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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Role of Lugol’s iodine in identifying the transformation zone for treatment – Steps for applying Lugol’s iodine to the cervix

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Steps for applying Lugol’s iodine to the cervix:

After completing the assessment with acetic acid, take a dry cotton swab and wipe out the excess acetic acid solution present on the posterior blade of the speculum.
Gently paint the whole cervix with a small cotton swab dipped in Lugol’s iodine solution.
The colour change is visible immediately; there is no need to wait.
The acetowhite area does not take up iodine stain and appears mustard yellow, and the normal squamous epithelium is stained dark brown.
Delineate the outer margins of the iodine non-uptake areas. Reassess whether the lesion occupies less than 75% of the ectocervix and can be fully covered by the tip of the largest cryotherapy probe. In thermal ablation, the probe can be applied to the cervix multiple times and the decision is based on the size of the iodine-negative area.
The columnar epithelium is not stained with Lugol’s iodine and retains its original red colour.

Application of Lugol’s iodine should be done after thoroughly completing the assessment with acetic acid, because the iodine stain covers all other features, including acetowhiteness of the epithelium.

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