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Atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment

Management of women with an abnormal VIA test


Women who test negative on VIA should be advised to undergo routine screening, depending on the recommended age and screening frequency of the country or programme. Unless they are HIV-positive, all VIA-negative women are usually screened every 3Ė5 years. HIV-positive women are screened every 1Ė3 years.

The success of a cervical cancer screening programme depends on appropriate management of screen-positive women. Because VIA positivity by itself does not indicate the presence of cervical premalignant or malignant lesions, ideally a confirmatory test should be performed. The confirmatory test is colposcopy, and all women who are VIA-positive or have suspected invasive cancer should be referred to the nearest colposcopy service. The colposcope enables examination of the cervix under a good light source and with different levels of magnification. Depending on the results of the colposcopic examination, a colposcopist may decide to either take a biopsy from the abnormal area or proceed directly to treatment. Some of the VIA-positive women may have a normal colposcopy result, and they are reassured and advised to attend screening after 3Ė5 years.

To learn more about colposcopy, access the Atlas of Colposcopy: Principles and Practice.

In resource-limited settings, where colposcopy and histopathology services have limited availability or are non-existent, the World Health Organization recommends a more realistic approach of offering treatment to VIA-positive women during the same visit as screening. This is known as the screen-and-treat approach, in which treatment is offered to screen-positive women directly without verification of disease by colposcopy or histopathology. The screen-and-treat approach has the potential to improve the efficiency of a screening programme, because it increases compliance of screen-positive women with treatment and reduces referral for colposcopy.

VIA as a screening test has the advantage of being a point-of-care test, because it provides the test results immediately and enables treatment decisions to be made during the same visit as screening. VIA simultaneously enables assessment of suitability for ablative treatment on the basis of the location of the squamocolumnar junction, the size and extent of the lesion, and abnormal features (whether suggestive of invasive cancer). Thus, at the end of the VIA examination the provider should not only give a diagnosis (VIA-negative, VIA-positive, or suspicious of invasive cancer) but also suggest the most appropriate management (routine screening, immediate ablative treatment, referral for colposcopy for further evaluation, or referral for excision treatment).

Treatment of cervical premalignant lesions
Cervical premalignant lesions may be treated by either ablative or excisional techniques. Ablative techniques use either cold injury (cryotherapy) or heat injury (thermal ablation) to destroy the abnormal epithelium of the transformation zone of the cervix. The most widely used excisional technique is large loop excision of the transformation zone (LLETZ), also known as the loop electrosurgical excision procedure (LEEP), in which the entire abnormal TZ is removed using a metallic wire powered by an electrosurgical unit.

Whereas excisional techniques can be used to treat all cervical premalignant lesions, ablative techniques are suitable only for lesions that fulfil certain selection criteria, as described below. Ablative techniques are simpler and have fewer complications compared with excisional techniques. In a screen-and-treat programme, every VIA-positive woman should be assessed for the suitability of the lesion for ablative treatment.

The following are the criteria to select a VIA-positive woman for ablative treatment:

  • The SCJ is fully visible on the ectocervix or at the external os.
  • The lesion occupies less than 75% of the ectocervix.
  • The lesion does not extend to the endocervix or to the vagina.
  • There is no suspicion of invasive cancer or adenocarcinoma in situ.

The abnormal area should be fully covered by the tip of the largest cryotherapy probe, if cryotherapy is the technique used for ablative therapy. This is not a requirement if thermal ablation is used, because the thermal ablation probe can be applied to the cervix multiple times.

If histopathology facilities are available, a punch biopsy should be obtained from the abnormal lesion before performing ablative treatment. The entire specimen removed during excisional treatment should be sent for histopathology.

  • To learn more about the principles of treatment of cervical premalignant lesions, please click on the following link.
  • To learn more about cryotherapy, please click on the following link.
  • To learn more about thermal ablation, please click on the following link.
  • To learn more about LLETZ, please click on the following link.


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