce strong white light.
In 1989, first computer aided colposcope was introduced.
Recently , Crisp et al, Mikhail described a system of digital
imaging as applied to colposcopic assessment. The system
provide digital image capture and processing.
Documentation
The record of colposcopic findings for each visit should be
documented carefully by the colposcopist themselves,
immediately after the examination. This record, which can
be stored on paper or electronically, forms the backbone of
any medical record system that can be used for continuing
patient care and performance.
20
The Objectives of colposcopic assessment are

To further assess of colposcopic assessment .
To confirm diagnosis by colposcopically directed biopsy
To exclude invasive disease
Colposcopic Technique
Favourable period for colposcopic examination is 8-10th day of
a cycle as the external os is widely open during this time and
abundance of watery secretions serves as a good refractory
medium and facilitates examination of endocervix.
If the upper limit of TZ is not visible, the examination may be
rescheduled and the patient is instructed to take Ethinyl
estrodiole 50mcg/day/5-7 days prior to examination which
causes canal dilation. In 15% unsatisfactory colposcopic
findings are seen, where endocervical curettings are taken.
Normal Colposcopic
findings40
1.Original Squamous epithelium

Smooth, pink, uniform, featureless epithelium without
columnar remnants. The vascular patterns are hairpin
capillaries and network capillaries. In Trichomonas vaginalis,
double capillaries with two or more crests at the top will be
seen as forklike.
21
2.Coloumner epithelium
Irregular surface with atypical grape like or villus appearance .
Each Villus contains fine capillary that is visualised with
saline. Under high magnification colour appears reddish
because of underlying stromal vessels.
3.Normal transformation zone
Area between the original SCJ and new SCJ in which
metaplastic epithelium has replaced the pre existing columnar
epithelium. Coppleson and Reid in 1967, described the
features of immature metaplasia in three stages after acetic
acid application.
Stage I
Individual villi assume opaque white appearance
Stage II
Individual villi retain their density, but fuse so that

intervening space are filled in.
Stage III
Villus configuration is lost and the new epithelium
has
a homogenous ground glass pattern. Care should
be
taken, not to configure this immature metaplasia
with
dysplasia.
22
Components of TZ are1. Branching vessels- Large Capillaries showing tree like

branching pattern found only in TZ in the walls of retention
cysts.
2. Nabothian follicles-Mucous filled retention cyst
3. Gland opening-small holes from which mucous seems to
pour, representing areas where the new squamous
epithelium has covered incompletely and underlying
columnar cleft is in continuity with the surface.
Abnormal Colposcopic Findings
CIN tend to be confined to the TZ. On contrast, subclinical
papilloma virus infection is not so limited and may involve the
TZ, the original SCJ and sometimes further extend caudally to
involve vagina and cranially to involve
the columnar
epithelium .subclinical papilloma virus infection beyond TZ

suggest absence of CIN.
1. Mosaic- Terminal capillaries surrounding roughly circular
or polygonal shaped blocks of acetowhite epithelium
crowded together giving the appearance similar to mosaic
tile.41
2. Punctuation-Dilated capillaries terminating on the surface
appear from the ends as a collection of dots and thus are
referred to as punctuation.41
23
3. Acetowhite epithelium-It is a focal colposcopic lesion

visible after application of acetic acid as a transient change.
The surface contour may be flat or may have papillary
projection or brain like convolutions42.
4. Leukoplakia- This plaque is white epithelium visible before
application of acetic acid. This is due to hyperkeratosis and
parakeratosis resulting in keratin on the surface and may
overlie normal as well as abnormal epithelium. It may be
thin which is usually not significant or thick with irregular
surface usually seen in pronounced atypical lesion.42
5. Atypical vascular pattern- are characteristic of invasive
cervical cancer and include looped vessels, branching
vessels and reticular vessels.41
Unsatisfactory Colposcopy43
When squamocolumnar junction is invisible or when
there is severe inflammation or atrophy or when the
cervix is not visible, it is called as an unsatisfactory
colposcopy.
Miscellaneous findings44
1. Non AW microcapillary surface-is associated with
congenital normal development, inflammation and
chemical irritants.
24
2. Exophytic condyloma- it is seen in HPV which occurs

either inside/outside the TZ. Surface is micropapillary or
microconvoluted AW areas may be flat or dense and
irregular vessels may be present.
3. Inflammation (vaginocervicitis)- Diffuse pattern of
hyperaemia, characterized by alterations in capillaries
that may be coiled, dilated or duplicated. Occur like
punctuate, mosaic like pattern as seen in trichomoniasis.
More marked inflammation produces yellow spots due to
lymphocytes collection, white spots, minute papillae. No
change on acetic acid application Iodine staining
produces partial uptake.
4. Atrophy- Thin estrogen deprived epithelium which is
prone to bleed upon introducing speculum in the form of
petechiae usually reversed by estrogen therapy.
5. Ulcers- Denuded surface epithelium and stroma due to
trauma, chemicals or microorganisms.
6. Erosion- Denuded surface epithelium only due to trauma
or acidity. Edges are of normal appearance.
7. Polyp- Appearance is characteristic of columnar
epithelium or typical or atypical TZ or their combinations.
Malignant polyps arsing from endocervical canal may
show, AW epithelium and vascular abnormality.
25
8. Deciduosis- Change during pregnancy in which stroma

becomes oedematous and hyperplastic.
9. Leukoplakia-White epithelium, that is present before the
application of acetic acid. It is a focal colposcopic lesion in
which hyperkeratosis or parakeratosis is present. It is
identified both inside or outside TZ.
Inflammatory lesions
Nonspecific acute inflammation
Cervix and Vagina appear red due to congestion of
connective tissue.
Increase in number as well as calibre of terminal vessels.
Fine regular, diffuse punctations may be seen often
involving ectocervix even beyond transformation zone.
Acetic acid does not produce any significant change
Chronic inflammation
White punctation against a pink background is called follicular
cervicitis. It is due to Lymphoid follicles in stroma.
Specific infections
1. Candida Albicans Thick cheesy curd like discharge is present.
Nonspecific appearance, mucosa is diffusely hyperaemic and
bleeds easily.
2. Trichomonas vaginalis Thin, yellowish green, bubbly discharge is seen.
26
Saline application reveals a strawberry appearance of the

cervix due to the presence of widespread red patches,
depicting dilated stromal papillae through the partly
denuded epithelium.
Characteristic vascular pattern-double crested capillaries
(DCC) are seen giving rise to fork or antler like appearance.
3. Herpes Simplex Characterized by generalized hyperaemia, vesicles and
shallow ulcers
4. Human Papilloma Virus Infection
Three types of HPV infection can be recognized colposcopically
a) Florid/Macroscopic varity
raised papillae are present, verrucous and bulbous
projections seen.
On acetic acid application-thick white surface with papillary
projections, each of which show a capillary loop. This is the
most reliable diagnostic feature.
b)Early /Micropapillary lesion
The epithelium proliferates forming projections called
Asperties , which appear as well demarcated white lesion.
c)Flat/Inverted lesion
Flat acetowhite lesion or white punctuation
regular mosaic punctation
27
SCREENING INTERVALS
ACS-American Cancer Society 2002 Guidelines45
1. Age to initiate screening- Three years after the onset of
sexual activity, not later than the age 21 years.
2. Screening frequency-Annually with conventional cytology
or every 2 years with liquid based cytology. After the age of
30, women with 3 consecutive normal tests may be screened
every 2-3 years.
3. Discontinuation- after age 70 years.
4. Routine screening for HPV infection- Not yet FDA
approved conventional or liquid based cytology combined
with test for DNA from high risk HPV types should be
performed not more often than every 3 years.
Colposcopic findings were recorded and colposcopy diagnosis
was made based on Modified Ried Colposcopic Index(RCI).4
Ried et al (1983) defined three objective categories based on
colposcopic index using four colposcopic signs i.e. colour,
margin (including surface contour), vascular pattern and
iodine response. Each category is offered scores of 0 to 2.47
Summation of scores is done.
Scores of 0-2: Predictive of minor lesion (CIN I or HPV)
3-5:Middle grade lesion (CIN I-II)
6-8:Significant lesion (CIN II- III)
28
Colposcopic Combined Index Table 1

