COLPOSCOPY EXAMINATION

First described by HANS HINSELMAN of Germany in 1925 as a screening tool for

cervical cancer.
WHAT IS COLPOSCOPY
Colposcopy is a gynecological procedure that illuminates and magnifies the vulva,
vaginal walls, and uterine cervix in order to detect and examine abnormalities of
these structures

WHY IS COLPOSCOPY DONE? 

Colposcopy is usually done if:  

 Pap smear is abnormal, or  
 When the cervix looks abnormal during the collection of a Pap smear.  
 Even if a Pap smear result is normal, colposcopy is ordered when the cervix
appears visibly abnormal  
 patient who presents with postcoital vaginal bleeding
 The purpose of the colposcopy is to determine what is causing the abnormal
looking cervix or the abnormal Pap smear so that appropriate treatment can be
given
Preparation
  Patients should not douche, use tampons, or have sexual intercourse for
24 hours before colposcopy. 
 Patients should empty their bladder and bowels before colposcopy for comfort. 
 For mild cramps or a sharp pinching when the tissue is removed ibuprofen can
be taken the night before and the morning of the procedure (no later than 30
minutes before the appointment). 
 Patients who are pregnant or allergic to aspirin or ibuprofen can instead take pcm
 Pregnant women may undergo colposcopy if they have an abnormal Pap test;
special precautions, however, must be taken during biopsy of the cervix.
HOW IS COLPOSCOPY DONE

A colposcope is the microscope. The Instruments has a range of magnifications

lenses.
Color filter detects the abnormal blood vessels on the cervix.
The colposcope is used to examine through the vaginal opening.

Typical mayo tray set up for colposcopy 

cotton balls, Monsel's solution, saline, vinegar, Lougal's iodine, cotton-tipped
applicators, rectal swabs (Texas Q-tips), Ring forceps, vaginal speculum, biopsy
forceps, ECC curette, endocervical speculum. Additional possible items benzocaine
solution, side-wall retractors, and cervix brush

 The first step of the procedure is examining the vulva and vagina for signs of
genital warts or other growths. 
  A Pap smear is then taken.
   Examine at the squamocolumnar junction
WHAT SPECIAL TESTS ARE DONE DURING COLPOSCOPY?  
Three special tests are done during colposcopy:  
 Acetic acid wash,  
 Use of color filters, and  
 Sampling (biopsy) of tissues of the cervix.

ACETIC ACID STAINING 

•acetic acid, diluted 3% to 5%
• It washes away mucus and allows abnormal areas to be seen more easily 
•stains the abnormal areas white. called "acetowhite lesions.”
 • Sometimes, however, normal areas can also stain white, but these areas have vague
or faint borders 
Lugol's solution or Schiller's solution : Normal cells will generally take up the iodine
stain (and turn brown) in a uniform manner, whereas severe precancers and cancerous
areas will not.

USE OF COLOR FILTERS

 Helps in examining capillaries in the area of the squamocolumnar junction. 
 Blue or green filtered light can cause abnormal capillaries to become more
obvious, usually inside an acetowhite area.  
 Normal capillaries are slender and spaced out evenly. 
 In contrast, abnormal capillaries can appear as red spots (thickened capillaries
seen on end) or can produce a pattern resembling hexagonal floor tiles.  
 The worse the cervical disease, the thicker and more widely spaced out are the
capillaries. 
 Thus, when cancer eventually develops, capillaries take on odd shapes, like
punctuation marks.

BIOPSY OF CERVIX
 The biopsy of abnormal areas is a critical part of colposcopy because treatment
will depend on how severe the abnormality is on the biopsy sample.  
 As part of the biopsy procedure, endocervical curettage(sampling of the tissues
within the endocervical canal, or the opening of the cervix to the uterine cavity) is
often performed.

