Screening of Cervical Cancer

Agenda

1. Introduction to Cervical Cancer

2. Structure of Cervix

3. Common Conditions of Cervix

4. Visual Inspection with Acetic Acid (VIA) Examination

• VIA Principle
• VIA Equipment and Consumables
• Preparation of 5% acetic acid
• Steps for Performing VIA
• VIA Result Interpretation
• Post VIA
• Grades of CIN

5. Management of Cervical Precancer

6. VIA Interpretation
2
1 Introduction to Cervical Cancer
 Cancer Burden in India

Common Cancers in India

Incidence (ASR) Mortality (ASR)

Women
Breast 25.8 13.3
Cervix 18 11.4
Ovary 6.7 4.8
Man
Lip. Oral cavity 14.8 8.1
Lung 7.8 7.2
Stomach 6.1 5.5

In India every year 1,23,907 women are diagnosed with cervical cancer, and 77,348 women die of it

ASR (Age- Standardized Rate) per 1,00,000

4
Source: Globocan 2020
Cervical
गर्भाशय Cancer
ग्रीवा का कैंसर (सर्वाइकल कैंसर)

What is cervical cancer? Why cervical cancer screening is important?

• In more than 80% of women the infection clears
on its own within a year
• Cervical cancer develops in the cervix of women
• Only in few women that the infection persists and
• Cells on the cervix grow abnormally and may lead to the development of Cervical
sometimes if left untreated can become cancerous Intraepithelial Neoplasia (CIN) or cervical cancer
later in life
• Cervical cancer is caused by infection from high-
• Invasive cervical cancer is preceded by a long
risk types of human papillomavirus (HPV)
precancerous or intraepithelial stage of 15-20
• HPV infects 80-90% of women in reproductive life years
• Pre-cancerous stage can be easily detected by
simple screening techniques like VIA
• Treatment of pre-cancer lesion is very simple and
effective

5
Risk Factors and Signs and Symptoms of Cervical Cancer

Risk Factors Signs and Symptoms

• Marriage at young age or becoming sexually active at

young age • Abnormal vaginal bleeding

• Multiple sexual partners • Post-menopausal bleeding

• Lack of hygiene in sexual organs • Post-coital bleeding

• Giving birth at young age (<17 years) or giving birth • Foul smelling/excessive vaginal discharge
frequently
• Unusual vaginal discharge tinged with blood
• Malnutrition, smoking or tobacco consumption
• Dyspareunia – painful intercourse
• Immunity supressing diseases like HIV- AIDS

In most women early stages of cervical pre-cancer can be symptomless, therefore it is important to screen
all the women (symptomatic as well as asymptomatic) in the age group of 30-65 years

During COVID-19, screening of symptomatic women should be prioritized 6

2 Structure of Cervix
Structure of Cervix

• Cervix is the lower one third of the uterus, it measures 3–4 cm in

length, and 2.5-3.5 cm in diameter

• It varies in size and shape depending on the age, parity and

hormonal status of the woman

Uterus
• Cervix is divided into two parts- Ectocervix and Endocervix

Internal OS • Cervix opens into the vagina through the external os

Endocervix • Portion of the cervix that is exterior to the external os is called the
External OS
ectocervix

• Cervix opens into the uterus through the internal os

Ectocervix • Endocervical canal which traverses the endocervix, connects the

uterine cavity with the vagina and extends from the internal to the
external os
8
Ectocervix

• Portion of the cervix that is exterior to the external os is called the ectocervix, ectocervix is covered by the stratified,
nonkeratinizing, glycogen-containing squamous epithelium, and appears pale pink in colour on visual examination

• Squamous epithelium is divided into 4 parts namely- basal, parabasal, intermediate and superficial layers from below
upwards

• It is ectocervix that is readily visible on speculum examination

Superficial

Intermediate

Parabasal

Basal

9
Ectocervix
Endocervix

• Portion of cervix above the external os is called the endocervix, it is lined by the columnar epithelium composing of a
single layer of tall cells. Columnar cells secrete the mucus that lubricates the cervix and vagina

• On visual examination, columnar epithelium appears red in colour with a granular velvet like surface

Crypt Opening

Basement
Membrane Columnar Cells

crypt

Endocervix 10
Squamo-Columnar Junction (SCJ)

• Columnar epithelium at its lower limit meets the squamous epithelium, the junction between the two epithelia is
known as the squamocolumnar junction (SCJ)

• SCJ is usually visible as a sharp border located near the external os

• Position of the SCJ in relation to the external os changes with age, pregnancy, hormonal status (oral contraceptive
pills) and menopause status