Colposcopic 0 (zero)
1(one)
2(two)
Condylomatous or
Regular
Rolled peeling
micropappilary
lesions
edges.Internal
Contour,indistinct
With
demarcation
acetowhitening
straight
between areas
Flocculated or
outlines
of
sign
Margine
feathered margin
Differing
Angular jasgged
appearance
lesions.Satellite
Lesions and
acetowhitening
beyond the
transformation
zone
Colour
Shiny,snow-white
Intermediate Dull,oyster
colour,indistinct
Shades
white
Fine-calibre
No
Definite
vessels, poorly
abnormal
punctuation
formed patterns
Vessel
And
acetowhitening
Vessels
mosaicism
Iodine
Positive Iodine
Partial
Negative
Uptake
Iodine
staining of
Uptake
significant
lesion
29
Modified forms of Colposcopy

Telecolposcopy
A video colposcope is used to record video clips which
were subsequently transmitted to a interpretation. This
is used to develop a secondary screening technique for
use in primary care.
Digital Colposcopy
Real time or downloaded for later review. Additionally,
the image may be subsequently modified which may
enhance visualization of potential abnormality, to allow
measurement of lesion.
Microcolposcopy48
Magnification of 100 to 300 times is used to look the
structure at ultra structural level.
Microcolpohysteroscopy49
In 1984 , Souutler and associates reported the use of
Microcolpohysteroscopy to define the extent of
endocervical involvement of CIN when the upper limit
of lesion could not be seen at colposcopy.
30
Problems encountered in colposcopy may arise due to

1.Inadequate expertise:- An inexperienced colposcopist may
find difficulty in assessment of various lesions. Recognition of
squamocolumnar junction is crucial to identify the upper limit
of lesion. A novice colposcopist may give more importance to
minor grades of mosaic or punctuation than major grades of
acetowhite epithelium leading to biopsy from a wrong area.
2.Interpretive problems and limitations:- There are various
conditions which create confusion in colposcopic
differentiation. Immature or active metaplastic epithelium may
be difficult to differentiate from early grades of CIN. Vascular
pattern may lead to confusing picture. Colposcopy may be
unsatisfactory at times.
3.Failure to follow standard diagnostic protocol:- Deviation
from an established protocol increases the probability of
inaccurate diagnosis resulting in inappropriate treatment
which may prove disastrous.50
Recent Advances :DySIS and Niris Imaging System-51
DySIS:
DySIS is a digital video colposcope that also uses dynamic
spectral imaging to evaluate the blanching effect of applying
acetic acid to the epithelium. It produces a quantitative
measurement of the rate, extent and duration of the
acetowhitening. The dynamic map(DySISmap) produced can be
31
overlaid on a colour image of tissue to help the clinician

determine the presence and grade of lesion .
DySIS consist of an optical head with white light emitting
diode for uniform illumination and magnification optics
coupled to a digital colour charged-coupled device, camera for
image capture. It also include a computer and control
electronics .The optical head does not come into contact with
the tissue. It magnifies images between 10 and 27 times. It is
mounted on a mechanical arm to position and stabilize it., and
locked into an extension shaft attached to the speculum, to
ensure a stable field of view during image acquisition. For this
reason, the speculum used with DySIS is different from the
standard speculum used in colposcopy. The average duration
of use per examination is less than 15 minutes.
Niris Imaging System51
The Niris Imaging System is a noninvasive device designed to
aid in the detection and diagnosis of early stage disease. It is
used for guidance of biopsy and surgery and post treatment
surveillance in various clinical applications, one of which is an
adjunct to colposcopy. It uses optical coherence tomography,
using near infrared light to produce real time, high resolution,
cross sectional imaging of tissue microstructure.
The major claimed benefit of the Niris Imaging System is its
ability to scan multiple layers of epithelial tissue. Niris provide
an optical biopsy by visualising tissue microstructure to a
depth of 1.6mm.
32
Niris device consist of an image-management console and

docking station, a laptop computer user interface , 2.7mm
front viewing screen, flexible optical probe and accessories. The
image acquisition and measurement tools are sufficiently fast
to allow image data to be analysed in real time and at the site
of care. According to the manufacture the average duration of
use per treatment for Niris alone is 2 minutes.
Niris probes can be used for around 200 procedures, and may
be processed for reuse. A disposable probe sheath can be used
to provide physical stability and help prevent crosscontamination.
LuViva - Cervical scan52
LuViva is a technologically advanced diagnostic device that
scans the cervix with light and uses spectroscopy to measure
how light interacts with the cervical tissue. Spectroscopy
identifies chemical and structural indicators of precancer that
may be below the surface of cervix or misdiagnosed as benign.
This technique is called biophotonics. Unlike Pap , HPV test or
biopsies, LuViva does not require laboratory analysis or a
tissue sample, and is designed to provide result immediately,
which eliminates costly, painful and unnecessary testing.
33
Managing Cytological Abnormalities53

With low grade lesions, colposcopy is done to rule out
potentially premalignant changes i.e., CIN 2 or 3; if these are
detected
management is undertaken according to the
appropriate protocol. If CIN 1 is highest grade identified at

colposcopy, conservative management is recommended. If no
lesion is identified on colposcopy, a random biopsy at the
transformation zone should be considered. As per consensus
opinion, if no dysplasia is identified at colposcopy , annual
screening
with
the
referring
health
care
provider
recommended until 3 negative pap smears
is
have been
reported.
Managing HSILThe risk a significant lesion is high with HSIL cytology. All
women with an HSIL result should have colposcopy. A visual
assessment and LEEP may be appropriate in some
circumstances, but a colposcopically directed biopsy and
tailored treatment is preferred.
If lesion is not detected at colposcopy and colposcopy is not
satisfactory, then diagnostic exicisional procedure should be
done. This can be achieved with a cone biopsy, or a LEEP
using a large loop. However, if no lesion was detected and
colposcopy was satisfactory, combined colposcopy and cytology
is appropriate at 6 month intervals for 2 visits.
34
Managing Histological abnormalities

Ones a lesion has been identified on colposcopy and biopsy
has been completed , a decision must be made regarding
management. The aim of treatment is to remove a potentially
precancerious lesion to prevent development of carcinoma. The
initial classification of cervical intraepithelial neoplasia as CIN
1,2 or 3 was proposed by Richart in 1973 and reinforced by the
World Health Organization in 1994.
Treatment modalities include excision and ablative approaches
(cryotherapy or laser ablation).Treatment is tailored to the
lesion identified on the cervix by either removal or ablation of
the entire transformation zone.
The International Federation of Cervical Pathology and
Colposcopy has classified the transformation zone into three
categories .54 A type 1 TZ is completely ectocevical and fully
visible. A type 2 TZ is fully visible, has an endocervical
component, and may have an ectocervical component. A type 3
TZ is predominantly endocervical not fully visible, and may
have an ectocervical component.
Using this classification, ablative methods can be used for a
type 1 or 2 TZ if following criteria are met: The TZ must be fully
visible; a colposcopically directed diagnostic biopsy must be
taken from the most dysplastic area in the TZ; There must be
no suspicion of invasive disease; there must be no suspicion of
glandular disease; there is no cytological disparity; patient has
not had previous treatment.
35
Cryotherapy is not recommended for treatment of CIN 3.

