Visual Inspection with Acetic Acid

This Sexual and Reproductive Health and Rights (STARS) - Cervical Cancer Screening and Treatment module allows nurses, midwives, clinical officers, and medical officers to become confident and competent in performing visual inspection with acetic acid (VIA) as part of cervical cancer screening and treatment procedures performed in primary health care facilities and mobile units in resource-constrained settings.

Learning Objectives[edit | edit source]

By the end of this module, learners will be able to:^[1]

1. counsel women before and after cervical cancer screening;
2. describe VIA principles, techniques, and interpretation of test results;
3. perform VIA step-by-step; and screen women using VIA tests;
4. make decisions related to treatment and/or referral of women with cervical precancers.

Anatomy and Physiology of the Female Genital Tract[edit | edit source]

• Cervix is the lower part of the uterus that projects through the anterior wall of the vagina.^[1]
• The cervix is covered by squamous epithelium and columnar epithelium that meet at the squamocolumnar junction (SCJ).
• The columnar epithelium on the ectocervix is replaced by squamous epithelium through a process known as metaplasia.
• The area of the cervix where metaplasia occurs is known as the transformation zone.
• The transformation zone (TZ) can be identified by certain features like crypt openings, nabothian follicles, etc.
• In postmenopausal women, the SCJ moves into the endocervical canal and part of the transformation zone may not be visible.

Screening with Visual Inspection using Acetic Acid (VIA)[edit | edit source]

• VIA is the naked eye inspection of the cervix after application of 3–5% acetic acid.^[1]
• VIA is safe, rapid, reliable, and inexpensive.
• Acetic acid acts by coagulating proteins of surface epithelium.
• Precancers contain greater amount of proteins, which get coagulated and give an acetowhite appearance.
• Wait for at least 1 minute for acetic acid to be absorbed and acetowhite area to appear.
• Distinct acetowhite opaque area indicates a positive test.
• Common benign conditions of the cervix include cervicovaginal infections and inflammations, cervical polyps, leukoplakia and genital warts.
• The test should be repeated on women with negative VIA test results after 5 years.

Management of VIA and HPV Positive Women[edit | edit source]

Women with positive VIA test should be treated with ablative therapy at the same visit if eligible.^[1]

Ineligible women should be referred for colposcopy.^[1]

HPV-positive women should be assessed for immediate cryotherapy or advised VIA depending on the protocol of the programme. [need thermal ablation reference]

CIN can be treated either by an ablative method like cryotherapy or excisional method like LEEP. [need thermal ablation reference]

Follow-up with women treated for positive VIA/HPV should be done after 1 year.^[1]

Women positive on follow-up screening should preferably be treated with LEEP/cold knife conization.

If a woman has the histology diagnosis of either CIN 3 or adenocarcinoma in situ, screening should be repeated every year for 3 consecutive years.

Treatment of Cervical Precancers by Cryotherapy and Follow-up[edit | edit source]

Cryotherapy is an ablative method for treatment of ectocervical precancerous lesions.^[1] It:

• uses freezing effect of compressed refrigerant gases – N2O/ CO2;
• destroys transformation zone by crystallization of water and denaturation of proteins.

The entire lesion should be visible on the ectocervix, fully covered by cryoprobe, occupying less than 75% of the ectocervix with no suspicion of cancer.

Watery discharge or spotting can occur until 4 weeks after cryotherapy.

Complete sexual abstinence should be followed for 4 weeks after the procedure.

Follow-up is recommended at 1 year of treatment.

A woman should report immediately if foul smelling discharge, fever of more than 38 °C, heavy vaginal bleeding or severe lower abdominal pain occur within 4 weeks

of treatment.

Anaesthesia is not required.

Treatment of Cervical Precancers by Thermal Ablation and Follow-up[edit | edit source]

Thermal ablation is an ablative method for treatment of ectocervical precancerous lesions.^[1][add thermal ablation]

Uses metallic probes heated to 100–120 °C.

Causes thermal destruction of cervical tissue.

Complete sexual abstinence should be followed for 4 weeks after the procedure.

Follow-up is recommended after 1 year of treatment.

The woman should report immediately if foul smelling discharge, fever of more than 38 °C, heavy vaginal bleeding or severe lower abdominal pain occur within 4 weeks of treatment.

Anaesthesia is not required.

