Session 3a

Cervical Cancer Screening

and VIA

Malawi Cervical Cancer Prevention and

Control Training 2020

Curriculum based on Malawi MOHP National Service Delivery Guidelines for Cervical Cancer Prevention and Control and WHO Guidelines.
Adapted in part from: Jhpiego, Cervical Cancer Prevention Learning Resource Package
Learning Objectives - 1

By the end of this session, participants will be able

to:
• Explain the different methods of screening for
cervical cancer
• Describe key points in screening protocol for
each screening method
• Explain the significance of the female pelvic
examination
• Perform bimanual and speculum examination
Session 3a: Slide 2
Learning Objectives - 2

By the end of this session, participants will be able

to:

• List inclusion, exclusion criteria for

conducting VIA
• Describe VIA procedure and next steps
• Refer clients for follow-up care as needed

Session 3a: Slide 3

Cervical Cancer Screening Methods

1. Visual Inspection with Acetic Acid

2. HPV DNA and cytology tests
3. Cytology tests using Pap smear

Session 3a: Slide 4

Screening protocols - VIA

• Routine screening should be done 25-49 years

• Screening for VIA PAP Smear HPV DNA testing
can be done after 49 years
• Screening women younger than 25 is not
recommended, but may be offered to sexually
active women 21–25 who request it
• After negative screening result, HIV-negative
women should be screened every 3 years; women
living with HIV should be screened every year
Session 3a: Slide 5
Screening protocols - 2

• After treatment, rescreen annually for 3 years.

• If cancer is suspected, do not treat immediately;
refer to a facility for diagnosis and treatment
• For prevention to be effective, clients with
positive results must receive effective treatment
• ‘Screen-and-treat’ approach is recommended to
minimise loss to follow-up

Session 3a: Slide 6

HPV DNA screening methods

• New procedures detect high-risk HPV DNA in

vaginal or cervical swabs

• Swab collected from cervix or vagina

• Requires specialized lab equipment to process

• CARE HPV test requires less sophisticated lab

• Detection of high-risk HPV does not necessarily

indicate pre-cancer or cancer
Session 3a: Slide 7
Cytology Test Using Pap Smear

• Cervical cytology is the study of the cells on

the cervix using the Papanicolaou (Pap)
smear.

• Collects cells from cervix with a special swab

• Cells studied under microscope for signs of HPV

and pre-cancerous or cancerous changes

• Read in lab by trained personnel

Session 3a: Slide 8

Pap Smears in Malawi

• Pap smears not routinely available in Malawi

• Pap smear may be method of choice (where

available and affordable) when VIA is not
appropriate

• Abnormal results may require colposcopy to

confirm presence of cervical lesion

Session 3a: Slide 9

 Visual Inspection with Acetic Acid

• Also called VIA

• Simple, evidence-based and effective method
• Short procedure, causes no pain
• Utilizes acetic acid (vinegar) to soak the cervix
• Conducted during a single patient visit
• Assessment is immediate
• Promotes linkage of screening with treatment
Session 3a: Slide 10
Adapted from Jhpiego
Inclusion criteria for VIA

• VIA is indicated for all women aged 25 - 49,

provided the SCJ is visible

• Screening women younger than 25 may be

offered to those sexually active and upon request

• Note: If client does not meet these indications

she may be offered HPV testing or PAP Smear or
visual inspection using speculum

Session 3a: Slide 11

Exclusion criteria for VIA

1. Pregnancy
2. During menses
3. Total hysterectomy
4. Cervicitis
5. Invisible SCJ (e.g. post-menopausal women)

Session 3a: Slide 12

 13

Screening Test Comparisons

Sensitivity and Specificity in

Detecting Cervical Disease (CIN2/3 or Cancer)

Test Sensitivity Specificity

38–83%1 >90%1
Pap Smear
47–62%2 60–95%2
56–94% (77%)1 74–94% (86%)1
VIA 80%3 92%3
65–90%2 64–98%2
HPV DNA
Clinician-collected 93–98%4 85%4
Self-collected 80–86%4 85%4

Sources: WHO 20061, FIGO 20092 , Sauvaget 20113, ACCP 2011.4

Session 3a: Slide 13
Adapted from Jhpiego
Acetowhitening & Cervical
Abnormality - 1
• The more severe the cervical abnormality, the
quicker and more pronounced the
acetowhitening effect. Usually:
 High-grade pre-cancerous lesions turn a dense
white colour, with well-defined edges.
 Low-grade pre-cancerous lesions appear whiter
than the surrounding tissue, but are usually not
as white as higher-grade lesions.