If excision with LEEP is used the size of loop electrode must be
adjusted depending on the lesion : a type 2 TZ requires larger
loop electrode than type 1 TZ to ensure the lesion is fully
excised. If the lesion is not seen in its entirety, colposcopy is
unsatisfactory and ablative therapies should not be used. Type
3 TZ with a lesion that extends into the endocervical canal or a
glandular lesion require a larger or longer excision for
adequate evaluation or treatment. Currently, cone biopsy,
diagnostic excisional procedure, Laser excision and LEEP may
be used but have different meanings to individuals
colposcopists.
Managing CIN 1
Conservative management with observation is preferred for CIN
1.women should be followed with repeat cytology testing at 12
months, which can be done by the primary care provider. If
patient requires further colposcopy and the CIN lesion persist
for 24 months or longer, treatment is acceptable. If colposcopy
is satisfactory, treatment may be ablative modalities.
Exception to a conservative approach occurs when a diagnosis
of CIN 1 is preceded by HSIL or AGS cytology.
Managing CIN 2 & CIN 3 in women 25 years old and over
Most women with CIN 2 or 3 should be treated. If colposcopy is
satisfactory i.e., a type 1 or 2 TZ , excision and ablative
therapy are both acceptable. However, an excisional procedure
is preferred for the treatment of CIN 3.If CIN 2 or 3 is identified
36
and colposcopy is unsatisfactory, an excisional procedure

should be performed. If the deep margins are involved,
consideration should be given to repeat excision. Most women
should have colposcopy repeated at 6 months. Hysterectomy is
not recommended as initial therapy for CIN 2 or 3 but may be
performed for women with persistent CIN.
Managing CIN 2 or 3 in women Less Than 25 years old
The evidence suggest that CIN 2 in the adolescent can be
observed with repeat colposcopy and cytology every 6 months
for up to 24 months. if dysplasia persists, patient should be
treated, with either ablative method or LEEP. If colposcopy is
unsatisfactory, treatment should consist of an excisional
procedure.
Follow-up Post treatment
The aim of follow up is to detect persistent or recurrent
dysplasia. Ones treated patient remains at risk of persistence
or recurrence and at long term risk of invasive cancer. Women
should be followed with cytology testing and colposcopy at 6
month intervals for 2 visits. HPV testing at 6 months combined
with cytology testing is acceptable.
37
Studies conducted in this field by different researchers and

their opinionHans Hinselman started performing colposcopies in Germany
in the 1924.He saw cervix under magnification in good light
and did many biopsies. In 1957 he was honoured in Brazil as
Doctor Honoris Causa.55
Khodakarami N et al 201156 of the total 100 women with
the mean age 36 years, the sensitivity, specificity, PPV, NPV
and accuracy of the Pap test, the VIA and the DC were studied.
The Pap test had low sensitivity but high specificity. Whereas
VIA had a high sensitivity in addition to being to being easy
and low cost.
Cantor et al
57
2008 recruited 1,850 patients into a diagnostic
or a screening group depending on their history of abnormal

findings on Papanicolaou tests. Colposcopic examinations were
performed and biopsies specimens obtained from abnormal
and normal colposcopic sites for all patients. They found that
colposcopy was more sensitive and specific in detecting LSIL
and HSIL in diagnostic group as compared to the patients in
screening group.
Nae-Fang Twu et al.(2007)58 opined that combination of Pap
smear and Speculoscopy has higher sensitivity in detection of
cervical intraepithelial lesion as compared to either of them
performed alone.
Irne et al.(2005)59 compared Multispectral imaging system
colposcopy, conventional colposcopy and PAP test. They opined
38
that MIS colposcopy had 1.7% false diagnostic rate as

compared to PAP test and conventional colposcopy which had
false diagnostic rates of 24.4% and 22% respectively.
Divya Hegade et al 201160 out of 225 patients, on biopsy,
there were 15 mild dysplasia,4 severe dysplasia and 3
squamous cancers. Pap smear had a sensitivity of 83%, of
specificity of 98%, and positive predictive value of 80% and
negative predictive value of 97.9%.VIA had a sensitivity of
70.8%, specificity of 95% and positive predictive value of 62.9%
and negative predictive value of 96.5%.since diagnostic values
of VIA is comparable to Pap smear, it is a good alternate to
cytology.
Allard et al(2005)61 conducted a study to determine if sites
selected for colposcopic biopsy and histologically proven
cervical intraepithelial neoplasia are distributed randomly
across the cervix. In 303 patients,479 biopsies were performed.
They concluded that the loci selected for biopsy and
histologicaly confirmed cervical intraepithelial neoplasia are
not randomly distributed across the cervix. There is a
predilection for the locations anterior and posterior to the
cervical os.
Benedet et al(2004)62 determined the diagnostic correlation
between referral cytology, initial biopsies and colposcopic
impression in patients assessed in a provincial cytology
screening program. The colposcopic impression correlated with
cytology within one degree in over90%of cases. Cytology
histology correlation within one degree occurred in 82%.They
39
concluded that both cytology and colposcopy have high

sensitivity but low to moderate specificity. Colposcopy is most
accurate in identifying high grade disease. colposcopic
impression correlates closely with the cytology diagnosis and
combining the two produces optimum results.
Basu et al(2003)63 determined the role of visual inspection
with acetic acid in the early detection of cervical neoplasia.
They found in there study that the sensitivity of visual
inspection with acetic acid(VIA) is higher than cytology in
detection of CIN2 -3 lesions.
Gerber et al (2001)64
determined the clinical significance
and the prediction of neoplasia among the patients with

persistent findings of ASCUS in a repeat Pap smear through a
colposcopic examination. Out of 186 colposcopic evaluations,
colposcopy was abnormal in 95/186 patients. Histology of
directed biopsies reveals 38 (21%) LSIL and 17(9%) HSIL
lesion. They concluded that colposcopic evaluation after
repeated Pap smear with ASCUS is an appropriate cost
effective management.
Marana et al.(2000)65 evaluated the use of colposcopic scoring
system for Biopsy decisions. They suggested that the
colposcopic storing system is practical tool for colposcopicguided punch biopsy decision and detection of high grade
cervical lesion in different patient groups.
Samira Khan et al(2007)66 Out of 300 women 25-65 years,
The positive predictive value of low or high threshold VIA,VILI
and cytology were 22%.72.7%,57.7% and 45.5%;such that the
40
compounding NPV were 80%, 80%, 88.9% , 77.5%. Overall

accuracy of high threshold VIA was comparable to VILI. High
threshold VIA and VILI have higher accuracy for detection of
precancerious lesions of cervix than pap smear indicating that
these test to be implicated for cancer screening which is more
cost effective.
Belinson JL et al (2001)67 ,in this study- visual inspection of
cervix with 5% acetic acid was done women aged 35-45years in
rural China. Women with doubtful lesions, had colposcopy and
cervical biopsy. The sensitivity of visual inspection equalled or
exceeded reported rates for conventional cervical cytology.
Visual inspection and colposcopy have similar profiles. The
benefit of an inexpensive point of care diagnosis and treatment
algorithm will be a powerful incentive to per visual inspection
for cervical cancer screening in developing countries.
Denny Lynette ,et al(2000)68 in this study women were
screened by direct visual inspection with acetic acid and other
methods. If an abnormality was identified women were referred
for colposcopy and biopsy. This two stage screening for cervical
cancer provides an alternative to conventional method for low
resource settings.
Sankarnarayanann Rengasway,et al,(1998)69 this study also
compared visual inspection of cervix after application of 3-4%
acetic acid (VIA) with cytology as method of detection of
cervical cancer and its precursors. As a conclusion- VIA and
cytology had similar performance but VIA merits further
evaluation as a primary screening test in low resource settings.
41
MATERIAL AND METHOD
MATERIAL AND METHOD

1.Source of Data Women attending Gynaecological OPD at
Patki Hospital and Research foundation, Kolhapur.
2. Method of collection of Data
A. Study design-prospective study
B. Study period- one year(Jan 2013- Jan2014)
C. Sample size- 100 cases who fulfilled selection criteria.
Total Gynaecology OPD patient visited in Patki Hospital per
year are 10,000 out of which 30% of patient come with
complains of leucorrhoea, pv discharge, spotting or routine
check-up, that is 3000.
So monthly patient around 250 out of which 8 to10 patients
require colposcopy and cervical biopsy.
Thats why yearly around 100-200 patients require colposcopic
examinations so 100 patients taken for our study in one year
study period.
42
MATERIAL AND METHOD
INCLUSION CRITERIA
1. Symptoms suggestive of cervical disease, chronic
leucorrhoea, backache, postcoital bleeding, postmenopausal
bleeding etc.
2. Suspicious looking cervix
3. Abnormal pap smear
EXCLUSION CRITERIA
1. HIV infected patient
2. Pregnant women
3. Clinically visible growth on cervix
4. Unmarried
5. Patient undergone prior treatment of cervical intraepithelial
neoplasia
Detailed clinical data was obtained and noted on a structural
proforma. After a brief explanation of the technique to the
patient and making her reassure, an informed consent was
obtained.
STEPS IN COLPOSCOPIC EXAMINATIONS
1. Patient was placed in dorsal position
2. First an unaided visual inspection of the cervix is performed
under good illumination and findings noted.
3. This is followed by taking exocervical scraping using a Ayres
spatula and endocervical sampling with endocervical brush,
43
MATERIAL AND METHOD
specimen fixed on a slide with 95% Ethanol and transported to

