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 – Transformation zone of the cervix

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The transformation zone (TZ) is the area of the cervix where the columnar epithelium has been replaced by or is being replaced by the metaplastic epithelium. It is bounded by the original SCJ at the outer (distal) limit and the new SCJ (simply called the SCJ) at the inner (proximal) limit. Although the SCJ as the proximal or inner boundary of the TZ can be easily identified, the original SCJ is no longer recognizable. The distal or outer limit of the TZ is identified by the location of the nabothian cyst or the crypt opening that is located farthest away from the external os.

If there is an acetowhite patch on the ectocervix that is connected to the SCJ, the farthest extent of the patch should be considered as the distal extent of the TZ.

The extent of the TZ varies with the woman’s age. In a woman of reproductive age, the SCJ is usually fully visible and the TZ is located on the ectocervix. With advancing age, the cervix shrinks and the SCJ recedes into the endocervical canal. As a result, the TZ may be partially or completely inside the endocervical canal.

The extent of the TZ can be identified by the location of the crypt opening or the nabothian cyst that is farthest away from the external os. In the presence of an acetowhite patch arising from the SCJ, the distal limit of the patch coincides with the distal limit of the TZ, unless there are nabothian cysts or crypt openings located beyond that.

It is crucial to identify the TZ correctly, because all cervical precancers and cancers that originate from the squamous epithelium are initially located in the TZ.

Delineation of the limits of the TZ is also essential for treating a precancerous lesion on the cervix. The entire TZ must be ablated or excised, irrespective of the location of the abnormality.

Pregnancy may lead to certain physiological changes of the cervical epithelium.

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