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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Management of women with a positive HPV test result – Triage with VIA

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In settings where high-quality cytology is not available, HPV-positive women may be triaged with VIA. Women who are HPV-positive but VIA-negative (i.e. triage-negative) are advised to repeat the HPV test after 1 year for women living with HIV and after 2 years for women in the general population. Women who are both HPV-positive and VIA-positive (i.e. triage-positive) are immediately assessed for eligibility for ablative treatment in a screen, triage, and treat setting. If eligible, they are treated with thermal ablation or cryotherapy. HPV-positive and VIA-positive women who are ineligible for ablative treatment or are suspected to have invasive cancer should be appropriately referred and managed. The details of the various techniques to treat cervical precancers are described later. To learn more about the techniques of VIA, please consult the Atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment.

Women who are known to be positive for HPV16 or HPV18 may be directly assessed for eligibility for ablative treatment, whereas those who test positive for other high-risk HPV types undergo VIA for triage.

The key difference between the use of acetic acid to determine eligibility for ablative treatment and to perform VIA as a triage test for HPV-positive women is that with the former strategy all HPV-positive women are treated (either by ablation or by excision), whereas with the latter strategy HPV-positive women are treated only if the VIA test result is also positive. Women who are suspected to have cancer with either strategy are referred for appropriate management.

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