11
Squamo-Columnar Junction (SCJ)
 Squamo-Columnar Junction (SCJ)

• During childhood and peri menarche, it is located at, or

very close to the external os

• After puberty and during the reproductive period, the

uterus grows under the influence of oestrogen. As a
result, the squamocolumnar junction is located in the
ectocervix, far away from the external os

• During peri- and post-menopausal period, the cervix

shrinks due to the waning effect of oestrogen. As a result
the SCJ moves inside the endocervical canal

Changes in position of SCJ with Age

12
Ectopy

• From puberty and throughout reproductive life, the uterus

grows under the influence of oestrogen

• This leads to the eversion of the columnar epithelium onto

the ectocervix, particularly on the anterior and posterior
lips, resulting in ectropion or ectopy

• On visual inspection, ectropion is seen as a strikingly

reddish ectocervix

Ectopy

13
Squamous Metaplasia

• During Ectopy, columnar epithelium on the ectocervix

becomes exposed to the acidic environment of the vagina

• This causes destruction of the columnar epithelium and its

gradual replacement by the newly formed squamous
epithelium

• This process through which the columnar epithelium on the

ectocervix is gradually replaced with squamous epithelium is
called squamous metaplasia

• Converted epithelium formed during this process is called

metaplastic squamous epithelium Squamous Metaplasia

14
Transformation Zone (TZ)

• SCJ formed between the metaplastic squamous epithelium and the columnar epithelium is known as the new SCJ

• Area between the original SCJ and the newly formed SCJ as a result of metaplasia is the transformation zone (TZ)

• Transformation zone (TZ) expand and shrink based on age, parity, infection and hormone

• More than 90% of pre-cancer lesions also known as cervical intraepithelial lesion(CIN) originate in the transformation
zone

15
Transformation Zone (TZ)

Original SCJ

Nabothian Cyst

New SCJ

Ectropion

Crypt Opening

Crypt opening

Transformation Zone

16
Types of Transformation Zone (TZ)

Depending on the location and the visibility of the SCJ, the transformation zone (TZ) is categorized into Type 1, Type 2, or Type 3

Type 1 TZ - SCJ is fully visible Type 2 TZ - SCJ is fully visible (with or Type 3 TZ - SCJ is within the endocervical
and is located fully on the without an endocervical speculum) and is canal and is only partially visible or not at
ectocervix located either fully or partially within the all visible, even using an endocervical
endocervical canal speculum

17
3 Common Conditions of Cervix
Physiological Changes in Cervical Epithelium

• During the peri-menopausal period and after menopause, the cervix shrinks
due the lack of oestrogen and consequently, the SCJ moves inside the
endocervical canal from the external os

• In post-menopausal women, the SCJ is often invisible on visual examination

Postmenopausal cervix

• Nabothian cysts appear as bulging blue-white or yellow-white nodules, having

a smooth delicate lining with branching blood vessels

• In some women, nabothian cysts can become large and distort the shape of
the cervix

• Position of the crypt opening or the nabothian cyst farthest from the SCJ helps
to identify the outer limit of the TZ
Nabothian Cyst 19
Physiological Changes in Cervical Epithelium

• Cervical condyloma appear as raised, grey-white areas within or outside the

transformation zone in the squamous epithelium and may be accompanied by similar
lesions in the vagina and vulva

• It usually appears as a distinctly lumpy, irregular lesion on the surface of the affected
area, the colour may be bright white and the surface irregular, pitted or spiky

• Warts by themselves do not progress to malignancy. Extensive warts, however, may

Cervical Condyloma hide high-grade lesions in the deeper tissue

• Cervical polyp is a localized overgrowth of the endocervical columnar epithelium and

may be visible as a single or multiple reddish soft tumour(s) protruding from the
external os

• A patient with polyps may present with abnormal menstrual bleeding or postcoital
bleeding

• Polyps do not have any potential to become malignant

Cervical Polyp 20
Physiological Changes in Cervical Epithelium

• Leukoplakia is a well demarcated white patch on the cervix often raised from the
surface

• Leukoplakia is visible to the naked eye even before the application of acetic acid

• A leukoplakia on the TZ close to SCJ is often due to cervical neoplasia and should
be referred for colposcopy

• Leukoplakia without underlying neoplasia requires no treatment

Leukoplakia

21
4Visual Inspection with Acetic Acid (VIA) Examination
Cervical Cancer - Screening Protocol

As per the operational guidelines of GOI NPCDCS Program

Target Population Frequency Procedure Facility Level

All women in the age Once in VIA Examination PHC and above
group of 30-65 years every 5
years

• All women in the age group of 30-65 years, should be screened for cervical cancer
using VIA, once in every 5 years, at PHC and above level facility

23
When not to perform VIA screening

• As per the guidelines of Government of India, all the women in the age group of 30-65 years
should be screened but a woman must not be screened under following conditions-

