1. patients with a normal cervix
2. in patients in whom the cervix is absent

or when evaluating the possibility of premalignant and malignant disease in:

1. immunosuppressed patients with premalignant or malignant vulvar lesions
2. suspected or known intrauterine DES exposure
3. those patients previously treated for premalignant or malignant vaginal lesions.

The indications listed above are aimed at diagnosing potentially malignant lesions, however vaginal colposcopy may be useful in other situations such as the examination of patients with otherwise unexplained vaginal signs or symptoms including introital dyspareunia.


PREMALIGNANT LESIONS
Vaginal neoplasia is more common in patients who have previously been treated for cervical or vulvar neoplasia. Therefore acetowhite vaginal lesions may appear in tissue contiguous to previously involved areas, i.e., at the vaginal apex, in the fornices or about the vestibule and lower vagina . It is estimated that 2.5% of women who have CIN develop VaIN. The premalignant vaginal lesions appear to be more homogenous than their vulvar counterparts. While it is estimated that 9 of every 10 truly premalignant lesions of the vagina occur in women over 40 years of age, the incidence of such lesions may be rising in younger women and may correspond to a similar rise in vulvar intraepithelial neoplasia, possibly a reflection of the increased incidence of infection with human papilloma virus generally noted in the younger population.

Vaginal Premalignant lesions are classified as VaIN (vaginal intraepithelial neoplasia) I, II or III, corresponding to mild, moderate or severe dysplasia, respectively. There is now a trend to classify these lesions as low grade or high grade intraepithelial neoplasia based on their histology, this is a spin off from the change in cervical cytological terminology. The propensity of these lesions to progress to a higher grade is less well established than for CIN, but evokes the same concern.

As with cervical examination, acetic acid (3-5%) is used and may be applied with swabs, sponges or by spraying. Acetowhite lesions will vary in their intensity of “whiteness” as do cervical lesions. VaIN lesions are distinguished as acetowhite surface lesions and by their yellow Lugol’s staining characteristics (1/2 strength Lugol’s iodine - the Shiller test). Such lesions frequently show sharp borders and stand out in relief contrasting with the surrounding darkly staining normal epithelium. The occasional flat non staining benign mucosal lesion may reflect differences in metaplastic epithelium, keratin production or glycogen storage or it may signal dysplastic change. Various shades of yellow depend upon the degree of epithelial glycogen content. Any non staining surface erosion that bleeds easily or is easily denuded may harbor inflammatory or neoplastic tissue. High grade acetowhite lesions may appear as flat or somewhat elevated pearly gray-white epithelium. Some lesions may appear smooth and may contains coarse punctation or the occasional atypical vessel. As with cervical lesions, aceotwhite vaginal lesions may or may not be associated with abnormal vascular patterns such as punctation and mosaic. The use of the green filter helps to identify abnormal vascular patterns and gives sharp contrast to non staining areas. As with the common flat or slightly raised lesions, spiculated, granular or papillary (warty) lesions may be diagnosed as VaIN I or VaIN II, especially in cases of concomitant benign vulvar warts. Micropapillary (warty) lesions are usually present when the mucosa is well estrogenated. The degree of dysplasia is confirmed by biopsy and similar rules of management may be applied as to cervical lesions.

Special cases:
Prior radiotherapy and immunosuppression are also predisposing factors for vagina dysplasia. Diethylstilbestrol (DES) associated changes in the vaginal epithelium of women exposed in utero to DES include adenosis and extension of the transformation zone beyond the cervix into the vaginal fornices. Over time, in may instances there is “healing” or maturation of the adenosis and a return to a more normal appearing transformation zone that has a vaginal extension. Nevertheless, in some women this process is incomplete and the colposcopic appearance of the vagina remains quite abnormal and concerning. Fortunately, occult carcinoma in the absence of abnormal cytology or a palpably suspicious lesion is rare.

Vaginal condyloma may appear similar to VaIN, and may occasionally be confused with vaginal rugae or papillations, though a rugose epithelium and it’s papillations represent normal tissue and stain darkly with iodine. Condyloma are frequently multifocal and commonly coexist with similar cervical or vulvar lesions. HPV disease can be focal, multifocal or multicentric necessitating complete examination. The discovery of one lesion should therefore precipitate a careful search for others.


MALIGNANT LESIONS
Primary invasive cancer is rare and most (80-90%) of vaginal carcinoma is secondary to an occurrence elsewhere. The majority of invasive lesions present with a clinically apparent lesion. The colposcopist may observe granular red lesions, white epithelium with or without abnormal vessels, ulceration, tumor formation and intraepithelial or sub epithelial hemorrhage in invasive lesions. Most of these are cancers are squamous, although adenocarcinoma and others (melanoma) are reported. Metastatic tumors to the vagina most commonly occur among women with concurrent or previously treated cervical cancer. Ovarian and rectal cancers, as well as choriocarcinoma, may metastasize to the vagina. Because in these instances cancer is generally suspected after gross visual inspection and palpation, colposcopy is not likely to be clinically useful.


