Ulceration is the defect of epithelium and underlying stroma. It is not an exclusive sign of invasion and can be seen in severe inflammation, caused either by infection or by physical or chemical trauma. The bottom can be covered with necrotic tissue or can be denuded and seen as red or pink stromal tissue.
Erosion
Erosion is common lesion on the cervix. Depending on the size, the lesion is called erosion or ulcer. Both can arise spontaneously. The edges can be sharp as in true erosion (inflammation or neoplasia) or the edges can be rolled indicating traumatic erosion.
Normal epithelium is less vulnerable than abnormal epithelium or atrophic epithelium. Abnormal epithelium can be easily detached from the stroma, which might be an indicator for the presence of clinically significant lesion.
Endometriosis
Endometriosis referred to the presence of ectopic endometrial tissue outside the uterus, in domain of any other body site including cervix. Although the exact pathogenesis of endometriosis in the cervix remains speculative, implantation of the endometrial tissue is the most likely mechanism. It is best supported by increased rate of endometriosis after therapeutic procedures on the cervix.
On colposcopy endometriosis of the cervix may appear as an ulcer or a cyst.
Condyloma of the cervix
Condyloma is a common name used to denote all epithelial lesions in the genital system induced by Human papilomavirus (HPV). The term Condyloma is derived from the Antiquity, when it was described to be a particularly common genital lesion known as a venereal or genital wart. In 1976 it was realized that HPV is also the causal etiological agent of other morphological types of lesions, distinct from the usual exophytic condyloma: subclinical lesions presented as flat condyloma and microcondyloma, which are frequently associated with cervical precancer (CIN) lesions
Polyp is a benign tumor originating from the columnar epithelium of the endocervix. These benign pedunculated lesions may be visible with the naked eye, while protruding from the canal. Depending on their histological composition three types of polypus exist: mucous, fibrous and angiomatous. All polyps should be excised and submitted to histopathological examination to rule out the rare occurrence of malignant transformation (usually squamous cell carcinoma).
Inflammation
Inflammation may be the result of physical and chemical trauma or infection. The inflammatory lesions of cervical and vaginal mucosa are associated with excessive, malodorous or non-odorous, frothy or non-frothy, grey or greenish-yellow or white discharge. Colposcopic features of cervical inflammation such as inflammatory punctation, congestion and ulceration as well as ill-defined, patchy acetowhitening are widely and diffusely distributed in the cervix and vagina and not restricted to the Transformation zone.
After repeated inflammation and tissue necrosis, the lesions are repaired and necrotic tissue is eliminated. The newly formed epithelium has numerous vessels, and connective tissue proliferation results in fibrosis of varying extent.
Papilloma
Papilloma is the joint name to describe epithelial proliferations originating from squamous epithelium and presenting with a papillary morphology. The typical example is squamous cell papilloma, which can be solitary or multifocal lesion, characterized by exophytic cauliflower-like proliferation where acanthotic epithelium is overlying connective tissue papillae. These lesions are entirely benign and are not necessarily induced by HPV infection.
Congenital Transformation zone
Congenital Transformation zone is a variant of squamous metaplasia, which may be seen in about 5% of women. During embryogenesis cuboid vaginal epithelium is replaced by the squamous epithelium. It is thought that this process begins at the caudal (lower) end of the urogenital sinus. If the conversion from cuboidal to squamous cells is not complete, but stops at a certain height of the vagina or on the periphery of the cervix, cuboid epithelium is subjected to the process of squamous metaplasia. The line of separation between congenital ZT and the original squamous epithelium is the point at which it stopped normal squamous cell development and therefore it is believed that congenital ZT is the result of delayed squamous transformation.
This type of transformation zone can be developed during intrauterine life or before the beginning of sexual activity and does not have increased risk of neoplastic transformation. The distinction should be made between ZT that occurs before puberty and one that occurs in adolescence or later, mostly because congenital fields that are not exposed to mutagens during active metaplasia have a minimal risk of neoplastic change. The changes are primarily confined to the cervix, but 4% of women epithelium of this type may be extended to the vagina, usually front and rear.
