20 C1 Comprehensive Colposcopy Skills Apgar Tedeschi

Comprehensive Colposcopy Skills
Barbara S. Apgar, MD, MS

Candice Tedeschi, RNC, NP
Disclosures
Barbara Apgar, MD, MS
Elsevier: Book co-editor. Apgar B, Brotzman G, Spitzer M.
Colposcopy Text and Atlas. 2002, 2008.
Co-author. Brotzman G, Spitzer M, Apgar B. Colposcopic Image
Library CD. 2004. SABK, Inc.
Candice Tedeschi, RNC, NP

Nothing to disclose
Thanks to Dr. Mark Spitzer and Dr. Alan Waxman for

sharing some their slides
Objectives
At the conclusion of this lecture, one should be
able to:
Discuss the evidence that has changed our
approach to colposcopic practice
Discuss tips to improve colposcopy skills
Describe the identification of colposcopic lesions
Identify colposcopic features that direct the
biopsy
Colposcopy:
The Old Approach
If its white, take a bite

If you dont know what it is, take a biopsy
Take lots of biopsies
Colposcopy:
The More Modern Approach
You cant biopsy everything so
you need to identify the worst
area using colposcopic criteria
and grading
Is this applicable in 2016?

Multiple Biopsies
408 women from ALTS with satisfactory colposcopy and <CIN 3 on
biopsy were diagnosed with CIN 3+ over the 2 years.
In 69.9%, the initial colposcopy was "true-positive" (CIN 2+)
The sensitivity of colposcopy did not vary by type of colposcopist
but was significantly greater when two or more biopsies were
taken instead of one (P<.01).
In order, taking multiple biopsies: nurse practitioners > general
gynecologists > gynecologic oncology fellows > gynecologic
oncologists (P<.01).
Conclusion: The sensitivity of colposcopy does not differ significantly
by type of medical training, but is greater when two or more biopsies
are taken.
Gage J et al. Obstet Gynecol 2006;108(2):264-72

Number of biopsies taken that lead to ultimate
diagnosis of CIN 3+
2675 women in ALTS with adequate colposcopy
on enrollment
Success in diagnosing CIN 2 or worse over the
course of the study
68.3% (142 / 208) when one biopsy taken
81.8% (108 /132) when two biopsies taken
83.3% (35 / 42) when three or more biopsies taken
Gage J et.al. Obstet Gynecol 2006;108:264-72

Inter-observer Agreement on
Biopsy Placement
Jeronimo J; Gage JC; Waxman A ; Apgar B; Brotzman G; Carter S; Gold MA; Krumholz
B; Mitchell K; OConnor D; Papa D; Rubin M; Spitzer M; Tedeschi C; Waage R.
Review of 100 images.

3 evaluators per image.
300 pairs of evaluators.
Allowed to select multiple areas for biopsy.
For the selection of the first choice of biopsy
placement, 55.7% of pairs of evaluators marked
overlapping areas.
Overlapping increased to 97% when the evaluators
added an additional area for biopsy.
Argument Pro: Endocervical
curettage should be performed
with every colposcopy.
8497 women in Shanxi provence China
364 with CIN 2,3, or cancer and satisfactory
colposcopy
The diagnosis of CIN 2,3 was made on ECC
alone in 20 (5.5%)
Authors recommend routine ECC with all
colposcopy exams
Pretorius et al Am J Obstet Gynecol 2004;191:430-434
Argument Con: Endocervical
curettage is of limited value.
Large Canadian Study

N= 13,115 colposcopies
ECC alone diagnosed CIN 2+ in 1.01%
99 ECCs needed to find one additional CIN 2+
Utility greatest in women 46 years of age and older
referred for high-grade cytology

Gage et al Am J Obstet Gynecol 2010;203(5):481
Does a positive ECC reliably localize
disease to the endocervical canal?
in 210 women with satisfactory colposcopy all positive