• Anytime during menstrual cycle

• During pregnancy

• Within 12 weeks of postpartum or abortion

• In such cases woman should be asked to come after menstrual cycle or after 12 weeks of
postpartum and abortion for VIA screening

24
VIA Principle

Visual naked eye examination of the cervix for early detection of cervical pre-cancer lesion after application of 5% acetic acid is
called VIA

• VIA is the naked eye inspection of the cervix after application of 3–5%
acetic acid using a good light source

• Results of VIA are immediately available and do not require any laboratory
support

• Dilute acetic acid (3–5%) when applied on the cervix causes dehydration of
cells and coagulation of the proteins on the surface epithelium

• Coagulated protein becomes prominent as a dense white patch

• Pre-cancers of cervix contain more protein which gets coagulated by acetic

acid and gives a white appearance

• The higher the grade of cervical pre-cancer, the denser is the intensity of White Lesion
the white patch
25
VIA : Equipment and Consumables

Equipment for VIA

• Examination Table
• White light source
• Cusco’s Speculum
• Forceps
• Syringe to measure glacial acetic acid
• Measuring cylinder to measure distilled
water

Consumables for VIA

• Glacial acetic acid

• Distilled water
• Cotton balls
• Normal saline
VIA Tray
• Examination gloves 26
VIA: Equipment and Consumables

• VIA consent form register and VIA screening register should also be available in the health care
facility

• Written consent should be obtained prior to VIA screening and entry should be made in VIA register
post screening

Consent Form VIA Screening Register

27
Preparation of 5% acetic acid - 100 ml

1 Wear gloves 2 Add 95 ml of 3 Measure 5 ml of 4 Pour acetic acid into

distilled water in glacial acetic measuring cylinder
measuring acid
cylinder

Note: Acetic acid should be

freshly prepared, unused
acetic acid should be
discarded after 24 hours

5 Pour diluted 5% acetic acid 6 Label the bottle with the date of preparation 28
into a glass bottle
Preparation of 5% Acetic Acid

• If the number of women to be screened in a health care facility is low, smaller volume of 5% acetic acid could be prepared

• Refer the table given below for volumes of distilled water and glacial acetic acid required for different volumes of 5% acetic acid

Volume of 5% acetic Volume of distilled

Volume of glacial acetic
acid water
acid (ml)
(ml) (ml)

20 1 19

40 2 38

60 3 57

80 4 76

100 5 95

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Preparation for VIA

• Keep VIA tray ready before the procedure

• Explain the screening procedure in detail to the woman and obtain written informed consent before screening

• The woman should be reassured that the procedure is painless, and every effort should be made to ensure that she is fully
relaxed and remains at ease during screening

• Check that the woman has emptied her bladder

• Wash hands thoroughly with soap and water and dry with clean, dry cloth or air-dry them, wear sterile disposable gloves on
both hands before screening

• Ask woman to lie down on examination table and help her to undress and drape her

• Inspect external genitalia and check urethral opening for discharge, in case of discharge clean the area with normal saline

• Select speculum of appropriate size and lubricate the blades with lubricant jelly or saline

• Gently insert speculum and adjust it so that the entire cervix can be seen

• Adjust the light source so that there is adequate light on the cervix
30
After fitting the speculum observe the following parts of cervix carefully

Observe the size and shape of the cervix and identify the
Observe following conditions of cervix
following parts

 External OS  Ectropion

 Columnar Epithelium (red in colour)  Cervical Polyp

 Squamous Epithelium (pink in colour)  Nabothian Cyst

 Leukoplakia
 Original SCJ and New SCJ
 Condyloma
 Transformation Zone/TZ, upper limit of which is
formed by SCJ  Cervicitis

• Observe whether there is any bleeding from the cervix, especially on touch, or ulcer proliferative growth

• Very early invasive cancer may present as a rough, reddish, granular area that may bleed on touch
31
VIA Procedure

• Now, gently, but firmly, apply 5% acetic acid using a cotton swab soaked in 5% acetic acid for 1 minute

• Carefully look at the cervix to see whether any white lesions appear, particularly in the transformation zone close to
the squamocolumnar junction, or dense, non-removable acetowhite areas in the columnar epithelium

• The results of VIA test should be reported after one minute (Reporting before one minute may miss lesions that
appear late). Note how rapidly the acetowhite lesion appears and then disappears

• If patient does not allow insertion and feels pain, reassure her, select a smaller sized speculum, use more lubricant
and be gentle

• Cervix is not visualized or partially visualized, Close the speculum partially, loosen the screw and manoeuvre to
expose the cervix. Choose a bigger sized speculum if required