laboratory. smears are reported with Bethesda system of
cervical cytology classification.
4. This is followed by application of 3 to 5% freshly prepared
Acetic acid to the cervix using sterile cotton swab. The cervix is
inspected after one minute and results noted as either positive
if there are acetowhite areas seen. Also note down
- location of AW area in relation to
-Squamocolumnar junction,
-Intensity of AW patch
-Margin of AW patch
5. Examination through Green filters
6. Staining the cervix with3% Lugols Iodine.
7. Biopsy was taken from abnormal area under colposcopic
guidance. Four quadrant biopsy was taken from ectocervix at
the squamocolumnar junction if no abnormality detected in
colposcopy. Specimen sent for histopathological examination in
formalin solution.
8. Recorded findings in odells diagram were taken to explain
the findings to women and relatives.
9. Apply Monsels paste/Botroclot to stop bleeding.
10. Document the findings by-Odells diagram
Hammands graph
44
MATERIAL AND METHOD
Video recording
EXAMINATION TABLE
Cuscos speculum
Gloves
swab holder
bowls for saline, acetic acid, Lugols solution
Endocervical Retractor
Biopsy forcep
For Cryocauterisation-cryocautery unit
Nitrous oxide cylinder
LEEP and LLETZ-Cautery
loops
smoke evacuator
Local anesthetic
45
FIGURES
Figure No.1 Colposcope
Figure No.2 Colposcopic Examination
46
FIGURES
Figure No.3 Squamocolumnar Junction
Figure No. 4 Normal Colposcopy
47
FIGURES
Figure No. 5 Acetowhite changes
Figure No. 6 Lugols Iodine Staining
48
FIGURES
Figure No. 7 Punctation
Figure No. 8 Polyps
49
RESULTS
OBSERVATIONS AND RESULTS

Table 2: Distribution of cases according to age
AGE
Group
20-29
30-39
40-49
50-59
Total
HPE findings
CIN
Normal
1
6
6
4
17
12
32
25
14
83
Total
Chi Square
Test
13
38
31
18
100
Chi square=
0.9175
d.f.=2
p=0.6321
40
35
30
25
CIN
20
TOTAL
15
10
5
0
20-29
30-39
40-49
50-59
50
RESULTS
Table 3: Distribution of cases based on Parity
Parity
1
2
3
>4
Total
HPE findings
CIN
Normal
1
7
7
27
6
32
3
17
17
83
Total
Chi Square
test
8
34
38
20
100
Chi Sqare=
0.5154
d.f.=2
p=0.7728
40
35
30
25
CIN
20
NORMAL
15
10
5
0
1
>4
51
RESULTS
Table 4:
Distribution of cases based on symptoms
HPE Findings
Complaints
CIN
12
2
1
2
17
WD
PCB
IMB
PMB
Ohers
Loss Wight
Total
Normal
44
5
10
3
16
5
83
Total
Chi square
test
56
7
11
5
16
5
100
Chi square=
3.483
d.f.=5
P=0.626
60
50
40
CIN
30
TOTAL
20
10
0
WD
PCB
IMB
PMB
OTHERS
LOSS
WEIGHT
52
RESULTS
Table 5 :Distribution of cases based on contraceptives used
Contraception
Barrier
O C pills
IUCD
Permanent
Nil
Total
HPE findings
CIN
Normal
5
2
7
1
16
10
29
4
26
17
83
Total
Chi square
test
5
9
17
39
30
100
Chi square
test
=3.528
d.f.=2
p=0.1714
40
35
30
25
CIN
20
TOTAL
15
10
5
0
Barrier
O C Pills
IUCD
Permanent
Nil
53
RESULTS
Unsatisfactory
3
7
3
4
17
mosaic
2 1 2 2
- 5 2
- 1
3 1
4 1
1 1
8 4
1
3
3
7
14
punctate
5
9
2
16
AW
5
16
7
3
31
Leukoplakia
1
2
3
polyp
Inflmation
20-29
30-39
40-49
50-59
Total
Erosion
Age
Normal
Table 6 : Colposcopic findings according to Age
Among 31 patients of cervical erosion, 16 patients were found

in age group of 30-39 years. While 17 patients having
Acetowhite epithelium on acetic acid application , 7 were in age
group30-39 years.
Erosion
Inflammation
polyp
leukoplakia
AW
Punctate
mosaic
Unsatisfactory
10
14
Total
31
16
17
14
Parity
Normal
Table 7 : Colposcopic findings according to Parity
54
RESULTS
Maximum number of abnormal colposcopic findings were seen

in para 2 and 3 patients.
Punctate
mosaic
Unsatisfactor
y
Loss
weight
Total
AW
others
leukoplakia
PMB
polyp
IMB
Inflammation
PCB
Erosion
WD
Normal
complaints
Table 8: colposcopic findings according to complaints
15
15
31
16
2 17
14
Among 31 cases of erosion of cervix, 15 patients were

complaining of white discharge. Out of 17 cases of AW
epithelium , 15 patients had complaints of WD.
55
RESULTS
Inflam
mation
polyp
Leukop
lakia
Permanen
t
11
Nil
10
Total
31
16
17
14
Barrier
OC pill
IUCD
Unsatis
factory
Erosion
AW
Punctat
e
Mosaic
normal
Contrac
eptive
Table 9:Colposcopic findings according to contraceptives
Among the patients having an abnormal colposcopic findings,

majority of patients were permanently sterilized.
56
RESULTS
Table 10 : PAP smear findings according to Age

Age
Normal
IA
20-29
30-39
40-49
50-59
Total
1
2
3
11
30
23
16
80
Mild
Moderate
Severe
dysplasia dysplasia Dysplasia
1
5
1
2
4
1
1
1
1
10
3
4
Among 10 patients of mild dysplasia on pap smear test,5

patients in age group 30-39 years, and 4 were in 40-49.
Table 11 : PAP test findings according to Parity

Parity
Normal
IA
1
2
3
>4
Total
1
2
3
7
28
31
14
80
Mild
Moderate
Severe
dysplasia Dysplasia Dysplasia
1
3
1
1
4
1
2
2
1
1
10
3
4
Maximum number of abnormal pap smears seen in para 2 and

para 3 patients.
57
RESULTS
Table 12: PAP test findings according to Complaints

Mild
Moderate
dysplasia dysplasia
4
1
2
1
1
1
1
Severe
Dysplasia
2
1
-
Complaints
Normal
IA
WD
PCB
IMB
PMB
Others
Loss
weight
1
2
48
4
10
4
12
Total
80
10
Among 10 patients of Mild dysplasia on pap smear,4 women

had complaint of white discharge.
Table 13 :PAP test findings according to Contraceptives

used
Contraceptive Normal
Barrier
OC pill
IUCD
Permanent
Nil
Total
3
3
IA
4
8
14
31
23
80
Mild
Moderate Severe
dysplasia dysplasia dysplasia
1
1
2
1
6
2
1
3
10
3
4
Among the patients having dysplasia on pap smear, 6 patients