ECCs (9.5%) disrupted an ectocervical lesion
69% of Women with CIN 2+ diagnosed on ECC alone

actually had ectocervical lesions on excision.
12.5% had high grade endocervical lesions
ECC missed 45% of endocervical lesions later found on

conization
Spirtos N, Obstet Gyncol. Nov 198770(5):729-33

Moniak CW. J. Reprod Med 2000;45(4):285-92
So when should we do ECC?
Maximize the chance of finding disease.
ASC-US or worse cytology and no lesion seen
on colposcopy
HSIL on cytology and excision not planned
Unsatisfactory colposcopy and excision not
planned
AGC / AIS on Pap
If follow-up not likely
Failure to do an ECC in a
Previously Treated Patient
The colposcopic principle that there is no such
thing as a skip lesion is only valid in a patient
who has not been previously treated
Once the transformation zone is disrupted by cervical
therapy, islands of metaplastic or lesional tissue may be
left behind the newly formed SCJ.
The colposcopy appears adequate and yet there may be
disease in the endocervical canal.
Conclusion: Whenever there is an abnormal Pap test

in a previously treated patient, ECC should be done.
Few tips to help
make your
colposcopic exam
easier
Getting an Adequate Colposcopy
Do not use a cotton-tipped

applicator to manipulate or
pry open the cervix at the
external os
This traumatizes the cervix

and may cause bleeding or
detach dysplastic epithelium
A cotton-tipped applicator
should be inserted into the
vaginal fornix and pushed
inward to cause the cervix to
deviate anteriorly or
posteriorly. This allows
easier visualization of the
SCJ
Taking a Biopsy
We know our patients and which ones may be
challenged by the colposcopy, biopsy, ECC.
Most patients will manage without anesthesia.
Closing the jaws of the biopsy forceps quickly and

suddenly startles the patient and she will perceive it
as painful
Close a sharp biopsy forceps very gradually.
Ask the patient to take a deep breath and cough
when the biopsy is taken.
Taking a Biopsy
Small biopsies are all you need; they hurt and
bleed less.
It may be easier to take a small biopsy by using a
portion of a regular Tischler than by filling the jaws
of a mini Tischler.
Small biopsy forceps will often slip off the intended
biopsy site
Misdirected biopsy, no biopsy at all or (even
worse) damaging or stripping the epithelium
making it un-interpretable.
Colposcopy at a Crossroads
Jeronimo, Schiffman. AJOG 2006
Historical success of the conventional

approach based on cytology, colposcopy and
histology in reducing cervical cancer incidence
is undeniable.
Optimizing the accuracy of colposcopy and

biopsy is now one of the leading concerns in
the cervical cancer screening process.
Important colposcopic considerations
Avoid using a single colposcopic sign to

formulate a colposcopic impression.
Differentiating the normal from abnormal
TZ requires more flexibility in biopsy.
Consider all the colposcopic findings.
Colposcopic findings are neither site nor

location specific >>> look everywhere!
26 year old with HSIL
1. Normal.
2. Low grade.
3. High grade.
4. Cancer.
25 year old with ASC-H.
1. Normal
2. Low-grade.
3. High-grade.
4. Cancer.
42 year old G5 P5 with LSIL
1. Normal.
2. Low grade.
3. High grade.
4. Cancer.
The Last Word
Grading when done systematically can help direct
biopsies to the lesions most likely to be of higher
grade
However
Even in the hands of expert colposcopists, grading is
not a substitute for biopsies
The only proven technique available to increase the

sensitivity of colposcopy is taking additional biopsies

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Comprehensive Colposcopy Skills

Barbara S. Apgar, MD, MS

Candice Tedeschi, RNC, NP

Thanks to Dr. Mark Spitzer and Dr. Alan Waxman for

If its white, take a bite

Is this applicable in 2016?

Gage J et al. Obstet Gynecol 2006;108(2):264-72

Gage J et.al. Obstet Gynecol 2006;108:264-72

Review of 100 images.

Large Canadian Study

in 210 women with satisfactory colposcopy all positive

69% of Women with CIN 2+ diagnosed on ECC alone

ECC missed 45% of endocervical lesions later found on

Spirtos N, Obstet Gyncol. Nov 198770(5):729-33

Conclusion: Whenever there is an abnormal Pap test

Do not use a cotton-tipped

This traumatizes the cervix

Closing the jaws of the biopsy forceps quickly and

Historical success of the conventional

Optimizing the accuracy of colposcopy and

Avoid using a single colposcopic sign to

Colposcopic findings are neither site nor

The only proven technique available to increase the

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