32
If acetowhite patch appears on cervix after application of 5% acetic acid, carefully observe characteristics of
acetowhitening

Characteristics of
VIA Positive VIA Negative
acetowhite lesion
Appear late and quickly disappears
Appears rapidly and may last for 1-2 minutes
Speed of appearance (within a minute)

Shiny and cloudy white, more dense, thick and Pale or dull white, less dense, thin,
Colour intensity opaque often translucent

Well demarcated, regular, raised from

Patchy with ill-defined, diffuse
Borders and demarcation surrounding epithelium
margins

Restricted to transformation zone mostly, lesions Distributed widely in the cervix, not
Location close to or abutting the squamocolumnar restricted to the TZ
junction

Colour uniformity Uniformly white Colour intensity varies across the lesion

33
VIA Results

VIA Category Description of the findings

VIA Negative 1. No acetowhite area
2. Columnar epithelium appearing temporarily white
3. Polyps with faint acetowhite colour
4. Nabothian cysts appearing white
5. Line-like acetowhitening at the SCJ
6. Patchy acetowhite areas without any definite margin
7. Thin acetowhite areas with tongue-shaped projections towards the external os
8. Acetowhite areas away from the SCJ

VIA Positive 1. Distinct, opaque acetowhite area that appears quickly and stay for
long, with well defined margin, close to SCJ, in the TZ

Suspicious of 1. Irregular surface that bleeds on touch

invasive cancer
2. Thick, dense large acetowhite areas with raised margin that may bleed on
touch
3. Presence of cauliflower growth and ulcers on cervix 34
Post VIA Task

• When visual inspection has been completed, use a fresh swab to remove any remaining acetic acid from the cervix
and vagina and dispose-off the swab

• Remove the speculum gently and immerse it in 0.5% chlorine solution for 10 minutes for decontamination

• Remove the sheet of examination table, clean the table with 0.5% chlorine solution and cover the table with clean
sheet before screening another woman

• Record the VIA test results and other findings in the VIA screening register

• Explain VIA result to the woman and answer her questions if any

35
 VIA Negative Lesion

1 2 3

No acetowhite area. Note the Temporary blanching of Indistinct transparent

advancing edges of squamous columnar epithelium after acetowhitening on an ectropion
metaplasia in the anterior and application of 5% acetic acid. after application of acetic acid.
posterior lips arrows Columnar epithelium (blue arrow) Indistinct transparent acetowhite
patches (blue arrows)
4

Polyp appearing faintly

acetowhite after application of
5% acetic acid. Polyp (blue arrow)

36
 VIA Negative Lesion

5 6 7

Nabothian cysts look like pearly Thin acetowhite patches without Metaplastic epithelium projecting
white buttons after application of definite margins, suggestive of towards the external os. Tongue-
5% acetic acid. Nabothian cysts (blue squamous metaplasia. Acetowhite shaped projections of thin acetowhite
arrows) patch (red arrow) epithelium (red arrow), SCJ (blue line)

Satellite Lesions- Multiple thin

acetowhite areas on the posterior
lip located away from the SCJ.
Acetowhite areas away from the
SCJ (red arrows), SCJ (blue line)

37
VIA Positive Lesion

1 2 3

Well-defined, opaque acetowhite area, Well-defined, opaque acetowhite area, Thin acetowhite area with well defined
with regular margins, in the anterior lip, with regular margins, in the margin in the transformation zone,
abutting the squamocolumnar junction, transformation zone, arising from SCJ touching SCJ
which is fully visible. Note the satellite
lesions in the lower lip

38
VIA Screening Checklist

Were acetowhite patches visible on the cervix after application of 5% acetic acid? if yes, observe characteristics

Characteristics of Observation
Observations of Acetowhite lesion Remarks
acetowhite patches (Y/N)

Speed of appearance Appeared immediately and stayed for more than a minute

Checklist could
Colour Intensity Opaque/Dull/Cloudy White, not transparent, or pinkish white be used by
service
providers for
Colour uniformity Distinct white patch on cervix, not blending with rest of the cervix
initial cases(10-
15) to get
Borders and acquainted with
Distinctly clear and sharp/ raised margin
demarcations
the framework
Close to or arising from SCJ/ close to external os if SCJ is not visible/
Location
in the TZ

VIA Result 1. VIA Positive 2. VIA Negative 3. Suspicious for Invasive Cancer*

39
CIN Grades

• CIN I: The dysplasia involves less than one third

the thickness of epithelium
Cancer Progression
• CIN II: The dysplasia involves less than one third to
two third the thickness of epithelium

• CIN III: The dysplasia involves nearly whole

thickness of epithelium

• From HPV infection to cervical cancer: CIN 3 is the

immediate precursor of invasive cervical cancer

• CIN lesions do not always progress to cancer and a

good number of them may spontaneously regress.
It has been estimated that the possibility of
regression of CIN 1, CIN 2 and CIN 3 lesions are
57%, 43% and 32% respectively.