AFTERCARE  
 If a biopsy was done, there may be a dark vaginal discharge afterwards.
  After the sample is removed, Monsel's solution applied to the area to stop
the bleeding. When this mixes with blood, it creates a black fluid that looks like
coffee grounds. This fluid may be present for a couple of days after the
procedure.It is also normal to have some spotting after colposcopy.
   Pain-relieving medication can be taken to lessen any postprocedural
cramping.  
  Women should not use tampons, douche, or have sex for at least a week after
the procedure (or until the doctor says it is safe) because of the risk of infection. 
RISKS  
 Women may have bleeding or infection after biopsy. 
 Bleeding is usually controlled with a topical medication. 
 If colposcopy is performed on a pregnant woman , there is a risk of premature
labor.  
o A woman should call her doctor right away if she notices any of the
following symptoms:  
o heavy vaginal bleeding (more than one sanitary pad an hour)  
o fever, chills, or an unpleasant vaginal odor  
o lower abdominal pain

INTERPRETATION
 Colposcopic diagnosis of cervical neoplasia depends on mainly 4 features 
 ACETOWHITENING MARGIN AND SURFACE  
 CONTOUR OF ACETOWHITE AREA  
 VASCULAR FEATURE &  
 COLOUR CHANGE AFTER APPLICATION OF IODINE SOLUTION
SENSTIVITY-87% TO 99% to diagnose cervical neoplasia  
SPECIFICITY-23% TO 87%

COLPOSCOPIC VIEW
  VASCULATURE-best seen before application of acetic acid
  ABNORMALITIES ARE 
o Punctuation 
o Mosaic pattern & 
o Atypical vessels
 Normally afferent & efferent capillaries within the villi of columnar epithilium
become compressed during metaplastic process & not incorporated within the
newly form epithelium 
   Instead they form a fine network below the basement membrane  
 When CIN develop as a result of of HPV infection afferent and efferent capillary
system incorporate in to the diseased dysplastic epithelium.
 This form the basis of punctate mosaic blood vessels

PUNCTATE PATTERN-terminating vessels in stromal papillae underlying the thin

epithelium appear as black point in a stippling pattern on colposcopy called PUNCTATE
AREAS  
MOSAIC PATTERN-epithilium appear as individually small large
round ,polygonal,regular or irregular blocks.
   This pattern appear cause of interconnecting blood vessel in stromal papilla
which is observed as cobbled area.
FINE PUNCTATION  
fine punctuation refer to looped capillaries viewed end on that appear to be of fine
calibre and located close to one another, producing a delicate stippling effect
  Fine mosaics are a network of fine-calibre blood vessels .
  found in low-grade (CIN 1) lesions.

COARSE PUNCTATION  

Coarse punctation coarse mosaic are formed by vessels having larger calibre and larger
intercapillary distances,  
occur in more severe neoplastic lesions CIN 2, CIN 3 lesions and early preclinical
invasive cancer.  
Sometimes, the two patterns are superimposed in an area so that the capillary loops
occur in the centre of each mosaic ‘tile’. This appearance is called umbilication
LEUKOPLAKIA  
 Leukoplakia or hyperkeratosis is a white well demarcated area on the cervix  
 The white colour is due to the presence of keratin .  
 Usually leukoplakia is idiopathic, 
  but it may also be caused by chronic foreign body irritation, HPV infection or
squamous neoplasia. 
  it should be biopsied to rule out high-grade CIN or malignancy
CONDYLOMA  
 Condylomata are multiple, exophytic lesions, that are infrequently found on the
cervix, but more commonly in the vagina or on the vulva  
 They present as soft pink or white vascular growths with multiple, fine, finger-like
projections on the surface, before the application of acetic acid.  
 Under the colposcope, condylomata have a typical appearance, with a vascular
papilliferous or frond-like surface, each element of which contains a central
capillary. 
 the surface of a condyloma may have a whorled, heaped-up appearance with a
brain-like texture, known as an encephaloid pattern  
 densely hyperplastic.  
 These lesions may be located within, but are more often found outside the
transformation zone  
 condyloma is whiter. .  
 Condylomatous lesions may not take up iodine stain or may stain only partially
brown.
COLPOSCOPIC VIEV AFTER APPLICATION OF 5% ACETIC ACID SOLUTION 
 Degree to which the epithelium takes up acetic acid correlated with the color
tone or intensity the surfacre shine and the duration of the effect and in turn
with the degree of neoplastic change in lesion  
 LOW GRADE LESION-appears less dense  less extensive thin and  irregular
margin or of angular margin with fine punctatin /mosaic  
 HIGH GRADE LESION-appears dense poaque  grey white aceto white areas
with coarse punctationor mosaic  and wid regular and well demarcated
borders.  These lesion often involve both lips and harbour atypical vessels