were permanently sterilized.
58
RESULTS
Table 14 : PAP Smear findings
Outcomes
Normal
Inflammatory
atypia
Mild dysplasia
Moderate
dysplasia
Severe dysplasia
Invasive cancer
Total
cases(n=100)
3
80
10
3
4
-
PAP Smear Findings
Normal
Inflammatory atypia
Mild dysplasia
Moderate dysplasia
Severe dysplasia
Invasive Cancer
59
RESULTS
Table 15: Colposcopic Appearance
Appearance
Normal
Erosion of cervix
Inflammatory changes
Polyps
Leukoplakia
AW area
Punctuate pattern
Mosaic pattern
No. of
cases
3
31
16
5
2
17
8
4
Atypical vessel
Unsatisfactory
14
Colposcopic Appearance
Normal
Erosin of Cervix
Inflammatory Changes
Polyps
Leucoplakia
AW Area
Punctuate Pattern
Mosaic Pattern
Atypical Vessel
Unsatisfactory
60
RESULTS
Table 16 : HPE findings
HPE findings
Chronic cervicitis
Cervicitis+ Erosion
Erosion of cervix
Epithelial hyperplasia
Polyp
Mild dysplasia(CIN 1)
Moderate dysplasia
Severe dysplasia
No. of
cases
46
28
2
2
5
8
5
4
HPE Findings
Chronic Cervicitis
Cervivitis + Erosion
Erosion of crevix
Epithelial Hyperplasia
Polyp
Mild Dysplasia (CIN 1)
Moderate Dysplaasia
Severe Dysplasia
61
RESULTS
Table 17: Correlation between Pap smear and Biopsy
Pap test
Positive
Negative
Total
HPE findings
positive
7
12
19
Negative
10
71
81
Total
17
83
100
PAP test
Sensitivity
Specificity
36.84%
87.65%
Positive predictive
Value
41.18%
Negative Predictive
Value
85.54%
Diagnostic Accuracy
78%
Likehood ratio of
Positive test
2.984
Likehood ratio of
Negative test
0.7205
Kappa Statistic
0.2552
Kappa value is used for assessing agreement between two

diagnostic tests.kappa= 0.2552 indicates there is fair
agreement between pap test and histopathology in diagnosing
the condition .
62
RESULTS
Table 18: Correlation between Colposcopy and Biopsy
Colposcopy
Positive
Negative
Total
HPE findings
Positive
Negative
14
15
3
68
17
83
Total
29
71
100
Biopsy
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Diagnostic accuracy
Likehood ratio of positive
test
Likehood ratio of negative
test
Kappa stastics
100%
4.225%
29.9%
100%
32%
1.044
0.0
0.02495
Kappa=0.5019 suggest that there is moderate agreement

between colposcopy and Histopathology.
63
RESULTS
Table 19: Correlation between colposcopy and pap test
Colposcopy
Positive
Negative
Total
PAP test
Positive
29
0
29
Total
Negative
68
3
71
97
3
100
Colposcopy
Sensitivity
Specificity
Positive predictive value
Negative predictive
value
Diagnostic accuracy
Likehood ratio of
positive test
Likehood ratio of
negative test
Kappa statistics
82.35%
81.93%
48.28%
95.77%
82%
4.557
0.2154
0.5019
The results given by colposcopy and PAP tests are only slightly
match as given by kappa=0.02495.
64
DISCUSSION
DISCUSSION
Cervical cancer was the second most frequent cancer
worldwide, in women after breast carcinoma. However, invasive
cancer of cervix was consider to be a preventable condition
as its associated with long pre invasive stage(CIN) making it
amenable to screening and treatment.
Present study was carried out in OPD at Patki Hospital
and Research Foundation, Kolhapur from January 2012January 2013.Hundread cases who fulfilled the selection
criteria were recruited for the study.
Regarding Age distribution high incidence of CIN
was
found among the age group of 30-49 years, with mean age 41
years which was seen in 19% of cases. Incidence of CIN was
6% in 20-29 years age group, 35% in 30-39 age group, 35% in
40-49 age group .Incidence of CIN was found to increase as age
increases.
AsmitaD., Shakuntala N., Rao S.R., Sharma S.K.,
Geetanjali S. (2013)in their study ,80% women were in age
group 30-50 years.70
Ghosh
P.,Gandhi
G.,Kochhar
P.K.,
Zutshi
V.,Butra
S(2012). showed in their study, mean age group of patient was

39 +9 years.71
Hegade Divya, Shetty H., Shetty P.K., Rai S.(2011) in their
study shown the prevalence of CIN more in 41-50 age group.72
65
DISCUSSION
Regarding parity, study showed increased incidence of

CIN among multiparous women 20.5% were para two, 15.7%
were para three.15% were para four or more. Similar study by
Ramesh G,Sudha R., Jayashree A.K., Padmini J.(2011) showed
the incidence of CIN more in multipara.73
P.Ghosh, G.Gandhi, P.K.Kocchar, Zutshi V. showed the
prevalence of CIN was significantly higher in parity more than
two.71
Relation between oral contraceptives and development of
CIN had been investigated by IARC-International agency for
Research in cancer and they concluded that the use of oc pills
increases the risk of CIN up to 4 fold after 5 or more years.
Among the 100 women studied 5% practiced barrier method
and among them none had CIN. 9% were taking OC Pills,
among them 11% (2/9) had CIN. 17% of women had IUCD
inserted among them 5% had CIN. There is no precipitous
carcinogenicity of Cu-T but long term follow-up is needed.74.
39% had permanently sterilized, among them 59% had CIN.
Anuja Bhalerao, Sayali Kulkarni, Sunita Ghike(2012)
suggested increase risk of cervical dysplasia among the
patients using contraceptives.75
Among
the
complaints
majority
of
women
(56%)
complaints of excessive white discharge per vaginum. Among

them CIN was found in 21.4%. 7% who complained of
postcoital bleeding 28.5% had CIN.
66
DISCUSSION
11% had intermenstrual Bleeding among them 9% had

CIN. 5% had postmenopausal bleeding out of them 40% had
CIN. Other complaints include loss of weight, loss of appetite,
UTI, Backache among them none had CIN.
Excessive vaginal discharge playing a role in contributing
to the development of CIN, was also proved to be risk factor in
study conducted by Anuja Bhalerao75 et al. and also by Asmita
D, et al.70
Pap smear was taken for all cases. It showed mild
dysplasia in 10%, moderate dysplasia in 3% and severe
dysplasia in 2%. 3% of smear were found to be normal. 80%
showed inflammatory atypia.
Sensitivity of PAP was found to be very low36% compared
to it is specificity which was 88%.This was attribution to the
high number of false negative smear.
Study conducted by Rageshwar Jyothi, Gupta Payal, Rao
rohini, Sood PL., Parashar Neelam.(2013) showed sensitivity of
pap test 65.62% is less than specificity.76
Same results were seen in study by Krishna Algotor, Atul
Nalawade, Shivani Sachdev
and also study by Sukhpreet
Singh77.
Accuracy of Pap smear in our study 78%.
The Accuracy of pap smear in study by Chaudhary R.D.
et al (2014) is 76% ,sensitivity 79% and specificity 81.02%.78
67
DISCUSSION
Strength of agreement between Pap test and Colposcopy

weighted by kappa statistic was 0.0249
indicates slightly
correlate with each other. Same results showed in studies by

Asmita D et al.70
While in our study strength of agreement between
cytology & HPE is (kappa=0.2552) indicate fair agreement.
Simillar results showed in other studies by Rajeshwar
Jyothi et al.(2013)76
In study (2014) agreement between these two tests are
0.516 i.e. showing moderate agreement.79
Among the 100 cases studied ,29% were diagnosed as
colposcopically abnormal. Among abnormal cases
AW areas
were diagnosed in 17%,punctuate pattern of vessels was seen

in 8% of women. Mosaic pattern of vessels was diagnosed in
4% of women. Normal findings was present in 3%,Erosion in
31%, inflammatory changes were seen in 16% and polyp were
diagnosed in 5%
Leukoplakia was found in 2% cases. Colposcopy was
unsatisfactory in 14% cases.
Sensitivity was found to be 83% and specificity was 81%.
This
showed
high
sensitivity
and
low
specificity
when
compared to pap smear.

Low specificity when compared to Pap smear was due to
the high incidence of unsuspected AW epithelium which might
68
DISCUSSION
to be inflammatory, immature metaplasia and latent HPV

infections.
Moss EL et al80, in 2009 study on 469 patients to
determine whether colposcopy is reliable in diagnosing cervical
intraepithelial neoplasia in women who have undergone a
previous cervical exicion biopsy. The sensitivity and specificity
of colposcopy were 93% and 51.9% respectively.
Pimple S A et al6.,in 2010 made an evaluation of
colposcopy Vs cytology as secondary triage women .The
estimates of sensitivity for colposcopy were 74% and specificity
92.9%.
In our study predictive accuracy of colposcopy is 82%.
When interpreting values from different studies we might
take into consideration that the accuracy of colposcopy
depends largely on the training, experience and skills of
colposcopist and accuracy of cytology requires laboratory
services and skilled cytologist.
Boonlikts 7,in 2011,in a 100 patient, study the correlation
between Reids Index and Histological results from biopsy
.overall predictive accuracy was 89% and had good correlation
with Histology, same like our study.
In
our
study
the
strength
of
agreement
between
colposcopy and HPE weighted by Kappa statistic was 0.5019,

i.e. showing moderate correlation between these two tests.
Similar correlation between colposcopy and Histology showed
by some other studies.76,79
69
DISCUSSION
Similar findings showed by study demonstrate high

accuracy
and
correlation
between
colposcopy
and
histopathology .81
In present study, pap smear and colposcopy were slightly
correlated statistically and pap smear had low sensitivity it
would be prudent to add colposcopy
as a complementary
method to make screening more effective.
70
DISCUSSION
Limitations of study
1. In this study ,sample is selected from the population
attending
OPD. This population is not representative of
general population. Hence when tests are used for screening

in
general
population
the
estimated
sensitivity
and
specificity may not be achieved.