BENIGN LESIONS
Many benign conditions may masquerade as neoplastic lesions and only through colposcopy and biopsy will the precise nature be ascertained. Atrophic changes are great mimics for colposcopists and pathologists. It is often difficult for a cytologist to distinguish basal cells associated with severe atrophy from glandular cells or severely dysplastic squamous cells. Prior radiation therapy to the vaginal vault may lead to bizarre, atypical vessels and distinguishing cytological benign radiation changes from more serious lesions is usually only settled after colposcopy and biopsy. Vaginal endometriosis and granulation tissue are usually apical vaginal findings whereas chronic ulcers or vaginal adenosis (columnar metaplasia) that may follow treatment with thermal energy sources or 5-fluorouracil are found anywhere in the vaginal canal. Such changes are associated with abnormal colposcopic findings and require biopsy for definitive diagnosis.


TECHNICAL ASPECTS
Use 3 -5 % acetic acid and 1/2 strength Lugol’s solution (the Schiller test) in separate steps.

Colposcopic examination of the vagina is performed with a typical colposcope at the usual (13 - 15 X) or lower magnification ( 7 - 10 X), and is similar to cervical examination. Three to five percent acetic acid is applied and a complete vault examination is performed. Subsequently 1/2 strength Lugol’s solution (the Schiller test) is applied to the mucosa and the examination is repeated.

Atrophy and vaginitis must first be cleared as noted later. Because of the geometry involved, the examination of the vagina may be a challenge. Viewing the lateral vaginal walls with their folds and rugae, is more time consuming than cervical colposcopy. Most vaginal neoplastic lesions occur in the upper one third of the vagina, with about 10% being found in the lower one third. The mid vagina is least likely to be the site of primary neoplastic change but has been found to be a site for extension of bladder or rectal carcinoma. Vaginal lesions may be multifocal. This requires that the lateral vaginal wall and fornices be examined carefully.

Application of 50-60% aqueous Lugol’s iodine (the Shiller test) will “light up” acetowhite epithelial lesions and their margins. The Schiller test (1/2 strength Lugol’s stain) is an important aid to vaginoscopy and should not be omitted. It is important that the entire vaginal wall be stained, which necessitates rotating the speculum 180 degrees to ensure the iodine reaches all of the surface of the vaginal canal and that all of the vagina is seen. One of the technical challenges in performing the colposcopic examination of the vagina on women who have undergone hysterectomy is that the mucosa at the lateral margins of the vaginal apex, referred to as “dog ears”, may be somewhat elevated and variably invaginated. Such invaginations, created by hysterectomy (angle sutures) prevent full examination of the entire mucosal surface of the vaginal cuff. This results in occult or “buried” lesional tissue that may result in invasive disease later on. Small tissue hooks and or grasping forceps may be used to evert such areas. Such lesions may require examination under anesthesia for full evaluation. At that time local excision, lesion ablation with laser or apical vaginectomy may be performed.

Postmenopausal women often present with atrophy, which hinders the identification of abnormal epithelial areas. Lack of glycogen in the epithelium, especially when associated with inflammation, decreases the reliability of vaginal colposcopy. The transition from lesional to normal tissue that is noted with Lugol’s solution (the Shiller test) is attenuated and the very atrophic vagina may appear diffusely “dirty brown”. A useful strategy for the atrophic vagina is to prescribe several weeks (4 - 6 weeks but not a long delay such as three months) of topical vaginal estrogen, which should correct atrophy and lessen patient discomfort. Estrogen therapy “brings out” or helps one identify the source of abnormal vaginal cytology by thickening the mucosa and diminishing tissue inflammation. Further, dilute acetic acid or iodine used for staining, may produce significant burning and be generally irritating to the atrophic vagina. The prevention of severe discomfort at examination is another reason for pre colposcopy estrogen therapy. Also consider that vaginal stenosis may add to examination difficulty, discomfort and anxiety at colposcopy. Unfortunately, estrogen does little for stenosis but is used as an adjunct to vaginal dilation prior to colposcopy of the stenotic vagina.

Finally, obtaining a good biopsy specimen of flat lesions from an atrophic epithelium (or stenotic canal) may be technically difficult because of the limited space and the thin friable mucosa. In these and other uncommon situations (i.e., children), the vaginal colposcopic examination may be performed under sedation or light anesthesia.