CERVICITIS-
 Inflamed with a reddish
  Appearance
 Bleeding on touch there are
 Ill defined patchy aceto white areas

AFTER APPLICATION OF IODINE 

 Normal vaginal and cervical squamous epithilium and mature metaplastic

epithilium contain glycogen rich and thus take up iodine stain turns black or
brown but 
 Dysplastic epithilium contains little or glycogen thus does not stain with iodine
remains mustard saffron yellow 
 Immature metapplasia partially stains cause columnar epithilium does not take
iodine. 
 Condylomatous lesion does not take iodine
Salpingectomy
Definition:
It is the process of surgically removing one or both of the fallopian tubes while
leaving the uterus and ovaries intact
• Complete salpingectomy is preferred over fimbriectomy because precursors to
fallopian tube cancer (or ovarian cancer) can be found throughout the fallopian tube
• However, if complete salpingectomy cannot be performed, then removing as much of
the fallopian
Types of salpingectomy
• Complete – [opportunistic salpingectomy/ Risk reducing salpingectomy ]
• Partial – [Tubal ligation like Bipolar coagulation , Monopolar coagulation
Fimbriectomy , Irving's procedure , Tubal clip ,Tubal ring , Pomeroy tubal ligation,
Essure tubal ligation , Adiana tubal ligation –Excision as treatment of ectopic]

Opportunistic salpingectomy
• Opportunistic salpingectomy is the removal of the fallopian tubes for the primary
prevention of ovarian cancer in a woman already undergoing pelvic surgery for
another Indication
• Eg cesarean section, sterlisation and other pelvic operations eg hysterectomy ,
myomectomy and treatment of endometriosis,
• in whom fertility is no longer desired
• or fallopian tubes are damaged
Risk-reducing salpingectomy
• women who have brca1 or brca2 germline mutations or family history should be
counseled regarding bilateral salpingo- oophorectomy, after completion of childbearing,
• they should be counseled regarding risk-reducing salpingectomy when childbearing is
complete followed by oophorectomy in the future,
Bilateral tubal ligation is not without risks
• Hydrosalpinx, torsion, and tubal pregnancy are all potential complications of tubal
ligation, which often require an additional procedure
How is the procedure performed?
• most common and preferred method is laparoscopy
• Some surgeons prefer to do away with a viewing instrument and would make an
incision in the lower abdomen to remove the tube instead. This process is termed
minilaparotomy.
• A more invasive approach is termed laparotomy and requires the surgeon to make a
large incision in the lower abdomen to allow a better exploration of the abdomen area.
This approach is especially considered if there is a need to remove both fallopian tubes.
• In rare cases, salpingectomy is performed through a surgical incision in the vagina,
termed colpotomy. In this method, the affected fallopian tube is approached through
the vagina.

Laparoscopic salpingectomy
Salpingectomy during cesarean delivery
Vaginal salpingectomy
Possible risks and complications of salpingectomy / midwife role
• 77% bilateral salpingectomy are performed at the time of hysterectomy for benign
indications.
• The respondents also performed bilateral salpingectomy at the time of sterilization
• Other than a significant increase in operative time for salpingectomy with hysterectomy
(16 minutes) and with sterilization (10 minutes),
• No significant differences in length of hospital stay, readmissions, blood transfusions,
or postoperative complications, infections, and fever have been identified in cases with
and without salpingectomy

Ovarian function
• Ovarian function does not appear to be affected by salpingectomy
• salpingectomy alone does not appear to significantly affect ovarian stimulation
parameters or clinical pregnancy rates.
• salpingectomy is recommended in cases of hydrosalpinx.

