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Why cervical cancer screening is important in Pakistan?
Cervical cancer is second most common cause of cancer deaths after breast cancer.
Globally > 280,000 women die of cervical cancer and 85% are from developing
 Life time risk of cervical cancer death is 1:80
Various methods of cervical cancer screening are available including
 1: Conventional cytology (Paps smear) (sensitivity 72% specificity 94%).
 2: Liquid-based monolayer cytology (sensitivity 61% to 66%, specificity 82%).
 3: Human Papilloma virus (HPV DNA) testing (sensitivity 88% to 91% specificity 73%
to 79%).
 4: Visual inspection of the cervix, using acetic acid (VIA) or Lugol's iodine (VILI)
(sensitivity 79% specificity 62%).
VIA eliminates the need for laboratories and transport of specimens.
Require very little equipment and provide women with immediate test results.
A range of medical professionals—doctors, nurses, or professional midwives—can
effectively perform the procedure, provided they receive adequate training and
 As a screening test, VIA has a better result than cervical cytology in accurately
identifying pre-cancerous lesions. This has been demonstrated in various studies
where trained physicians and mid-level providers correctly identified 45% to 79% of
women at high risk of developing cervical cancer.
When to Perform VIA
 VIA can be performed at anytime during the menstrual cycle, including during
menses (providing flow is not too heavy), during pregnancy, at a postpartum
examination, or during a post abortion checkup. It can also be done when a woman
comes for care related to STIs, or follow-up care.
 VIA is indicated on any sexually active woman age 30 or above, until the age of 40 to
50 and those complaining of excessive vaginal discharge or postcoital bleeding.
Preparing the Woman for VIA
 Health care providers need to council the woman about explanation of the
procedure, why it is being done, what the possible findings might be, as well as what
follow-up care might be necessary.
 A brief history should also be taken including
 Menstrual history,
 Bleeding pattern (irregular or postcoital bleeding),
 Parity, age, current pregnancy status.
 Contraceptive method.
 Family history of cancer especially in mother or sister.
Equipment Needed for VIA
 Examination Table
 Light Source
 Bivalve speculum
 Instrumental tray
o Cotton swabs & sponge holding forceps.
o Examination gloves
o 4% acetic acid (or white vinegar)
o 0.5 % chlorine solution
o Report form for the result
How to prepare 5% dilute acetic acid?
1. Glacial acetic acid : 5ml
2. Distilled water : 95ml
Carefully add 5ml of glacial acetic acid in to 95ml of distilled water and mix.
Unused acetic acid should be discarded at the end of the day.
Note: It is important to remember to dilute the glacial acetic acid, since the
undiluted strength causes a severe chemical burn if applied to the epithelium.
Assemble equipment and arrange on the tray.
Ensure that the light source is working.
Assist woman onto the examination table after she has emptied her bladder.
Put on gloves.
Inspect the external genitalia for the presence of lesions, papules, vesicles,
ulcerations, condylomata, discharge, redness, swelling, excoriation.
Lubricate the speculum with clean, preferably warm, water.
Slowly and carefully insert the speculum without scraping the cervix.
Adjust the speculum, so the entire cervix is in view and adjust the light as needed.
Observe the size and shape of the cervix and the external os.
Identify the anterior and posterior lip of the cervix, red columnar epithelium, pink
squamous epithelium, the squamo-columnar junction, and the transformation zone.
Inspect the cervix for cervicitis, discharge ectopy, nabothian cysts, ulcers, warts,
polyps, leukoplakia (thickened, white patches), or tumors.
Is there any bleeding from the cervix, especially after you touch it?
Use a dry cotton swab to wipe away any discharge, blood, or mucus from the
Observe all four vaginal fornices to make sure they are free from any growth.
Record any abnormal visual findings.
Soak a clean swab in 3% to 5% acetic acid and apply to the cervix . Wait at least 1 full
minute for the acetic acid to be absorbed (use a watch). Tell the woman that she
might feel a slight burning sensation.
Check the transformation zone carefully, especially near the squamocolumnar
junction, for any dense, non-movable acetowhite areas in the epithelium.
Look around the entire transformation zone for any raised and thickened white
plaques or acetowhite lesions.
If acetowhite areas are identified, note the location, extension, intensity of
whiteness, borders and demarcations, as well as size.
Larger, thicker, more opaque lesions with clearly defined borders next to the
squamocolumnar junction suggest more severe cervical disease.