2. Colposcopy has no standard criteria or scoring system,
therefore
the
colposcopic
interpretation
are
relatively
subjective.
71
SUMMARY
SUMMARY
This study was a prospective observational study conducted in
the department of Patki Hospital and Research Foundation
during the period from Jan 2012-2013
100 women who fulfilled the inclusion criteria were included in
our study
The objective of this study was to correlate the findings in
women with unhealthy cervix by cytology, Colposcopy and
colposcopic guided biopsies and to assess the utility of
colposcopy in detecting the premalignant and malignant
lesions of cervix.
To summarize,
Majority 70.5% of CIN occurred in the age group of 30-49
years. Incidence of CIN was found to increase as age
increases.
Out of 17 patients with CIN , 41% were para 2,
35.2% were para 3 and 17.6% were greater than para 4.
Among the 9 women who took OC pills, 12% had CIN.
Incidence of CIN
in permanently sterilized group was
59% and among IUCD users were 5.9%. None of the

women who practiced barrier contraceptives had CIN.
Among women who were diagnosed to have CIN, 70.5%
complained of excessive vaginal discharge.
Pap smear had sensitivity of 29% and specificity of 88%
which was attributed to the high number of false negative
smear.
72
SUMMARY
Accuracy of Pap smear was found to be 78%.

Colposcopy showed a sensitivity of 83% and specificity
81%. Positive predictive value and Negative predictive
value were found to be 48% and 95% respectively.
Accuracy of colposcopy was found to be 82% which was
comparatively more accurate than Pap smear. This
accuracy was high for high grade lesion than the low
grade lesion.
Colposcopy and Biopsy were positive in 14 out of 17 cases
while pap smear and biopsy were positive in only 5 out of
17 cases. This indicated the usefulness of colposcopy in
diagnosing lesion missed by Pap smear.
Strength of agreement between colposcopy and
Histopathology by Kappa statistic is 0.5019, i.e. showing
moderate correlation between these two tests.
Strength of Agreement between Pap test and colposcopy
weighted by kappa statistic 0.0249 indicates , slight
correlation between these two tests.
73
CONCLUSION
CONCLUSION
Aim of reducing the incidence of cervical cancer by
identifying the cause and risk factor is indeed an uphill
task. Cancer
detection
Screening
of
cervical
is
the
cancer
main weapon
at
for
early
pre-maliganant
and
malignant stage. Invasive cancer of cervix is considered to

be preventable since it is associated with long pre-invasive
stage making it amenable for screening and treatment.
From
the
results
of our study , it
is evident
that
colposcopy is definitely more sensitive and accurate than

pap smear. By combining
pap
smear, Colposcopy
and
colposcopic guided Biopsy, we can maximise the sensitivity

and specificity of cancer cervix screening.
Colposcopy was found to be useful in understanding
the morphology of cervical lesions, both of neoplasic and
non neoplastic ones and was very helpful in planning their
management.
Cytology is an accepted method for screening for
cervical neoplasia and the value of colposcopy has been
recognized, mainly
in
the
evaluation
of patients
with
abnormal cervical smear, because of the low sensitivity ,

false negative cytology and
poor compliance for follow
up. So, it has been felt that apart from cervical smear ,
evaluation colposcopy with colposcopic guided biopsy is an
important
diagnostic
method
for
the detection
of
preneoplastic and early cervical cancer.

74
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Luckic A., Lannaccio S., Di Properzio M., Carico E.,
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Borsch C.,Lambercht E.Microcolpohysteroscopy
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Das S.K., Nigam S., Batra A., Chandra M.
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Gage J.C., Duggan M A., Nation JG., Gao S., castle
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Eugenio Fusco, Francesco Padulo, Emanuela
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Cantor S B., Cardenas-Turanzas M, Cox D D.,
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Allard J E., Rodriguez M., Rocca M., Parker MF.
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Benedet J., Matisic J P., Bertrand MA. An analysis
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88
ANNEXURE I
INFORMED CONSENT FORM
Subject identification number for this

trial_________________________________
Title of the Project
________________________________________________
_____________________________________________
Name of the Principle Investigator ___________________Tel.No.
_________________
I have received the information sheet on the above study and have read
and/or understood the written information.
I have been given the chance to discuss the study and ask questions.
I consent to take part in the study and I am aware that my participation is
voluntary.
I understand that I may withdraw at any time without this affecting my
future care.
I understand that the information collected about me from my participation
in this research and sections of any of my medical notes may be looked at
by responsible persons(ethic committee members/regulatory authorities) . I
give access to these individuals to have access to my records.
I understand I will receive a copy of the patient information sheet and the
informed consent form.
________________________
Signature/Thumb Impression of subject
signature
Date of
__________________________
89
ANNEXURE I
Printed name of the subject in capitals
______________________________
Signature
Date of
Signature /Thumb Impression of legally

Accepted representative
____________________________________________________
Printed name of legally acceptable representative in capitals
___________________________________________________________
Relationship of legally accepted representative to subject in capitals
____________________________
Signature of the person conducting the
Informed consent discussion in capitals
signature
Date of
__________________________
Printed name of the person conducting
The informed consent discussion in capitals
___________________________
Signature of impartial witness
Signature
Date of
____________________________
Printed name of the impartial witness
In capitals
90
ANNEXURE II
STUDY PROFORMA
1.Name of patient
2.Date of admission
3.Record number
4.Age
5.Tel.no
.
6.Address
7.Education
8. Socioeconomic status
9. Chief complaints
10.Occupation
11.Obstetric history- Married life
-Age of marriage
-Parity index
12.Menstrual history-Age of monarchy
-cycle pattern
-LMP
-Age of Menopause
13.Past history-
Systemic illness
-STD
-Biopsy from cervix
91
ANNEXURE II
-H/O Hormonal theropy

-abnormal vaginal bleeding
14.Family history-H/O circumcision of husband
-H/O malignancy in family
15.General examination
16.Local Examination17.Systemic examination-
Speculum examination-
Discharge-normal/Bloody/foul smelling/Greenish/curdywhite
Appearance of cervix before acetic acid Colposcopic recordSCJ
SCJ
Saline
TZ
Green filter
Acetic acid
Lugols iodine
Biopsy taken from
Diagnosis
Treatment
Advice
92
ANNEXURE II
ODELLS DIAGRAM AND HAMMONDS GRAPH
93
MASTER CHART
KEY OF MASTER CHART