 Counselling
• Counseling women who are undergoing routine pelvic surgery about the risks and
benefits of salpingectomy should include an informed consent discussion about the role
of oophorectomy and bilateral salpingo- oophorectomy
• The risks and benefits of salpingectomy should be discussed with women who desire
permanent sterilization.
• Obstetrician–gynecologists should counsel women who have undergone
salpingectomy of potentially relevant signs and symptoms of ovarian cancer

Time of prophylactic salpingectomy

 Opportuinistic salpingectomy with CS or hysterectomy or other pelvic operations
 planned
 -Tubal sterlization salpingectomy
 -Risk-reducing salpingectomy
 Family history –-- early age of onset of ovarian cancer in
the family –
Gene mutation
-At age 35–40 for BRCA1 carriers or
-At age 40–45 for BRCA2 carriers

 • Low risk cancer : bilateral salpingectomy with ovarian retention (BSOR)

• Moderate risk cancer : with family history /
risk reducing bilateral salpingectomy early age of onset of Ovarian cancer in the family -
or risk reducing salpingectomy-delayed oophorectomy early age of onset of Ovarian
cancer in the family
Then bilateral oophorectomy upon completion of child-bearing

• High risk cancer (carrying BRCA mutations).

 BILATERAL MASTECTOMY (90% ‐ 95% )
 risk reducing salpingectomy-delayed oophorectomy
 bilateral oophorectomy upon completeion of child birth or salphingo-
oopherectomy
 salphingo-oopherectomy: reduction of ovarian cancer
Recommendations and conclusions
• Population-based screening should not be encouraged as a method of “ovarian”
cancer risk reduction (strong, high).
• Salpingectomy at the time of hysterectomy or as a means of tubal sterilization
appears to be safe and does not increase the risk of complications such as blood
transfusions, readmissions, and postoperative complications, infections, or fever
compared with hysterectomy alone or tubal ligation.
• Ovarian function does not appear to be affected by salpingectomy at the time of
hysterectomy based on surrogate serum markers or response to in vitro
fertilization.
 • The surgeon and women should discuss the potential benefits of the removal
of the fallopian tubes during a hysterectomy in women at population risk of
ovarian cancer who are not having an oophorectomy.
• Removal of the ovaries in premenopausal women may increase the risk of
cardiovascular disease and is not recommended without clinical indication
(strong, high).
• Counseling women who are undergoing routine pelvic surgery about the risks
and benefits of salpingectomy should include an informed consent discussion
about the role of oophorectomy and bilateral salpingo-oophorectomy.
• postpartum salpingectomy and salpingectomy at time of cesarean delivery
appear feasible and safe.
• The risks and benefits of salpingectomy should be discussed with women who
desire permanent sterilization.
SEXUAL ABUSE/ SEXUAL VIOLENCE

Definition
Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or
advances or acts to traffic, or otherwise directed, against a persons sexuality using
coercion , by any person regardless of their relationship to the victim, in any setting
including but not limited to home and work.
Sexual violence includes rape, defined as physically forced or otherwise coerced
penetration – even if slight – of the vulva or anus using a penis, other body part or
an object. The attempt to do so is known as attempted rape. Rape of a person by 2 or
more perpetrators is known as gang rape.
 
Forms and contexts of sexual abuse

• Rape within marriage or dating relationships

• Rape by strangers
• Systematic rape during armed conflict
• Unwanted sexual advances or sexual harassment, including demanding sex in return
for favours
• Sexual abuse of mentally or physically disabled people.
• Sexual abuse of children
• Forced marriage or cohabitation, including the marriage of the children.
• Denial of the rights to use the contraception or to adopt other measures to protect
against sexually transmitted diseases.

Types of sexual abuse

 • Non-consensual, forced physical sexual behavior (rape and sexual assault).