Session 3a: Slide 14

 Normal Cervices

Images: Jhpiego
Abnormality - 2

Flashcard No. 37 Flashcard No. 16

Abnormal Cervices
Acetowhitening & Cervical

Lesion

Lesion

Flashcard No. 49 Flashcard No. 38

Session 3a: Slide 15
Provider Role is to Ensure…

• Women who come for screening:

 receive appropriate information and counselling
 understand what is involved and give informed
consent for screening and follow-up

• National guidelines are followed

• Screening is well organized and no opportunity

to screen targeted women attending services is
missed

Session 3a: Slide 16

Visualizing Transformation Zone

• During VIA, provider should make sure the SCJ

and entire transformation zone are visible

• Abnormal lesions generally arise in the

transformation zone, close to the SCJ

• Satellite lesions can also occur outside the

transformation zone

 Usually, satellite lesions result from low-risk

HPV infection and do not cause cancer
Session 3a: Slide 17
 Satellite Lesion

Session 3a: Slide 18

Image: African Centre of Excellence for Women’s Cancer Control, used with permission.
When to perform VIA - 1

• Can be done at any point in menstrual cycle

• Can be performed at post-miscarriage visits

• Can be performed on women with HIV or other

STIs however
 Discharge from severe infection or obvious cervical
cancer may obscure cervix

 If not obvious cervical cancer, treat with antibiotics for

STI and reschedule
Session 3a: Slide 19
When to perform VIA - 2

• Can be done during a family planning visit

 Recent sexual intercourse does not affect

screening

• A woman more than 20 weeks pregnant should

return for screening 6-8 weeks postpartum

 Advanced pregnancy can cause bleeding and

increased vascularity (blood vessels) on the
cervix, which can be confused with cervical
cancer
Session 3a: Slide 20
Abnormal Vaginal Discharge

Session 3a: Slide 21

 Example:
Cervixes obscured by discharge

Session 3a: Slide 22

Image: African Centre of Excellence for Women’s Cancer Control, used with permission.
Cervicitis

• Yellow cervical mucus from

cervical os

• Cervix that bleeds easily

when touched with swab
may have cervicitis or
suspected cancer

• Any bleeding cervix MUST

be referred as suspected
cervical cancer

• If patient has cervicitis, treat per STI guidelines and have

client return in one month Session 3a: Slide 23
VIA Procedure

Session 3a: Slide 24

 Pelvic examination and VIA
Procedure: Step by Step
1. Take a history
2. Pelvic examination
a. Preparation for the exam

b. External genital exam

c. Speculum exam

d. VIA procedure

e. Bimanual exam
Session 3a: Slide 25
 Screening Room

Always assemble
equipment ahead
of time.

Session 3a: Slide 26

Image: African Centre of Excellence for Women’s Cancer Control, used with permission.
Equipment

• Exam couch with knee crutches / leg rests / stirrups

• Good light source (can be a bright torch light)

• Sterile bivalved speculum (e.g., Graves speculum)

• Ring forceps or pick-up forceps

• Steel or plastic container containing 0.5% chlorine

solution for decontaminating instruments

• Steel or plastic container with a polythene bag for

contaminated disposable supplies
Session 3a: Slide 27
Supplies

• Disposable or high-level disinfected examination

gloves (need not be sterile)
• Cotton swabs, cotton-tipped buds, gauze
• Acetic acid solution (3–5%) or white vinegar
• Soap and water (or alcohol-based handrub)
• Sanitary pads or a roll of cotton wool
• Plastic aprons
• A recording form and a pencil
Session 3a: Slide 28
 Prepare for the Client’s Arrival

Session 3a: Slide 29

Image: African Centre of Excellence for Women’s Cancer Control, used with permission.
Take a History

• Welcome the client. Ask about:

 her age, education, marital status
 number of pregnancies, births and living children
 last menstrual period, menstrual pattern, previous and
present contraception
 cervical cancer screening tests, dates and results
 medical history including medications, drug allergies
 social and sexual history including age of sexual
initiation, first pregnancy, HIV status, STIs
Session 3a: Slide 30
Pre-Screening Counselling &
Informed Consent
• Explain to the client:
 Why you are screening for cervical cancer
 How the test will be done
 What will happen after the test
 Possible findings

• Ensure client understands that she can refuse

screening and/or treatment

• Ask client to sign consent form

Session 3a: Slide 31
Client Assessment

1. Counselling
2. Breast examination
3. Abdominal palpation
4. Pelvic examination

Session 3a: Slide 32

 Preparing the Patient for
a Pelvic Exam
• Ask client to urinate to empty bladder prior to exam

• Place a pillow so that the client will be lying on the

lower half of the table with her head on the pillow,

• Adjust table and stirrups to comfortable and safe

height and position.

• Drape a sheet or towel over the client

• State to the patient, “During the exam, let me know

if at any time you experience discomfort.”

Source: National Network of STD/HIV Prevention Training Centers, 2011. Session 3a: Slide 33
 Positioning the Patient

• Put the client in lithotomy

position and make her
relaxed.
• Drape a sheet, towel, or
the woman’s clothing so
you can see her and the
perineum is visible.