Fields of congenital Transformation zone can have different size, from small around the cervical canal to those which fully grasp at the upper vagina. Colposcopically these fields of AW epithelium often have dramatic image of mosaic, with or without punctuations and are resistant to glicogenation. This finding may persist for several years. Although the level of glicogenation of the epithelium is constantly increasing, it never reaches full glicogenation and and after the application of iodine these fields remain unstained.
Cervical stenosis is the pathologic narrowing of the uterine cervix. It is defined as cervical narrowing that prevents the insertion of a 2.5 mm wide dilator.
Causes of cervical stenosis may be different and include: congenital cervical stenosis, chronic infection (chronic cervicitis), trauma caused by previous treatment of the cervix, cervical endometriosis and stenosis secondary to a tumour or radiation therapy.
All techniques for performing an excisional biopsy of the cervix, cold knife cone, laser conization and large loop excision of the TZ are associated with a long term risk of cervical stenosis. Such complication can result in difficulty to visualize the SCJ. An unsatisfactory examination after previous excisional procedure compromises the ability of colposcopy to function as a follow-up tool.
Occasionally, stenosis of external cervical opening can be seen in postmenopausal cervix, sometimes progressing to complete obliteration. Such a finding is usually accompanied with adhesions in the endocervical canal.
Congenital abnormalities
Congenital abnormalities of the cervix are relatively rare conditions that occur as one of the following problems.
Failure of fusion of the Müllerian ducts during embriological development results in a duplicated (two cervices) or septate cervix (one cervix with two openings). The septum can be present along the entire length of the cervical canal or can be partial or even restricted to the external opening
From the point of colposcopy it is necessary to think of those congenital malformations of the uterus where two cervices are present. The association of a double uterus with bilateral synchronous premalignant and malignant cervical changes is even more uncommon. Usually, in these cases the disease is developing on the cervix belonging to the vagina which is more often functional. If both cervices (in one or two separate vaginas) are exposed to HPV infection, it can be expected that both can be at risk for developing the disease.
Congenital agenesis Cervical agenesis is complete absence of the cervix which is estimated to occur in les than 100 000 women. Milder forms of the condition, in which the cervix is present but deformed and nonfunctional, are known as cervical atresia or cervical dysgenesis. These anomalies are often associated with abnormal or absent vaginal development and urinary tract or musculoskeletal (notably spinal) abnromalities.
In utero exposure to non-steroidal oestrogens mainly Diethylstilbestrol (DES), which was used widely in the USA until early 1970, apart from causing clear cell vaginal cancer, was associated with other problems such as hypoplastic T-shaped uterus as well as various gross and microscopic colposcopic abnormalities (eg, cervical rings, collars and hoods, epithelial changes and a shift in the location of the squamocolumnar junction).
If any surgical procedure on the cervix has previously been performed, the topography of the TZ can be significantly altered. The fields of metaplasia, CIN and invasive cancer in the canal or in endocervical glands can skip the destruction and remain as iatrogenic, skip lesions. They can persist on the surface of endocervical canal surrounded by glandular epithelium which proliferates over the treated field or can be covered by new squamous epithelium. Alternatively, these islands can be buried in cervical stroma, particularly if the sutures have been applied.
Reparative and healing changes themselves can mimic residual disease. Late effects of previous treatment may give confusing colposcopis picture, particularly to the less experienced colposcopist. The finding may resemble recurrent disease. As colposcopic interpretation is based on intact, unaltered Transformation zone, the interpretation of postoperative changes must be very careful.
Cervical stenosis can additionally compromise colposcopic examination. In cases where SCJ is visible previous treatment does not seem to impair the ability of colposcopy to diagnose any cervical abnormality. However, there is a suggestion that the sensitivity of colposcopy to differentiate negative/low grade disease from high grade/invasion is lower in previously treated women.