40
Invasive Cancer

VIA Positive, Invasive Cancer

• There is a clinically visible ulcero-proliferative growth on the cervix that turns densely white after application of acetic
acid and bleeds on touch

41
5 Management of Cervical Precancer
Management of
Cervical Cancer
6 VIA Interpretation

44
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of Acetowhite
VIA Interpretation
Lesions

Speed of Appearance Appeared immediately and stayed for

more than a minute

Colour Intensity Opaque, thin acetowhite area

Margins and Demarcations

Distinct, sharp margins

Fig: 1.1
Fig: 1.2 Colour Uniformity Distinct white patch on cervix, not
blending with rest of the cervix
Yellow arrow: Columnar epithelium Blue line: New SCJ
Location Arising from SCJ, In transformation
Green arrow: Squamous epithelium Green line: Original SCJ
zone
Green arrows: Acetowhite area
The cervix is exposed adequately. No
abnormal discharge is seen The SCJ becomes prominent. A thin acetowhite
area with sharp but irregular margins is visible VIA Result
VIA Positive
at the 12–2 o’clock position

There is a definite acetowhite area

Remarks
Type of Transformation Zone : Type 1 with well-defined margins
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance Appeared immediately and stayed for

more than a minute

Colour Intensity
Opaque, thin acetowhite area

Margins and Demarcations

Distinct, sharp margins

Fig: 2.1
Colour Uniformity Distinct white patch on cervix, not
Fig: 2.2
blending with rest of the cervix
Blue line: New SCJ
Yellow arrow: Columnar epithelium
Blue arrows: Acetowhite areas Location
Arising from SCJ, In transformation zone
Red columnar epithelium is visible
Green arrow: Mucus
around the external os.
Green line: Original SCJ
VIA Result
Thin acetowhite areas with irregular margins VIA Positive
are seen on the anterior lip (at the 10–1 o’clock
position) and the posterior lip (at the 4 o’clock
position
The thick white mucus plug at the external os
Remarks should not be mistaken for an acetowhite area
Type of Transformation Zone : Type 1
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance
Appeared slowly and disappeared quickly

Colour Intensity
Thin acetowhite area

Margins and
Demarcations Sharp and irregular

Fig: 27.1
Fig: 27.2 Colour Uniformity Distinct white patch on cervix, not
blending with rest of the cervix

Blue line: New SCJ

The cervix appears normal
Green arrows: Acetowhite area Location Away from transformation zone
Green line: Original SCJ (satellite lesions), far away from SCJ
Yellow arrow: Nabothian Cyst

The outer limit of the TZ can be well delineated VIA Result

by the location of the Nabothian cyst. The thin VIA Negative
acetowhite area at the 12 o’clock position is
located outside the TZ and is not significant
Acetowhite areas located outside the
Remarks
transformation zone are not significant
Type of Transformation Zone : Type 1
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics
Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance Appeared immediately and stayed for more

than a minute

Colour Intensity
Opaque, thin acetowhite area

Margins and
Demarcations Distinct, sharp margins

Fig: 3.1
Fig: 3.2 Colour Uniformity Distinct white patch on cervix, not blending
with rest of the cervix
Blue line: New SCJ
Green arrow: Polyp
Blue arrows: Acetowhite area
Yellow arrows: Scattered white dots Location
Yellow arrows: Strawberry appearance Arising from SCJ, In transformation zone
Green line: Original SCJ
A few red patches are visible on the
A thin acetowhite area with irregular margins
posterior lip, giving rise to strawberry
and attached to the SCJ is seen on the anterior VIA Result
appearance of the cervix. VIA Positive
lip (at the 10–12 o’clock position). The multiple
scattered white dots on the posterior lip are
due to cervicitis The thin dot like acetowhite areas near external os
are due to squamous metaplasia. Cervix is VIA
Remarks positive due to well defined acetowhite area between
Type of Transformation Zone : Type 1 10-12 o’clock position
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance Appeared slowly and disappeared

quickly

Colour Intensity
Transparent/ Pinkish white

Margins and Demarcations

Ill-defined, discontinuous margins

Fig: 25.1
Fig: 25.2 Colour Uniformity Discontinuous acetowhite areas-
suggestive of squamous metaplasia
Blue line: New SCJ
Yellow arrow: Columnar epithelium Yellow arrow: Tongue-shaped transparent
epithelium Location
Green arrow: Squamous epithelium Green line: Original SCJ Arising from SCJ, In transformation zone

