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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Treatment by cryotherapy – Post-treatment advice and follow-up

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Post-treatment advice:

Explain to the woman that she will have a clear or slightly bloodstained watery vaginal discharge that may persist for up to 4 weeks, and she may have to use sanitary towels.
She should avoid tampons.
Inform her of the following warning signs that may occur within 4 weeks:

Foul-smelling, purulent vaginal discharge
Fever for more than 2 days
Moderate to severe lower abdominal pain
Excessive vaginal bleeding (other than the blood loss during normal menstruation)
Bleeding with clots

If the woman develops any of the above-mentioned symptoms, she should return to the clinic without delay or seek medical attention elsewhere.
Counsel the woman not to have sexual intercourse for 4–6 weeks because this may cause bleeding from the raw wound and/or infection. (Note: If the couple is unable to abstain from sexual intercourse, the man should use a condom.)
Advise her to return for follow-up as described later.

Note: Antibiotics are not routinely prescribed after cryotherapy. Paracetamol tablets may be given for 1 or 2 days for pain.

Follow-up after cryotherapy:

Advise the woman to return to the clinic for a check-up after 1 month to ensure that she does not have any complaints. Review the histopathology report if a biopsy was obtained just before cryotherapy. In a screen-and-treat programme, the 1-month follow-up visit is often omitted.
Recall the woman for the next check-up after 12 months.
The HPV test is the preferred test to be done at the 12-month follow-up visit. If the HPV test is not available, cytology or VIA should be performed. The cervix can be evaluated with colposcopy.
If there is a persistent lesion at follow-up and/or the HPV test result is positive, it is preferable to excise the transformation zone, although cryotherapy may be repeated if the usual criteria for ablation are fulfilled.

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