ABCDE-
Serial number
OPD number
Name
Age in years
Parity
P-para
L-living
F-Inclusion criteria
-
WD-white discharge
IMB-intermenstrual bleeding
PMB-postmenopausal bleeding
PCB-postcoital bleeding
Suspicious cervix
G-PAP results
- N- Normal
-INF-inflammatory
-Mild dysplasia
-moderate dysplasia
H-Colposcopy result[Type the company name] | KEY OF MASTER CHART
94
MASTER CHART
-Normal
-Inflammation
-polyps
-Erosion of cervix
-leukoplakia
-AW areas
Punctate pattern
-mosaic pattern
-Atypical vessel
-unsatisfactory
I-Biopsy results-
cervicitis
-erosion of cervix
-polyp
-mild dysplasia
-moderate dysplasia
-severe dysplasia
[Type the company name] | KEY OF MASTER CHART
95
MASTER CHART
Sr.
No.
Name
OPD
No.
Age
Parity
complaint
Contraception
Used
PAP test
Colposcopy
Findings
HPE Findings
Kamal T.Jadhav
232
30
P2L2A1
WD
PERMANENT
ATYPIA
NORMAL
CERVICITIS
Meena M.Gokhale
255
48
P3L2
OTHERS
PERMANENT
ATYPI
POLYP
POLYP
Shanti R.Mane
278
32
P2L2
WD
BARRIER
ATYPIA
AW
CERVICITIS
Rani S. Thorat
283
45
P3L3A2
IMB
IUCD
ATYPIA
EROSION
CERVICITIS+EROSION
Manda T.Kambale
302
40
P4L2A1
WD
PERMANENT
ATYPIA
EROSION
CERVICITIS
Veena B.Shete
316
30
P3L3
PCM
NIL
ATYPIA
INFLAMMATION
CERVICITIS
Neeta V.Gongane
328
20
P4L3A2
WD
OC PILL
ATYPIA
POLYP
POLYP
Girija N.Joshi
349
31
P2L2
WD
NIL
ATYPIA
AW
CERVICITIS+EROSION
Mukta G.Parage
374
47
P5L4A3
PCB
IUCD
EROSION
EROSION
10
Aasma M.
Mujawar
Bindiya
N.Gangvani
Vasanti D.Vaidya
389
41
P3L3
WD
PERMANENT
MILD
DYSPLASIA
ATYPIA
INFLAMMATION
CERVICITIS
398
56
P2L2A1
WD
PERMANENT
ATYPIA
AW
CERVICITIS+EROSION
406
22
P2L2A2
IMB
NIL
ATYPIA
EROSION
CERVICITIS
420
32
P2L2
WD
OCPILL
CIN 1
448
31
P3L3
LOSS WT
NIL
EROSION
CIN 3
468
42
P5L3A1
WD
PERMANENT
MILD
DYSPLASIA
SEVERE
DYSPLASIA
ATYPIA
AW
15
Seema M.
Patrawale
Ujjwala B.
Kambale
Dipali S.Satpute
LEUCOPLAKIA
CERVICITIS
16
Malvika J.Shende
475
57
P2L2
PCB
PERMANENT
MODERATE PUNCTATE
CIN 2
17
Pradnya L. Patil
493
21
P4L4
WD
NIL
NORMAL
CERVICITIS+
EROSION
11
12
13
14
EROSION
96
MASTER CHART
18
Shabana B.Attar
500
33
P3L3A2
WD
BARRIER
ATYPIA
EROSION
CERVICITIS
19
Mrunal L.Kulkarni
510
43
P2L1A2
WD
NIL
ATYPIA
EROSION
20
Deepika B.Shaha
527
32
P2L2
PMB
IUCD
ATYPIA
EROSION
CERVICITIS
+EROSION
CERVICITIS+EROSION
21
Neeta G. Bhurat
537
49
P3L3
WD
PERMANENT
ATYPIA
AW
CIN 1
22
543
24
P4L3
WD
NIL
ATYPIA
POLYP
POLYP
23
Vaishali
A.Bansode
Gauri H.Madane
562
34
P4L4
WD
OC PILL
ATYPIA
AW
24
Shanti G.Godbole
579
59
P3L3A2
WD
NIL
ATYPIA
EROSION
CERVICITIS
+EROSION
CERVICITIS
25
Anjali J.Patwane
590
44
P5L4A2
PCB
IUCD
ATYPIA
EROSION
26
Shobha S.Dardare
597
33
P2L2
IMB
PERMANENT
ATYPIA
MOSAIC
CERVICITIS
+EROSION
CIN 2
27
Meenakshi D.kale
601
31
P4L3
WD
NIL
ATYPIA
POLYP
POLYP
28
Nur A.Bagwaan
611
24
P5L3A2
WD
IUCD
ATYPIA
EROSION
29
Savita B.Varje
625
35
P4L4A2
WD
PERMANENT
ATYPIA
EROSION
CERVICITIS
+EROSION
CERVICITIS+EROSION
30
Revati K Navale
638
45
P4
WD
PERMANENT
ATYPIA
UNSATISFACTORY CERVICITIS+EROSION
31
658
53
P3L3
WD
PERMANENT
ATYPIA
EROSION
32
Anagha
G.Deshpande
Aarati S. Kalambe
672
32
P2L2
WD
OC PILL
ATYPIA
CERVICITIS
+EROSION
UNSATISFACTORY CERVICITIS
33
Nutan M.Shahane
685
45
P2L1A2
WD
PERMANENT
ATYPIA
INFLAMMATION
CERVICITIS
34
Sarika S. Bobade
692
54
P3L3
WD
IUCD
ATYPIA
INFLAMMATION
CERVICITIS
35
Hemangini
704
36
P1A4
WD
PERMANENT
ATYPIA
PUNCTATE
CIN 1
97
MASTER CHART
G.Suryawanshi
36
Vijaya H.Rokade
710
25
P2L2A3
OTHERS
NIL
ATYPIA
EROSION
37
Mangal R.Ghate
726
33
P2L2
IMB
NIL
ATYPIA
INFLAMMATION
38
Savita K. Patil
740
46
P3L3
WD
IUCD
AW
39
Shanta B.Patil
769
34
P1L1
WD
NIL
MILD
DYSPLASIA
ATYPIA
CERVICITIS+
EROSION
CERVICITIS
+EROSION
CIN1
INFLAMMATION
CERVICITIS EROSION
40
Nilofar J. Jamadar
776
57
P3L3
WD
BARRIER
ATYPIA
AW
CERVICITIS
41
Naina G. Baraskar
782
37
P2L2
WD
PERMANENT
ATYPIA
42
Anju H. Sharma
793
26
P3L3
WD
NIL
ATYPIA
NORMAL
CERVITIS
43
Janaki R. Basate
799
46
P1L1
LOSS WT
PERMANENT
INFLAMMATION
44
806
35
P2L2
WD
OC PILL
EPITHELIAL
HYPERPLASIA
CIN1
45
Maduri
p.Kumbhar
Komal H.Raut
MILD
DYSPLASIA
ATYPIA
817
47
P2L2
IMB
PERMANENT
ATYPIA
46
Sonali B.Bhende
828
33
P3L3
WD
BARRIER
47
Pankaja P.Gurav
846
44
P2L2
OTHER
NIL
SEVERE
DYSPLASIA
NORMAL
UNSATISFACTORY CERVICITIS+
EROSION
EROSION
EROSION
48
Kamala R.Patil
852
38
P3L3A2
WD
OC PILL
ATYPIA
UNSATISFACTORY CERVITIS
49
858
27
P2L2
PCB
PERMANENT
ATYPIA
AW
50
Rohini
D.Savarkar
Meena D. Raut
864
47
P3L3A2
WD
NIL
ATYPIA
EROSION
51
Nandini G.Bhsale
870
31
P2L2A1
OTHERS
IUCD
ATYPIA
EROSION
PUNCTATE
INFLAMMATION
CERVICITIS
CERVICITIS+
EROSION
CERVICITIS
CERVICITIS+
EROSION
98
MASTER CHART
52
Shweta H.Rane
884
48
P3L3A2
LOSS WT
PERMANENT
INFLAMMATION
CERVICITIS
NIL
MILD
DYSPLASIA
ATYPIA
53
Payal M. Meheta
890
34
P3L3A1
WD
AW
CERVICITIS
54
Nikita M.Khopre
899
48
P2L2
IMB
IUCD
ATYPIA
POLYP
POLYP
55
Versha G. Ukhane
909
36
P5L3
OTHERS
NIL
ATYPIA
NORMAL
39
P3L3
WD
IUCD
ATYPIA
EROSION
CERVICITIS+
EROSION
CERVICITIS
56
Rajeshwari H.Patil
918
57
Diya V. Bafna
922
46
P3L3
WD
ATYPIA
EROSION
CERVICITIS
58
Tulasi H.Sharma
950
35
P2L2
LOSS WT
NIL
ATYPIA
EROSION
CERVICITIS
59
Lakshmi V.Shinde
968
49
P2L2
OTHER
NIL
ATYPIA
60
Meenal T.Hakane
978
55
P3L3A1
WD
PERMANENT
ATYPIA
AW
CIN 1
61
Shilpa S.Votkar
985
52
P3L3A1
IMB
IUCD
ATYPIA
INFLAMMATION
62
Prajkata R.
Shevate
Manda G.Borate
992
36
P3L2A3
PMB
PERMANENT
ATYPIA
EROSION
CERVICITIS+
EROSION
CERVICITIS
1010
50
P2L2
PMB
PERMANENT
ATYPIA
1023
29
P5L5
PMB
NIL
1039
49
P3L2A3
WD
PERMANENT
SEVERE
DYSPLASIA
ATYPIA
66
Martha
A.Fernandiz
Snehal
G.Boravankar
Lalita j. Chogule
EROSION
MOSAIC
CIN 3
1048
43
P3L3A1
OTHER
OC PILL
67
Harshita D.Shetti
1056
39
P2L2
PMB
PERMANENT
68
Amrita M. Chavala
1062
41
P4L3
OTHER
NIL
63
64
65
PUNCTATE
CIN 1
ATYPIA
LEUCOPLAKIA
CERVICITIS
MILD
DYSPLASIA
NORMAL
EROSION
CERVICITIS
INFLAMMATION
CERVICITIS
99
MASTER CHART
69
1070
35
P2L2
WD
PERMANENT
ATYPIA
AW
CIN 1
70
Ruchika
H.Bhalerao
Radhika S.Nene
1087
42
P2L2A1
OTHER
IUCD
ATYPIA
INFLAMMATION
CERVICITIS
71
Mayuri B. Mane
1107
39
P3L3
WD
PERMANENT
EROSION
CERVICITIS
72
Aanjana C.Nakate
1123
28
P2L2
WD
BARRIER
MILD
DYSPLAIA
ATYPIA
AW
CERVICITIS
73
Janvi
F.Sahstrabuddhe
Saraswati N.Gune
1145
44
P3L3
LOSS WT
PERMANENT
ATYPIA
INFLAMMATION
1150
36
P2L2
IMB
PERMANENT
EROSION
1169
43
P4L3A2
WD
OC PILL
INFLAMMATION
CERVICITIS
1176
34
P3L2A1
OTHER
IUCD
77
Jayashree
A.Sankpal
Nupur
H.Golwankar
Gayatri M Gosavi
MILD
DYSPLASIA
ATYPIA
EPITHELIAL
HYPERPLASIA
CERVICITIS
1190
51
P4L2
PCB
PERMANENT
78
Mayuri S.Singh
1205
38
P3L3
WD
IUCD
MODERATE EROSION
DYSPLASIA
MILD
EROSION
DYSPLASIA
ATYPIA
INFLAMMATION
79
Rupa J. Munde
1230
52
P3L3
PMB
PERMANENT
ATYPIA
80
Jaya V.Mandalik
1246
29
P5L4
IMB
NIL
ATYPIA
81
Suvarna U.Khote
1288
37
P3L3
OTHERS
NIL
82
Sharvari M.Ponatil
1292
45
P4L4
WD
PERMANENT
83
Anandi
D.Zambare
Kshma G. Nimkar
1310
53
P1L1
WD
IUCD
+EROSION
ATYPIA
EROSION
CERVICITIS
+EROSION
MODERATE PUNCTATE
CIN 2
DYSPLASIA
ATYPIA
1350
54
P1L1
OTHER
PERMANENT
ATYPIA
74
75
76
84
AW
NORMAL
CERVICITIS
CERVICITIS+
EROSION
CIN 2
EROSION
100
MASTER CHART
85
Kusum N.Modi
1367
38
P2L2
OTHER
PERMANENT
ATYPIA
PUNCTATE
86
Sonia D. Pande
1388
56
P1L1
IMB
PERMANENT
ATYPIA
87
Yamini H. Bhat
1401
55
P3L3
OTHER
OC PILL
ATYPIA
88
Sahyadri P.Mone
1415
37
P3L3
WD
NIL
EROSION
89
Sukanya G Kamat
1445
58
P1L1
WD
PERMANENT
MILD
DYSPLASIA
ATYPIA
90
Uma G. Bapat
1455
50
P1L0
WD
NIL
ATYPIA
EROSION
91
Reshma
G.Inamdar
Esha S.Rajput
1489
51
P6L5
OTHER
NIL
ATYPIA
MOSAIC
CERVICITIS
1510
37
P2L2
WD
NIL
ATYPIA
AW
CERVICITIS+EROSION
Madhvi G,
Vedpathak
Amruta V.Kawale
1547
29
P3L3
WD
IUCD
ATYPIA
AW
CERVICITIS
1556
40
P3L3A3
WD
PERMANENT
ATYPIA
PUNCTATE
CERVICITIS
1566
38
P2L1
IMB
PERMANENT
ATYPIA
EROSION
CERVICITIS+EROSION
96
Anita G.
Dabholkar
Savita Khapre
1598
40
P3L3A4
PCB
NIL
ATYPIA
MOSAIC
CIN 3
97
Vrunda B.Rokade
1606
29
P2L2
WD
PERMANENT
ATYPIA
EROSION
CERVICITIS+EROSION
98
Reena U. Khot
1632
41
P3L3
WD
IUCD
ATYPIA
AW
CERVICITIS
99
Manasi V. Kadam
1686
39
P4L2A2
WD
NIL
ATYPIA
INFLAMMATION
CERVICITIS
1697
42
P2L2A3
WD
NIL
SEVERE
DYSPLASIA
PUNCTATE
CIN 3
92
93
94
95
100 Nayan J.Raghav
CIN 2
CERVICITIS
101