Pink arrow: Nabothian cyst The columnar epithelium appears white

temporarily. Transparent acetowhite
VIA Result
The cervix appears normal epithelium with tongue-shaped projections VIA Negative
towards the external os is seen at the 12
o’clock position
Tongue-shaped transparent epithelium
Remarks projecting towards the external os
Type of Transformation Zone : Type 1 indicates metaplasia
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of Acetowhite
VIA Interpretation
Lesions

Speed of Appearance Appeared immediately and stayed for

more than a minute

Colour Intensity
Opaque, dense white

Margins and Demarcations

Distinct, sharp margins

Fig: 4.1
Fig: 4.2 Colour Uniformity Distinct white patch on cervix, not
blending with rest of the cervix

Blue line: SCJ Blue line: New SCJ

Location Arising from SCJ, In transformation
The “fish mouth” appearance of the Green arrow: Acetowhite area zone
external os in a parous cervix. Green line: Original SCJ

A thin acetowhite area with irregular margins

VIA Result
and arising from the SCJ is seen at the 12 VIA Positive
o’clock position.

Well defined acetowhite areas with

Remarks sharp margins in the transformation
Type of Transformation Zone : Type 1 zone
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of Acetowhite
VIA Interpretation
Lesions

Speed of Appearance Appeared immediately and stayed for

more than a minute

Colour Intensity
Opaque, cloudy white

Margins and Demarcations

Distinct, sharp margins

Fig: 5.1
Fig: 5.2 Colour Uniformity Distinct white patch on cervix, not
blending with rest of the cervix
The cervix is covered with mucoid Blue line: New SCJ
discharge.
Green arrow: Acetowhite area Location Arising from SCJ, In transformation
Green line: Original SCJ zone

Large ectropion pushing the SCJ far out on the

ectocervix. A thin acetowhite area with a well- VIA Result
VIA Positive
defined margin and attached to the SCJ is seen
on the anterior lip at the 11 o’clock position.
On VIA, it is often difficult to distinguish
between metaplasia and low-grade precancers,
Remarks and it is prudent to categorize the lesion as
Type of Transformation Zone : Type 1 VIA-positive
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics
Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance
Appeared slowly and disappeared quickly

Colour Intensity
Transparent/ Pinkish white

Margins and
Demarcations Ill-defined, discontinuous margins

Fig: 23.1
Fig: 23.2 Colour Uniformity Discontinuous acetowhite areas-
suggestive of squamous metaplasia
Blue line: New SCJ
Yellow arrow: Columnar epithelium
Blue arrows: Acetowhite areas
Location
Green arrow: Squamous epithelium In transformation zone
Green line: Original SCJ
A red patch of columnar epithelium is
The SCJ is fully visible. Indistinct thin
seen around the external os VIA Result
acetowhite patches are present at the 12–2 VIA Negative
o’clock position

Transparent acetowhite areas with

indistinct margins indicate metaplastic
Remarks
Type of Transformation Zone : Type 1 epithelium. Such metaplastic epithelium is
part of the transformation zone
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance Appeared slowly and disappeared

quickly

Colour Intensity Streak like acetowhitening in columnar

epithelium

Margins and Demarcations Ill-defined, blending with rest of the

cervix

Fig: 24.1
Fig: 24.2 Colour Uniformity Discontinuous acetowhite areas-
suggestive of squamous metaplasia

Yellow arrow: Lateral vaginal wall Blue line: New SCJ

Blue arrows: Acetowhite areas Location
A lax lateral vaginal wall is seen Arising from SCJ, In transformation zone
bulging between the speculum blades. Green line: Original SCJ
The cervix appears normal
The SCJ is fully visible. Streaks of thin
VIA Result
acetowhite epithelium are seen at the 10 VIA Negative
o’clock and 2 o’clock positions.

Streak-like acetowhitening without

Remarks definite margins is not significant, and
Type of Transformation Zone : Type 1 the cervix is categorized as VIA-negative
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics
Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance Appeared immediately and stayed for more

than a minute

Colour Intensity
Opaque, thin acetowhite area

Margins and
Demarcations Distinctly clear and sharp

Fig: 6.1 Colour Uniformity Distinct white patch on cervix, not blending
Fig: 6.2 with rest of the cervix
Blue line: New SCJ
The cervix is covered with mucoid Green arrows: Acetowhite area
discharge. Green line: Original SCJ Location
Arising from SCJ, In transformation zone
Yellow arrows: Islands of columnar epithelium

