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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Neoplastic changes of the cervical epithelium – HPV structure and types

Click on the pictures to magnify and display the legends

HPV viral particles have a double-stranded DNA molecule at the centre and a coating of protein (capsid) that contains two structural proteins (L1 and L2).

HPVs are categorized into different types according to their genetic makeup. Not all types are associated with cancer. There are 12 types of HPV that can cause cervical cancer and a few other cancer types (vulvar and vaginal cancers in women, penile cancer in men, and anal and oropharyngeal cancers in both sexes); these are called high-risk or oncogenic HPV types. Each type is known by a number, and the high-risk HPV types are HPV16, HPV18, HPV31, HPV33, HPV35, HPV39, HPV45, HPV51, HPV52, HPV56, HPV58, and HPV59. Of these, HPV16 and HPV18 are the most oncogenic. HPV16 and HPV18 are associated with nearly 70% of cervical cancers.

High-risk HPV infection is a necessary but not a sufficient cause of cervical cancer, because most women who develop the infection will not develop the cancer. There are co-factors that may increase the susceptibility of an individual woman to having persistent HPV infection, which may ultimately transform into malignancy. These co-factors include being infected at an early age, having multiple childbirths at an early age, smoking, HIV infection, other genital tract infections (Trichomonas vaginalis, Chlamydia trachomatis, and herpes simplex virus 2), and immunosuppression. Circumcision and regular use of condoms prevent viral transmission, although neither is 100% protective.

Two HPV types (HPV6 and HPV11) are responsible for nearly 90% of genital warts. Because HPV6 and HPV11 are not associated with any cancers, they are known as low-risk or non-oncogenic types.

Click here to learn more about the genesis of cervical cancer via HPV infection

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