Infection Prevention Practices[edit | edit source]

Infection prevention is of paramount importance in all health interventions.^[1]

The basic steps for processing instruments, surgical gloves and other items are: decontamination, cleaning, high pressure saturated steam sterilization, and high-level disinfection (HLD).

HLD can be done either by boiling or chemical methods using 0.5% chlorine solution or 2% glutaraldehyde.

Biomedical wastes should be disposed-off in appropriate coloured bins.

Checklist for VIA[edit | edit source]

*The highlighted steps are considered as critical^[1]

Counselling Prior to VIA[edit | edit source]

Greet the woman respectfully and introduce yourself*^[1]

Provide general information about preventing cancer by early detection

Explain the importance of cervical cancer screening*

Explain how VIA test and ablative therapy can prevent cervical cancer*

Give information about the pelvic examination and how it is done

Describe how VIA test is done and the possible test results*

Explain the treatment options if VIA test is not normal*

Respond to the woman's possible concerns about:

• Pelvic examination
• VIA test
• Ablative therapy

Ask about any religious belief or attitude that may affect the woman's decision to undergo VIA test

Sample Counselling messages[edit | edit source]

Why are you here?

You are here today to have a special test that can detect an abnormal change on the cervix (lower part of the womb). Such change may turn into cancer if not treated and is known as cervical precancer. The test is known as VIA and involves examination of the surface of the cervix after application of 3–5% dilute acetic acid (vinegar). The test can detect or rule out the presence of precancer of the cervix. The test can also detect cancer of cervix.^[1]

How will the test be done?

The procedure usually takes five to 10 minutes to be completed. You will be made to lie down on the examination table with your legs folded at the knees. A small spoon-like instrument (speculum) will be placed in your vagina to expose the cervix. A mild solution of vinegar will be applied on the surface of your cervix for 1 minute. If there is any precancer or cancer that will be obvious as a white patch and we will be able to tell you the result immediately after the test. The test generally does not cause any pain and is safe. You may feel mild irritation during application of the vinegar solution but it is harmless and goes away on its own after a few minutes. If your VIA test is positive (cervix shows precancer change) you will be advised other tests like colposcopy (a procedure that involves magnified inspection of the cervix with an instrument named colposcope) and/or cervical biopsy (a procedure where a small piece of tissue from the abnormal area on the cervix is taken for examination). If your colposcopy and/or biopsy tests are abnormal then you will be advised to take appropriate treatment.^[1]

What should you do after the test?

Generally there is no pain or discomfort after the procedure and you may continue with your normal day-to-day activities. No precautions are necessary. If the test results are normal you need to come back for the same test after three years unless you cross 49 years of age. If the test is positive we will explain to you where to go for further check-up and treatment.^[1]

What problems can occur during or after the test?

You may experience brief, mild discomfort during the placement of the speculum in your vagina or during application of a dilute solution of acetic acid (vinegar). Sometimes, slight vaginal bleeding (spotting) may occur.^[1]

History Taking and Review of Available Clinical Information[edit | edit source]

1. Personal information: name, age, husband's name, address, telephone number and LMP
2. Obstetric history
3. History of past illness
4. History of previous cervical cancer screening test (s)
5. Ask for any of the following symptoms: Persistent foul smelling white discharge, post-coital bleeding, post-menopausal bleeding, irregular menstrual bleeding
6. Record all relevant information on the case record form

Getting Equipment and Instruments Ready[edit | edit source]

1. Keep necessary equipment ready^[1]
2. Check availability of consumables
3. Ensure that the light source is ready to use
4. Arrange instruments and supplies on a high-level disinfected tray or container

Steps of VIA[edit | edit source]

Check that the woman has emptied her bladder^[1]

Help her onto the examination table, help her to be undressed and drape her

Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry them

Put one pair of new examination disposable gloves on both hands

Inspect external genitalia and check urethral opening for discharge*

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

Insert the speculum and adjust it so that the entire cervix can be seen

Fix the speculum blades in the open position so that the speculum remains in place with the cervix in view

Adjust the light source so that you can see the cervix clearly*

Examine the cervix for cervicitis, ectropion, nabothian cysts, growth, ulcers or contact bleeding

Identify the cervical os, squamocolumnar junction (SCJ) and transformation zone*

Soak a clean swab in 3–5% acetic acid and apply it to the cervix*

Wait for 1 minute for the acetic acid to be absorbed and any acetowhite change to appear*

Inspect the SCJ carefully

Look for any new white patch (acetowhite area) appearing on the cervix:*

• Density
• Margin characteristics
• Location in relation to SCJ or external os
• Number of quadrants involved

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

Remove the speculum

Help the woman to get up from the examination table and sit comfortably

Interpretation of Findings[edit | edit source]

Download and print the Jhpiego Flash Card Set (available in English, French, and Spanish) to practise visual inspection of the cervix.