Multiple thin milky white areas with

geographical margins and detached from the VIA Result
VIA Positive
SCJ are visible on both the anterior and
posterior lips. A thin acetowhite area with
Milky white areas with geographical margins,
distinct and regular margin is at 4 o’clock detached from the SCJ and mostly outside the TZ, are
position typical of HPV infections caused by low-risk HPV
Remarks types. This case is VIA-positive because of the
Type of Transformation Zone : Type 1 acetowhite lesion that is attached to SCJ and has a
well-defined margin
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of Acetowhite
VIA Interpretation
Lesions

Speed of Appearance Appeared slowly and disappeared

quickly

Colour Intensity
Transparent / Pinkish white

Margins and Demarcations Ill-defined, blending with rest of the

cervix

Fig: 26.1
Fig: 26.2 Colour Uniformity Discontinuous acetowhite areas-
suggestive of squamous metaplasia

Squamocolumnar junction is fully Squamocolumnar junction is visible around the Location

visible on the ectocervix external os. Thin acetowhite areas on the Outside transformation zone
anterior and posterior lips with irregular
margins.
VIA Result
VIA Negative

Temporary blanching of the columnar

Remarks epithelium after application of acetic
Type of Transformation Zone : Type 1 acid is normal
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics
Characteristics of
VIA Interpretation
Acetowhite Lesions
Speed of
Appeared immediately and stayed for more than
Appearance
a minute

Colour Intensity
Opaque, cloudy white

Margins and
Demarcations
Distinct, sharp margins

Fig: 7.1 Distinct white patch on cervix, not blending with

Fig: 7.2 Colour Uniformity
rest of the cervix
Blue line: New SCJ
Green line: Original SCJ Location
Blue arrow: Columnar epithelium Arising from SCJ, In transformation zone
Green arrow: Acetowhite area with distinct
margin
Yellow arrow: Nabothian cyst
Green line: Original SCJ VIA Result
VIA Positive
Yellow arrow: Nabothian cyst
Hypertrophied cervix. A nabothian
The white area at the 6 o’clock position is
cyst is present at the 10 o’clock Thin acetowhite area is on the TZ though the
opaque and has a smooth well-defined continuity with SCJ is not very distinct. The case
position
outer margin. It is difficult to assess should be considered as VIA-positive due to the
continuity with SCJ Remarks
features of the acetowhite area. Application of
Lugol’s iodine would have helped to delineate
Type of Transformation Zone : Type 1 the complete lesion better
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance Appeared immediately and stayed for

more than a minute

Colour Intensity
Opaque, cloudy white

Margins and
Demarcations
Distinct, sharp margins

Fig: 8.1
Fig: 8.2 Distinct white patch on cervix, not
Colour Uniformity
blending with rest of the cervix
Blue line: New SCJ
Yellow arrow: Columnar epithelium
Green arrow: Acetowhite area
Location
Green arrow: Squamous epithelium Green line: Original SCJ Arising from SCJ, In transformation zone

The ectocervix is covered by pink Yellow arrow: Mucus

squamous epithelium. Red columnar VIA Result
VIA Positive
epithelium is seen around the Thin acetowhite areas with irregular
external os margins are visible at the 12 o’clock
Thin acetowhite areas with irregular
position, abutting the SCJ and within the TZ
margins are usually due to metaplasia or
Remarks
CIN1. If the margin is well defined, it is
Type of Transformation Zone : Type 1 prudent to categorize the lesion as VIA-
positive
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance
Appeared slowly and disappeared quickly

Colour Intensity
Transparent, pinkish white

Margins and
Demarcations Diffused margins blending with columnar
epithelium

Fig: 21.1
Fig: 21.2 Discontinuous acetowhite areas-
Colour Uniformity
suggestive of squamous metaplasia
Blue line: New SCJ
Green arrow: Squamous Red arrow: Columnar epithelium
epithelium Yellow arrow: Polyp Location
Columnar epithelium- outside TZ
Green line: Original SCJ
Yellow arrow: Polyp
Faint acetowhite patches are present at VIA Result
VIA Negative
A small mucous polyp is seen the 10–11 o’clock position, with indistinct
protruding through the external os margins
Remarks The mucous polyp appears faint white
because of metaplasia
Type of Transformation Zone : Type 1
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance Appeared immediately and stayed for

more than a minute

Colour Intensity
Opaque, thin acetowhite area

Margins and Demarcations

Distinct, sharp, irregular margins

Fig: 9.1 Fig: 9.2 Colour Uniformity Distinct white patch on cervix, not
blending with rest of the cervix

