Introduction Different approaches to screening and treatment of cervical precancer Anatomical considerations

Anatomical considerations Gross anatomy of female genital organs, External genitalia Internal genital organs Gross anatomy of the cervix Cervical epithelium Squamous epithelium Columnar epithelium Squamocolumnar junction (SCJ)

Physiological changes of the cervical epithelium

Ectropion Squamous metaplasia Transformation zone of the cervix Changes induced by pregnancy Atrophic changes Congenital transformation zone (CTZ)

Neoplastic changes of the cervical epithelium

Genesis of cervical cancer – Role of HPV HPV structure and types Genesis of precancerous lesions and cervical cancer Cervical intraepithelial neoplasia (CIN) Adenocarcinoma in situ (AIS) Cervical cancers

HPV tests – Variation between tests Instruments, consumables, and setup required

for collection of samples for HPV testing (provider-collected) for self-collection of samples for HPV testing

Procedure to collect samples for HPV testing

Sample collected by a health provider Counselling of a woman undergoing HPV testing History taking Preparation for sample collection for HPV testing Steps for inspection of the external genitalia Steps for insertion of the speculum and exposure of the cervix Steps for collection of cervical samples Steps for self-collection of samples Storage of the samples after collection, and transportation to the laboratory

Interpretation of HPV test results Management of women with a positive HPV test result

Management of women with a positive HPV test result The different strategies Triage with cytology Triage with VIA Triage with colposcopy

Treatment of cervical intraepithelial neoplasia – principles Steps to determine eligibility for ablative treatment

Criteria used to determine eligibility for ablative treatment Steps to determine eligibility for ablative treatment

Role of Lugol’s iodine in identifying the transformation zone for treatment

Role of Lugol’s iodine in identifying the transformation zone for treatment Steps for applying Lugol’s iodine to the cervix Pre-treatment assessment

Treatment by cryotherapy

Principles Cryosurgical unit Ancillary instruments and consumables Steps Side-effects and complications Post-treatment advice and follow-up Video

Treatment by thermal ablation

Principles The benchtop model The battery-operated model Complications Video

Using an HPV test as the test of cure in women treated for cervical abnormalities or cervical intraepithelial neoplasia (CIN) Infection prevention

Standard procedures for protection from infection Essential steps for infection prevention in a cervical cancer screening clinic Preparation of 0.5% chlorine solution

Case studies

VIA triage outcome (applicable in screen-and-treat setting only) – negative cases VIA triage outcome – positive cases VIA triage outcome – suspicious of cancer cases

Foreword Acknowledgement Authors Suggested citation Copyright

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Using HPV tests for cervical cancer screening and managing HPV-positive women – a practical online guide

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Anatomical considerations – Gross anatomy of female genital organs – Internal genital organs

Click on the pictures to magnify and display the legends

The components of the internal genital organs include the following:

Uterus: It is a hollow fibromuscular pear-shaped organ within which the fetus develops during pregnancy. It is located between the urinary bladder anteriorly and the rectum posteriorly. The parts of the uterus are:

Fundus: The uppermost curved part that connects to the fallopian tubes at the corners.
Body of the uterus: Starts from below the fundus and gradually narrows to form the lower part, known as the cervix.
Cervix: The lower fibrous part that extends from the body of the uterus to open into the vagina. During a speculum examination, only part of the cervix is visible to the naked eye.

Ovaries: These are small, egg-shaped glands located on either side of the uterus. They secrete hormones (estrogen and progesterone) that regulate the menstrual cycle and the fertility of a woman. The ovaries produce the ova, or egg cells, that are released during the menstrual cycles.
Fallopian tubes: These are two narrow tubular structures attached to the corners of the fundus of the uterus. They allow the passage of ova released from the ovaries to the uterus. Fertilization of ova by sperm normally occurs within these tubes.
Vagina: This is a fibromuscular tubular structure located between the urinary bladder and the urethra anteriorly and the rectum and the anal canal posteriorly. The cervix opens into the vagina at its upper end through the anterior wall. The vagina extends below to the introitus. When a woman is in the standing position, the vagina is directed upwards and posteriorly. When a woman is lying down on her back, the vagina is directed upwards and backwards.

The direction of insertion of the speculum during the collection of a sample for HPV testing should be oriented towards the direction of the vagina, pointing towards the hollow of the sacrum, as shown in the diagram.

While self-collecting a vaginal specimen for HPV testing, a woman should direct the swab in the same direction (upwards and backwards while she is in a standing or squatting position).

The next section discusses the gross anatomy of the cervix.

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