The role of colposcopy in modern gynecology.

UNLABELLED The purpose of this review is to demonstrate that colposcopy, introduced in 1925--which is, notably before the development of great technological advances in modern gynecology--continues to be a valid technique without essential innovations to the original method described at the beginning of the last century. Colposcopy was developed in Germany during the rise of Nazism with the Second World War being an important barrier for the spread and diffusion of the technique. Colposcopy, however, continued to progress in a few countries such as Spain, Italy, Brazil, France and Switzerland. When colposcopy was introduced in the United States during the 70s, its use was mostly restricted to specialists who were almost exclusively dedicated to cervical pathology and knowledgeable about cytopathology, anatomic pathology, and colposcopy and who were competent both in the diagnosis and treatment of cervical lesions. These circumstances were completely different from what happened in the majority of European countries where colposcopists were trained as gynecologists and their histocytological knowledge, which was focused on the lower genital tract, was somewhat more extensive than that acquired by specialists in gynecology. There are two clearly different trends in relation to the use of colposcopy with characteristic geographic distribution: countries with an Anglo-Saxon influence in which colposcopy is performed selectively, and countries with a German medical inheritance in which colposcopy is carried out routinely during a standard general gynecological consultation. However, this difference is not restrictive and by no means can it be stated that colposcopy is systematically being used by all European or Latin American gynecologists for reasons related to training in the colposcopic technique. In 1977, we introduced the concept of dynamic colposcopy with the aim of differentiating it from the descriptive immobility of the original classification of Hinselmann (1954) that had remained almost unchanged by his immediate followers. Briefly, the objective was to turn colposcopy into a diagnostic tool able to identify the pathological substrate corresponding to traditional colposcopic images. We established ten differential signs that allow us to classify an ATZ area as subsidiary or not to be biopsied. The classification system proposed in Rome (International Federation of Cervical Pathology and Colposcopy [IFCPC], 1990) supports our original concept because by identifying major or minor changes in the original images, a diagnosis of the severity of the lesion can be established. With regard to specificity, the figures range between 48% and 10% with 96% for sensitivity. Obviously, a wide range of colposcopic specificity must be related to the expected efficacy of the method. When after biopsy of an atypical colposcopic image, only a low-grade lesion is detected, should this be considered a false positive colposcopic result? Although histopathologic findings are accepted as the "gold standard"...it is well known that a certain degree of subjectivity can be present. Inter- and intra-observer differences (when the same pathologist is reviewing the diagnosis after a certain time lapse) may be present. It has been argued that microbiopsy under colposcopic control gives rise to a wide error range and that it cannot be considered representative of the lesion. It is likely that this situation may occur when colposcopy-guided biopsy is performed by inexperienced hands or when biopsy is limited to small and insufficient sampling. A very important colposcopic sign, such as complete visual inspection of the squamocolumnar junction is frequently missed. Any lesion with boundaries in the endocervix, cannot be simply assessed by means of microbiopsies from the ectocervix unless there is no doubt regarding the severity of the lesions. Microcolpohysteroscopy (MCH) may be of great value in these cases by showing the limits of endocervical involvement. CONCLUSIONS According to the evidence presented here, it can be concluded that "colposcopy is in good health" and that probably the popularity of this technique in the field of gynecology would increase if cytopathologists and gynecologists' tasks were limited to their own fields rather than turning them into improvised specialists for their counterpart disciplines. The coordinating role of the gynecologist as a specialist for integral women's health should continue to be defended and in this respect, colposcopy should be considered a routine technique in daily practice.