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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Physiological changes of the cervical epithelium – Ectropion

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There are many normal variations (also known as physiological changes) of the cervix, which are essentially due to changes in the hormonal status in women. It is important to identify these conditions and distinguish physiological variations from abnormal features of the cervix.
At menarche (the onset of menstruation) and during early reproductive period, the female genital organs develop under the influence of estrogen hormone. The cervical epithelium undergoes gradual changes that can be seen on while examining the cervix.

During childhood and until menarche: The ectocervix is almost completely covered by squamous epithelium and the SCJ lies close to the external os.

At menarche and during the reproductive period: The cervix enlarges under the influence of estrogen, leading to eversion of the columnar epithelium out onto the ectocervix. As a result, the SCJ relocates and lies on the ectocervix at a variable distance from the external os. This condition, in which the columnar epithelium is present on the ectocervix, is known as ectropion or ectopy.

Ectropion is visible as a red velvety patch of variable size on the ectocervix around the external os. Because ectropion is a physiological condition, it does not require any treatment and disappears on its own with advancing age. The woman may complain of excessive mucoid vaginal discharge and/or slight bleeding (spotting) after intercourse.

The next section discusses further changes of the cervical epithelium that occur with advancing age.

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