Session 3a: Slide 34

Photo: African Centre of Excellence for Women’s Cancer control, used with permission
Pelvic Exam

• Helps to evaluate the cervix, position and size of the

uterus, and to identify any pelvic abnormality

• Three elements of pelvic exam:

1. Inspection of the external genitalia, External
urethral meatus, vaginal introitus, Exam /
and perianal region Visual Exam
2. Speculum examination of the
vagina and cervix Internal
3. Bimanual (two hand) examination Exam
of the uterus, cervix, ovaries, and
adnexa
Session 3a: Slide 35
External Genital Examination

• Inspect for:
 Redness or swelling
 Lumps
 Unusual discharge
 Sores
 Tears or scars

Session 3a: Slide 36

 Speculum Exam: Inserting the
Speculum
• Select appropriate
speculum

• Show speculum to client

and explain what you will
do/what she should
expect

• Note: Avoid use of

lubricant except post
menopause
Session 3a: Slide 37
Source: Jhpiego, 2002. National Network of STD/HIV Prevention Training Centers, 2011.
 Speculum: before and after insertion

Session 3a: Slide 38

Images: African Centre of Excellence for Women’s Cancer Control, used with permission.
 Identify the SCJ

Session 3a: Slide 39

Image: African Centre of Excellence for Women’s Cancer Control, used with permission.
 Speculum Examination Procedure

• Inspect vaginal mucosa/secretions (amount, color, odor)

• Inspect cervix and os

• Conduct screening procedure

(e.g. VIA or Pap smear)

• Inspect vagina as you gently, slowly withdraw speculum

• Close blades as speculum emerges to avoid stretching

or pinching mucosa

Session 3a: Slide 40

Source: Jhpiego, 2002. National Network of STD/HIV Prevention Training Centers, 2011.
Perform VIA

• Position bright light so the cervix can be easily seen

• Carefully check for acetowhite lesions on the SCJ

and within

• Wait for 3 minutes until you have a definite result to

tell the client the result of the exam

• Discuss the results with the client

• Do not make comments such as ‘your cervix looks

healthy’ during speculum exam or screening,
because you may find a problem later
Session 3a: Slide 41
 Cervix Before and During
Application of Vinegar

Before application After 1 minute

After 2 minutes After 3 minutes

Session 3a: Slide 42
Image: African Centre of Excellence for Women’s Cancer Control, used with permission.
 Bimanual Examination Procedure

Uterus
Fallopian
(Womb)
Tube
Uterus
(Womb)
Cervix

Ovary

Image: Hesperian Foundation Session 3a: Slide 43

After the Examination

• Inform the client you are removing the speculum,

then gently remove it
• Place speculum in container of soapy water
• Assist the patient to sit up and ask her to get
dressed
• Remove gloves and put them in hazardous-
waste basket
• Wash your hands with soap and water
Session 3a: Slide 44
 VIA Test Results: Three Possibilities

VIA Result Findings

VIA-Negative Smooth, pink, uniform, featureless. No
acetowhite lesions. Ectopy, polyps,
cervicitis, inflammation, Nabothian cyst.

VIA-Positive Raised, thickened white plaques or

acetowhite epithelium with well-defined
borders, usually near SCJ

Suspected Proliferative lesion (cauliflower-like growth),

Cancer destructive, with bleeding, ulceration and/or
necrosis.
Source:
Session 3a: Slide 45
 VIA: Clinical importance of
localising the lesions (1)

VIA positive: Thick, acetowhite

A: areas with well-defined borders that
appear in the TZ.

VIA Negative: Faint acetowhite

B: areas without defined outline.

VIA Negative: An acetowhite line

C: that appears just on the edge of the
exocervix.
Source:
Session 3a: Slide 46
 VIA: Clinical importance of
localising the lesions (2)

D: VIA Negative: Far from the SCJ.

VIA Negative: Streak-like acetowhite

E: appearance is not significant.

VIA Negative: Pale dot-like areas

F: on the endocervix.

Source:
Session 3a: Slide 47
Discuss Results and Next Steps

• If positive, determine mode of management

• If negative, re-test in 3 years if HIV negative, or
in 1 year if HIV positive
• If cancer is suspected, recommend next steps
• If anything abnormal, explain what it might mean
• Thank the client for her visit
• Record the results
• Prepare for the next client
Session 3a: Slide 48
Key Points - 1

• Early detection and treatment of pre-cancerous

lesions can prevent cervical cancer.
• Routine cervical cancer pre-screening should
start at 25 years of age and end at 50.
• Screening alone will not prevent a single case of
cervical cancer.
• After a negative result with VIA, HIV-negative
women should be screened every three years;
women living with HIV should be screened every
two years. Session 3a: Slide 49
Key Points - 2

• If cancer is suspected, refer to a facility for

diagnosis and treatment as soon as possible.
• Detection of high-risk HPV does not necessarily
mean that pre-cancer or cancer is present; it
indicates HPV infection only.
• For all post-menopausal women who present for
cervical pre-cancer screening, a speculum
examination is necessary.
• If abnormal discharge, treat and delay screening
for one month. Session 3a: Slide 50