• Unwanted touching, either of a child or an adult.
• Sexual kissing, fondling, exposure of genitalia, and voyeurism, exhibitionism and
up to sexual assault.
 • Exposing a child to pornography.
• Saying sexually suggestive statements towards a child (child molestation).
• Also applies to non-consensual verbal sexual demands towards an adult.
• The use of a position of trust to compel otherwise unwanted sexual activity without
physical force (or can lead to attempted rape or sexual assault).
• Incest ( sexual deviancy ).
• Certain forms of sexual harassment.
• Spousal sexual abuse is a form of domestic violence. When the abuse involves
forced sex, it may constitute rape upon the other spouse, depending on the jurisdiction,
and may also constitute an assault.
• Sexual misconduct can occur where one person uses a position of authority to compel
another person to engage in an otherwise unwanted sexual activity.
• Sexual harassment in education might involve a student submitting to the sexual
advances of a person in authority in fear of being punished, for example by being given
a failing grade.
• For example, sexual harassment in the workplace might involve an employee being
coerced into a sexual situation out of fear of being dismissed.
THE IMPACT OF SEXUAL ABUSE ON PREGNANCY & CHILDBIRTH
Emotions run high during pregnancy, partially due to changes in hormonal levels and
body, but also because societal values of pregnancy recognize child-bearing as a rite of
passage all adults should experience. A woman’s body is specifically designed for giving
birth and her body will change in preparation; in the nine months of pregnancy a woman
will face uncertainty – she has no choice on the sex of her child nor when and how her
body choses to respond. While she is surrounded by medical professional and well-
meaning family and friends providing unsolicited advice, the expectant mother may be
very confused emotionally. If she is a sexual abuse survivor as well her feelings of
anxiety may be intensified

Triggers
Common triggers during the pregnancy experience will arise and can be prepared for;
vaginal exams or other invasive procedures, labour pain and pain before and after
birth especially in the vagina, abdomen, back, breasts and perineum may solicit a
resurgence of memories. Once again an authority figure with whom compliance and
trust is expected, incites feelings of helplessness and being overpowered as they may
feel totally under their control (imaginary or not). Reminders during pregnancy or labour
to ‘relax and it won’t hurt’ or, to direction to remove clothes and lie on her back
may have an opposite effect from its intended purpose. Triggered memories surface
in the form of flashbacks which add to the emotional trauma she may experience during
labour (Kitzinger, 1992). All birthing mammals look for a safe dark place to give birth,
her survival reflex dominates all other emotion and her labour may be prolonged due
to the influx of catecholamine’s that accompanies the fight or flight response (Odent,
1999). Women need to feel safe and not disturbed for an efficient labour.

How to respond to these concerns

1. Recognize and accept that some fears and concerns make sense and give the
woman permission to be afraid or concerned. Remind her that you are there to support
her every step of the way.
2. Try to separate her pregnancy experience from her past abuse. Keep her in the
moment by engaging her in dialogue during exams and procedures or maintaining eye
contact.
3. Discuss whether or not to disclose her abuse history and the impact it may be
having on her pregnancy experience with other care providers so that they may develop
a plan of care that meets her needs.
4. Openly discuss fears and concerns the expectant mother may be experiencing and
develop safety plans to address them.
5. Develop a birth plan that is flexible and clearly stated that outlines the expectant
mother’s preferences and fears – this may include putting a sign on the door asking
people to knock upon entering the birthing room, wearing socks during the labour or
having medical procedures thoroughly explained.

6. If there is a supportive partner, family member or friend enlist their support,

having a loved one close during times of stress can be very comforting. Labour
dysfunction will most frequently occur during the first stage due to her inability to control
the pain and intense feelings of fear and stress triggered by the fight for survival
response. (Tallman & Hering, 1998). It is very important that as her birthing assistant
you have:
• Established a bond with her and a minimal level of trust very early in her pregnancy
so that you are able recognize her distress and provide appropriate solutions;
• Ensuring continuity in communications and interaction between all members of
the pregnancy support team prior to labour so that the expectant mother has
established a level of safety with those supporting her;
• Bring extra support and care during her labour stages, advocate for her, interpret,
and be the interface between her and the nurses if they are not aware of her unique
needs;
• Many of the other members of the pregnancy support team will not stay for the
duration of labour, you can be the consistent member of the team if you remain with her
throughout the process;
• During the transition stage of labour flashbacks or dissociation may increase in
frequency, if they are too intense she may lose focus and may slow down or stop
dilation altogether or refuse to push – continue to reassure her and maintain eye contact
to keep her focused and in the moment;
• Consistently provide reassurance, validate her feelings and emotions as well as her
possible physical manifestations (screaming, closing her legs, refusing to be touched,
etc.)