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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Treatment of cervical intraepithelial neoplasia – Principles

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Cervical precancers are treated with either of the following techniques:

Ablation of the transformation zone: The epithelium and part of the subepithelial stroma of the transformation zone are destroyed using either cold injury (the procedure is called cryotherapy) or heat injury (the procedure is called thermal ablation).
Excision of the transformation zone: The epithelium and part of the subepithelial stroma of the transformation zone are removed either using a large loop powered by an electrosurgical unit (the procedure is known as large loop excision of the transformation zone; LLETZ) or using a surgical blade (cold-knife conization; CKC). LLETZ is also known as loop electrosurgical excision procedure (LEEP).

The entire transformation zone undergoes HPV-induced clonal change and is at risk of developing CIN. Therefore, the whole transformation zone should be treated (ablated or excised), irrespective of the size or location of the lesion.

When the HPV test is used as a primary screening test in a screen-and-treat setting, all HPV-positive women are treated without further triage with VIA, cytology, or colposcopy. In a screen, triage, and treat setting, HPV-positive women are treated only when the triage test result is abnormal. In other settings (mostly higher-resource settings), women are treated after the diagnosis is confirmed to be CIN2 or CIN3 on histopathology. HPV-positive women with CIN1 may be followed up after 1 year and treated if there is persistence or progression of the lesion. These women may be treated immediately when follow-up cannot be ensured.

The choice of treatment (ablation or excision) depends on certain features of the cervix that can be visualized during examination after application of acetic acid for 1 minute.

The next section describes the selection criteria for ablative treatment and the steps to determine eligibility for ablative treatment.

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