Role of Colposcopy in Cervical Erosion

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Role of Colposcopy in Cervical Erosion

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TO STUDY THE ROLE OF

DR. PRIYANKA T.SURYAWANSHI (M.B.B.S.)

DR. UJJWALA S. PATKI (MD)

CERTIFIED BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled "To Study the

CERTIFICATE BY THE GUIDE

This is to certify that Dr.Priyanka T.Suryawanshi

Dr. Ujjwala S. Patki( M.D.)

CERTIFICATE BY HEAD OF DEPARTMENT

I attribute the successful completion of my dissertation to the

Foundation, Kolhapur, Maharashtra.

specificity, positive predictive value. Negative predictive value,

Accuracy was found to be 82%.

Histopathology is moderate., while strength of agreement

LIST OF ABBREVIATIONS USED

LSIL- Low grade squamous intraepithelial lesion

2 AIMS AND OBJECTIVES

4 MATERIAL AND METHOD

5 OBSERVATIONS AND RESULTS

10 ANNEXURE1: INFORMED CONSENT

Colposcopic Reid Index

Distribution of cases according to Age

Distribution of cases according to parity

Distribution of cases according to symptoms

Distribution of cases according to contraceptives

Colposcopic findings according to age

Colposcopic findings according to Parity

Colposcopic findings according to Complaints

Colposcopic findings according to contraceptives

Pap smear findings according to Age

Pap smear findings according to parity

Pap smear findings according to Complaints

Pap smear findings according to Contraceptives

Pap smear findings

Correlation between Pap test & Biopsy

Correlation between colposcopy & Biopsy

Correlation between colposcopy & Pap test

programs are limited

infrastructure, trained personnel and

A colposcopic evaluation and guided biopsy remains a

intraepithelial lesion, in order to identify the women who

Germany in the 1924.

are intrinsic to the in vivo tissues, have lead to development of

AIMS AND OBJECTIVES

AIMS AND OBJECTIVES

Screening test should be simple, minimally invasive, easy to

proximally into the endometrial cavity at the internal os.11

at variable level relative to the Cervical Os and changes with

columnar junction (SCJ) is the point at which the squamous

basement membrane. It consist of single row of cuboidal or

behaves like a sexually transmitted disease. It is more

There is significantly increased

risk of cervical cancer in patient who have used oral

infection has been demonstrated in almost 100%

invasive cervical carcinoma. HPV types are 6, 11, 42, 44 ,

carcinoma. The mechanism by which HPV affects cellular

Premalignant and Malignant squamous lesion of

squamous epithelium. Proximally CIN involves the cervical

I.Negative for Intra epithelial lesion or malignancy

Atypical squamous cells of undermined significance

Low grade squamous intra epithelial lesions

HSIL ( moderate and dysplasia, carcinoma in situ, CIN