Article published in MEDI FOCUS in 2006
PRACTICAL COLPOSCOPY : A step towards early
diagnosis of cervical dysplasia

Big Questiion “Is this  Cancer Preventable”?

• Carcinoma  Cervix accounts for over one lac new cases / year in India
• Carcinoma Cervix is preventable because it has a pre-invasive stage which lasts for 3-15 yrs
• Prevention is the ideal method of control
• Identify local epideomological factors responsible for high incidence in India.
• Institute effective strategies in target population

Invasive cancer cervic does not usually develop all of sudden .
Natural History of Cervical Cancer is  over simplified below

* Director. Life Care Centre (East Delhi)
   Chairperon , Women Wing IMA  and  East Delhi Gyanecologist Forum
**  Consultant Gynaecologist, Lifecare Centre and Max Balaji Hospital
Unfortunately there are no early symptoms. When symptoms appear, disease may be advanced .

Current  Screening and Diagnostic Techniques

• Exfoliative Cytology  -  Pap Smear (Screening method)
• Visual Inspection Of Cervix - V.I.A . V.I.L.I (Screening Method)
• HPV Testing (Screening method)
• Cervical Biopsy- Punch, Wedge, Cone.
• Colposcopy directed  cervical biopsies
• Histopathology

The effectiveness of cytologic screening by pap test is  limited by suboptimal sensitively, limited reproducibility  in women with big erosion and  markedely hypertrophied cervix. Aggressive approach using VIA  and VILI  is needed as addational tool of clinical examination to minimise the risk of cervical cancer specially in India where  pap smear screening is not  feasible or practical due to poor follow up and money constraints.

Histopathology remains the  gold standard for the diagnosis of intraepithelial neoplasia and  invasive
cancer. The main purpose of colposcopy is to pick up the  site of biopsy to detect intraepithelial neoplasia and early neoplasia of the cervix as it provides a well lighted 20 times magnified  view of the cervix. In practice we often face discordance  between  histopathology, cytology and the colposcopic diagnosis in hypertrophied cervix with big cervical erosion. However the  colposcopically  directed biopsy, enhances the skills of both the novice and the experienced  gyanecologist to pick up the case early. The  main objective to decrease the incidence and associated mortality of  carcinoma cervix,  although the principal efforts are directed towards the early detection and prevention of cervical cancer all together.

Many recently introduced photocolposcopes have capabilities for video  recording and  software for digital  management of patient data, making  them excellent tools for  teaching  colposcopy, patient treatment and monitoring.

Life Care Centre started its video colposcopy unit two year back (2003) with aim to
-  Establish  correlation  between pap’s smear , colposcopy and  histopathological  
   examination in case of big cervical erosion with hypertrophied cervix.
-  Promote  dissemiantion of knowldege to medical fraternity  and  commnity at large.

During these two years time  two hundred fifty three cases of  hypertrophied cervix with big cervicl erosion were enrolled and evaluated  by pap smear, colposcopic ad colposcopy directed biopsy. Majority of these patiens often reported with vaginal spotting . contact bleeding or excessive white discharge. HPV testing was  not done as routine, as women found if unaffordable.

All  had  baseline pap smear using Ayre’s spatula and endocervical brush. The commulative incidence of CIN I to CIN III was 7.5% . All were subjected to video colposcopy.  Normal colposcopy reassured the patient as it is  associated with markedely  decreased risk of cervical intraepithelial neoplasia. Where as  positive colposcopy  results following acetic acid  and lugol’s iodine staining identified  a small  sub group of patients that required biopsy and confirmedto have  mild to moderate dysplasia. 5 out of 17 cases with CIN I and II were not confirmed histopathologically. While 12  cases  of mild dysplasia were picked up where pap smear failed to give any clue.

Conclusion
The pap smear is very good at detecting prevalent CIN in an asymptomatic patient with apparently  healthy cervix . However colposcopy test using acetoacetic and lugol’s iodine staining is better in picking  early cases of intraepithelial dysplasia in hypertrophied cervix with cervical erosion. Patient with  negative pap test and negative colpocopy  are unlikely to develop CIN III during the subsequent 3 to 4 years. This study provided  pivotal data of recommending  video colposcopy  in women with   big cervical erosion as part of screening test of cervical cancer and intraepithelial dysplasia and not rely on pap’s smear alone. More research is needed in this area.