Documentation[edit | edit source]

Record the VIA test results and other findings in the woman's case record form*

If acetowhite change is present, draw a map of the cervix and the diseased area on the record

VIA findings should be recorded using the nomenclature of the International Federation of Cervical Pathology and Colposcopy (2011 IFCPC nomenclature).

Post-Procedure Counselling/Referral[edit | edit source]

Negative VIA Test[edit | edit source]

If VIA test is negative:^[1]

• Discuss the results of VIA test and the significance of a negative test*
• Tell her when to return for the next screening*
• Tell her to contact the clinic immediately if any symptoms like postcoital bleeding, intermenstrual bleeding or foul smelling discharge from the vagina occurs
• Assure the woman that she can return to the clinic for any medical advice or attention if required
• Tell her to maintain her records carefully

Positive VIA Test or Suspected Cancer[edit | edit source]

If VIA test is positive and patient is eligible for ablative therapy:^[1]

• After completing VIA, ask the woman if she is more comfortable discussing the test results while lying down or sitting up on the table
• Ask her if she would prefer to have her husband/partner or any other family member present with her
• Inform her about the VIA test findings and the significance of the positive test*
• Give her (along with any family member preferably husband/partner) detailed information about how treatment will benefit her*
• Tell her how she will benefit by getting ablative therapy in the same sitting
• If the woman is not ready to have treatment on the same day, give her the option of coming back on another specified day. Emphasize the need for treatment
• Give detailed information about the ablative therapy procedure*
• Explain the side effects she may experience during and after the procedure*
• Encourage the woman to ask questions and respond with care
• Give the woman some time to decide
• Obtain informed consent for ablative therapy*

If VIA test is positive but patient is not eligible for ablative therapy or cancer is suspected:^[1]

• Ask her if she would like her husband/partner or any other family members to be present with her
• Inform her about the VIA test findings and the significance of a positive test*
• Explain the treatment required and how treatment will benefit her*
• Give detailed information of the referral centre (including clinic days and timings) that she needs to visit for further check-ups*
• Explain in brief that she will undergo colposcopy and may requre treatment if abnormalities are suspected on colposcopy
• Inform the woman if cancer is suspected on VIA and explain the necessity of early treatment to her. Give specific information on the nearest centre where she can get cancer treatment facilities*
• Tell her that she should preferably be accompanied by her husband/partner or any other family member at her next visit
• Tell her to maintain her records carefully
• Encourage the woman to ask questions. Answer questions with care

Decontamination and Sterilization[edit | edit source]

Dispose of the swabs in appropriate disposal bags^[1]

Immerse the speculum in 0.5% chlorine solution

Immerse both gloved hands in 0.5% chlorine solution.

Remove gloves by turning them inside out

Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry

Ensuring Quality of Services and Programme Monitoring in Cervical Cancer Screening[edit | edit source]

Programme monitoring is the continuous oversight of all activities related to the programme to ensure that services are delivered according to the plans and the programme achieves its objectives.^[1]

A system of supportive supervision is essential to ensure adherence to the performance standards by all providers at all times.

Good quality standards for screening services at the facility should be maintained.

Screening rate, screening test positivity rate, treatment rate, coverage of target population, age specific cervical cancer incidence are performance indicators and

should be monitored.

References[edit | edit source]

Sections of the STARS - Cervical Cancer Screening and Treatment module are copied or adapted from: Training of health staff in VIA, HPV detection test and cryotherapy - Facilitators' guide. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017. Licence: CC-BY-NC-SA-3.0 IGO; and WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions. Geneva: World Health Organization; 2019. Licence: CC-BY-NC-SA-3.0 IGO. The World Health Organization (WHO) is not responsible for the content or accuracy of any translation. The original English edition shall be the binding and authentic edition.