Reporting VIA test results
VIA negative or normal (-)
VIA positive (+)
VIA positive, invasive cancer
VIA positive (+)
Is scored when there are distinct, well defined, dense, opaque or dull
white , acetowhite areas, touching the squamocolumnar junction
(SCJ) or touching the external os (if SCJ not seen) .
Circumferential white lesion surrounding the os or the whole cervix
turns white after application of acetic acid.
VIA Positive (acetowhite lesion abuting sequmocolumnar junction)
VIA positive (well defined acetowhite lesion touching external os)
VIA negative or normal cervix
Acetowhite lesions far away from the transformation zone.
Streak like acetowhitening.
Dot like areas in the endocervix, which are due to grape-like columnar epithelium
staining with acetic acid.
No acetowhite lesions.
Blush white lesions or faint patchy lesions or doubtful lesions without definite
Polyp protruding from the os taking up acetowhitening.
Nabothian cysts taking up acetowhitening and appearing as whitish acne (pimples).
Faint line-like acetowhitening at the junction of columnar and squamous epithelium.
When there are shiny or cloudy white lesions with ill-defined, indefinite margins.
VIA negative (dot like acetowhitening in endocervix)
VIA negative ( faint patchy lesion with indefinite margins)
VIA positive, invasive cancer
 Is scored if there is clinically visible ulcero-proliferative growth on the
cervix that bleeds on touch.
VIA Positive, invasive cancer: Proliferative
growth with dense acetowhitening and
VIA positive, invasive cancer:
Ulceroproliferative growth with
acetowhitening and bleeding.
Management of VIA positive
 Women with acetowhite lesions are usually treated with cryotherapy or
loop electrical excision procedure (LEEP).
 Cryotherapy is a simpler and less expensive outpatient procedure that
requires a steady supply of compressed refrigerant gases (N2O or CO2).
Cryotherapy is effective in treating 90% of suitable patients and can often
be done during the screening visit. It is less effective when lesions extend
into the endocervix or are larger than the probe tip.
 LEEP is 90% to 95% effective in treating high-grade precancerous lesions.
However, in developing countries this may only be available at regional
centers. Both LEEP and cryotherapy have failure rates of 10% to 15%;
therefore, post-treatment follow-up within 1 year is recommended.
 Women with very early stage invasive cervical cancer may be offered
hysterectomy at the regional hospital
VIA Result reporting form
Total No. of patients attended OPD on that day. [ ]
No. of patients screened
[ ]
Clinic/Serial/Hospital number ________
◦ Date of testing
[ ][ ]-[ ][ ]-[ ][ ]
Name: _________________________
Address: _______________________
Age (in years)
[ ][ ]
Education (1: Nil; 2: Primary; 3: Middle;4: High school; 5: College; 6: Not known) [ ]
When did you have your last menstruation?
(1: Less than 12 months ago; 2: More than 12 months ago)
Marital status: (1: Married; 2: Widowed; 3: Separated;
Age at marriage or first sexual intercourse
Total number of pregnancies/miscarriages:
Do you suffer from the following?
(Use to indicate if the response is yes; otherwise, leave blank):
Excessive vaginal discharge
Itching in the external anogenitalia
Ulcers in the external anogenitalia
Lower abdominal pain
Pain during sexual intercourse
Bleeding after intercourse
Intermenstrual bleeding
Low back ache
 Visual examination findings
(Use  to indicate if the response is ‘Yes’, otherwise, leave blank):
Squamocolumnar junction fully seen
Cervical polyp
Nabothian follicles
 Findings one minute after application of 5% acetic acid (VIA)
(1: Negative; 2: Positive; 3: Positive, invasive cancer)
If VIA positive, does the acetowhite lesion extend into the endocervical canal?
(1: Yes; 2: No)
If VIA positive, how many quadrants are involved in the acetowhite lesion(s)?
(1: Two or less; 2: Three; 3: Four quadrants)
(Draw the location of the squamocolumnar junction with a dotted line and the acetowhite area(s) as a
continuous line)
If invasive cancer, stage (1: IA; 2: IB; 3: IIA; 4: IIB; 5: IIIA; 6: IIIB; 7: IVA; 8: IVB; 9: Not known)
Biopsy taken? (1: Yes; 2: No)
(If yes, indicate the biopsy site(s) in the diagram with ‘x’ mark)
 Action taken:
1) Advised follow-up after five years;
2) Advised medication for cervicitis and follow-up after six months;
3) Referred for colposcopy;
4) Referred for immediate treatment;
5) Referred for staging and treatment of invasive cancer;
6) Other, specify______________) [ ]