Colposcopy terminology

The terminology surrounding the clinical reporting of colposcopic examinations has continued to evolve, reflecting the improved understanding of cervical oncogenesis and the normal and abnormal appearances of the cervix. It is timely to review the current terminology used in Australia and align it to internationally accepted standards.

In Australia, the current commonly used nomenclature is the terminology recommended by the International Federation for Cervical Pathology and Colposcopy (IFCPC) in 2002.[1] In 2008, IFCPC formed a nomenclature committee to review the previous IFCPC terminologies (1975, 1990 and 2002) and publications that critically analysed each colposcopic sign, aiming to create an evidence-based terminology. The committee, chaired by Jacob Bornstein, was composed of 13 colposcopists from different countries and one pathologist from Australia. After an exhaustive and transparent process the final terminology was reviewed and approved by all committee members, the IFCPC board and the IFCPC general assembly held at the World Congress in Rio de Janiero in July 2011.[2]

As the representative body of the national societies for colposcopy and cervical pathology, the IFCPC recommended that the 2011 terminology replace all other terminologies and be implemented without delay for diagnosis, treatment and research. It is recommended that the 2011 IFCPC terminology[2][3] (see the following section) should be used in Australia and replace other terminology.

General assessment[2][3]

The colposcopist should assess and record the following:

• adequate/inadequate: records whether the cervix has been visualised or not and includes the reason if inadequate (e.g. vaginal stenosis, cervix obscured by inflammation, bleeding, scarring)
• squamocolumnar junction visibility: this refers to the internal margin of the TZ that is either completely visible, partially visible, or not visible
• TZ should be classified as Types 1,2,3 according to the visibility of all or part of the upper limit of the squamocolumnar junction:
  • Type I – the whole TZ including all the upper limit is ectocervical
  • Type 2 – the upper limit of the TZ is partly or wholly visible in the canal and is completely visible around 360 degrees
  • Type 3 – part or the entire upper limit of the TZ cannot be seen in the canal. In Type 3 TZ the outer limit may be visible on the ectocervix, in the canal or also not visible (Figure 7.1).

Figure 7.1. Description of transformation zone (TZ) categories

Normal colposcopic findings

The colposcopist should assess the following:

• Identify the outer limit of the original squamocolumnar junction.
• Identify the columnar epithelium, and upper limit of the TZ.
• Look for and note the following normal findings: ectopy, metaplastic squamous epithelium (mature or immature), nabothian cysts, crypt (gland) openings, deciduosis in pregnancy or atrophy.

Abnormal colposcopic findings (after application of acetic acid)

Aceto-white changes:

• Minor (Grade 1)
  • thin aceto-white epithelium; irregular geographic border
  • fine mosaic, fine punctation
• Major (Grade 2)
  • dense aceto-white epithelium, rapid appearance of aceto-whitening, cuffed crypt (gland) openings
  • coarse mosaic, coarse punctation, sharp border, inner border sign, ridge sign

Suspicious for invasion

Atypical vessels

• additional signs (suspicious for invasion): fragile vessels, irregular surface, exophytic lesion, necrosis, ulceration (necrotic), tumour/gross neoplasm suspicious for invasion

Lugol’s staining (Schiller’s test) if performed:

• stained/non-stained

Location of the lesion:

• Is this inside or outside the TZ?
• location of the lesion by clock position

Size of the lesion:

• number of cervical quadrants the lesion covers
• size of the lesion (as percentage of cervix)

Miscellaneous findings

• Stenosis (partial or complete), congenital anomaly, post treatment consequences, endometriosis, congenital TZ, condyloma, polyp (ectocervical/endocervical) inflammation.

Excision treatment types

This includes stratification and measurement of treatment excision specimens (Australian modification of IFCPC excision nomenclature).

Excision treatment by whatever mode defined by the length of cervical tissue excised as:

• Type 1 < 10 mm
• Type 2 > 10 mm and < 15 mm
• Type 3 > 15 mm

(See Treatment.)

NB: This stratification is modified from that of the IFCPC (2012) because, traditionally in Australia, excision specimens are measured using two diameters (anterior to posterior; 12 to 6 o’clock, and side to side; 3 to 9 o’clock) and length (external os to endocervical margin).