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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Procedure to collect samples for HPV testing – Steps for collection of cervical samples

Click on the pictures to magnify and display the legends

Note the characteristics of the discharge (if any) in the vagina or at the external os of the cervix.
Sometimes the cervix may not be visualized properly because of excessive discharge covering the cervix. If needed, use a sterile cotton swab soaked in normal saline to gently clean the cervix. However, cleaning the cervix is not necessary as a routine step before collecting samples for HPV testing and should be avoided if possible.
Look for the presence of obvious growths or ulcers on the cervix.
Try to identify the SCJ as the junction between the pink smooth squamous epithelium and the red granular columnar epithelium.
Note the location of the SCJ in relation to the external os. If the SCJ is completely inside the endocervical canal, the columnar epithelium cannot be visualized and the entire ectocervix is covered by pink squamous epithelium.
Insert the sample collection brush or broom into the external os until the outer or lower bristles touch the ectocervix (do not insert the brush or broom completely into the endocervical canal).
Rotate the brush or broom in a clockwise direction 5 or 6 times (check the manufacturer’s instructions, which may be different), maintaining gentle pressure on the cervix.
Remove the brush or broom from the canal while avoiding contact of the outside of the brush or specimen with any other object.
Insert the end of the brush or broom into the specimen collection tube, and swirl it to rinse it thoroughly in the liquid.
If using a brush, snap off the shaft of the brush at the score line, leaving the end of the brush inside the tube.
If using a broom, detach the broom from the end of the shaft, leaving the broom inside the tube.
Replace the cap on the tube, and tighten it securely.
Place the tube in a specimen bag or container for transportation to the laboratory.
Make sure that the laboratory requisition form accompanies the sample.

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