Blue line: New SCJ

Blue arrows: Transparent acetowhite Location
Arising from SCJ, In transformation zone
areas
Green line: Original SCJ
Copious curdy white discharge is Yellow arrow: Nabothian cyst
present VIA Result
Transparent acetowhite areas with ill-defined VIA Positive
margins are present in the TZ (on the anterior
lip at the 1 o’clock position and on the
posterior lip at the 6 o’clock position)
Well-defined acetowhite area at 1o’clock
Remarks position
Type of Transformation Zone : Type 1
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance Appeared immediately and stayed for

more than a minute

Colour Intensity
Opaque, thin acetowhite area

Margins and Demarcations

Distinct, sharp, irregular margins

Fig: 10.1
Colour Uniformity Distinct white patch on cervix, not
Fig: 10.2
blending with rest of the cervix
Blue line: New SCJ
Green line: Original SCJ Location
Yellow arrow: Nabothian cyst Green arrows: Acetowhite area Arising from SCJ, In transformation zone
Yellow arrow: Nabothian cyst
The location of the nabothian cyst helps
The blister-like swelling at the 2 to identify the outer limit of the TZ. A VIA Result
VIA Positive
o’clock position is a nabothian tongue-shaped thin acetowhite area
cyst. with irregular margins is seen on the
The presence of tongue-shaped thin acetowhite
anterior lip at the 12 o’clock position areas and nabothian cysts in the TZ is most
Remarks likely to indicate squamous metaplasia.
However, it is better to give a VIA-positive
Type of Transformation Zone : Type 1 diagnosis because the margins are distinct
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance
No acetowhite area

Colour Intensity
-

Margins and Demarcations

-

Fig: 18.1
Colour Uniformity
Fig: 18.2 -

Yellow arrows: Petechial haemorrhagic

spots Location
-
Green arrow: Squamous
epithelium Green line: Original SCJ
VIA Result
The ectocervix is covered by pale The SCJ is not visible. A few petechial VIA Negative
atrophic squamous epithelium haemorrhagic spots are present, mostly
on the posterior lip. No acetowhite area
Small haemorrhagic spots (petechial spots) are
Remarks commonly seen on atrophic cervical epithelium
Type of Transformation Zone : Type 2
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance
No acetowhite area

Colour Intensity
-

Margins and Demarcations

-

Fig: 19.1
Colour Uniformity
Fig: 19.2 -

Green arrow: Squamous epithelium Location

Green line: Original SCJ -
Red arrow: Columnar epithelium
Yellow arrow: Mucus plug
Red granular columnar epithelium VIA Result
VIA Negative
is visible on the ectocervix No acetowhite area on the cervix. A
mucus plug is seen at the external os
The small bleeding points seen on the columnar
epithelium are due to injury caused by a cotton
Remarks swab during application of acetic acid. The
columnar epithelium is fragile and is easily
Type of Transformation Zone : Type 1 prone to trauma
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of
VIA Interpretation
Acetowhite Lesions

Speed of Appearance
Appeared slowly and disappeared quickly

Colour Intensity
Transparent, pinkish white

Margins and
Demarcations Diffused margins blending with columnar
epithelium

Fig: 20.1
Fig: 20.2 Discontinuous acetowhite areas-
Colour Uniformity
suggestive of squamous metaplasia
Blue line: New SCJ
Red arrow: Columnar epithelium
Green arrow: Squamous epithelium Location
Green line: Original SCJ Columnar epithelium- outside TZ
Red arrow: Columnar epithelium

Red velvety columnar epithelium The columnar epithelium appears white

temporarily. The SCJ sharply demarcates VIA Result
is visible on the ectocervix VIA Negative
between the granular columnar epithelium and
the smooth squamous epithelium. No
Temporary blanching of the columnar
acetowhite area
Remarks epithelium after application of acetic acid
is normal. The epithelium soon regains its
Type of Transformation Zone : Type 1 normal red colour
 Cervix BEFORE application Cervix AFTER application of Were acetowhite patches visible on the cervix after
of 5% acetic acid 5% acetic acid application of 5% acetic acid? if yes, observe characteristics

Characteristics of Acetowhite
VIA Interpretation
Lesions

Speed of Appearance Appeared slowly and disappeared

quickly

Colour Intensity
Transparent/ Pinkish white

Margins and Demarcations

Ill-defined, discontinuous margins

Fig: 22.1
Fig: 22.2
Colour Uniformity Discontinuous acetowhite areas-
suggestive of squamous metaplasia
Red arrow: Columnar epithelium Blue line: New SCJ
Blue arrows: Streak-like acetowhite areas
Location Arising from SCJ, In transformation
Green arrow: Squamous epithelium
zone
Green line: Original SCJ
The ectocervix is covered by smooth
pink squamous epithelium. A red patch A thin transparent layer of metaplastic
of columnar epithelium is seen around epithelium is seen projecting towards the VIA Result
VIA Negative
the external os external os

The transparent acetowhitening

Remarks without a distinct margin is due to
Type of Transformation Zone : Type 1 squamous metaplasia
Thank You!