Cervical cancer is a major health problem worldwide, especially in developing countries like Egypt where it is the second most common cancer in women. Screening is important for early detection and treatment of pre-cancerous lesions to prevent the development of invasive cancer. The document discusses various screening methods for cervical cancer including cytology-based tests like Pap smears and HPV testing as well as visual inspection methods. It also reviews the prevalence of pre-cancerous lesions in Egypt and limitations of screening in low resource settings.
The document discusses cervical histology and screening for cervical cancer. It describes the squamocolumnar junction (SCJ) and transformation zone of the cervix. The location of the SCJ changes with age due to regenerative changes. Screening guidelines from ACOG and WHO are provided regarding what ages to screen and what tests to use. Screening methods like Pap smear, HPV testing, visual inspection with acetic acid are outlined. Management of abnormal screening results including follow up testing and treatment options like cryotherapy, LEEP, and hysterectomy are summarized.
The document discusses cervical cancer screening and treatment methods. It covers:
1. Premalignant stages of cervical cancer including cervical intraepithelial neoplasia grades 1-3 (CIN 1-3).
2. Screening methods for developing countries including visual inspection with acetic acid (VIA) and HPV testing, which are effective and affordable options.
3. Treatment of precancerous lesions generally involves cryotherapy, cold coagulation, or loop electrosurgical excision procedure (LEEP) depending on the severity, with a "see and treat" single visit approach recommended.
This document discusses cervical cancer screening. It begins with the epidemiology of cervical cancer, noting it is the 3rd most common gynecologic cancer in the US but 2nd most common in countries without screening. Risk factors include early sexual activity, multiple partners, HPV infection, and low socioeconomic status. Screening with Pap tests has reduced cervical cancer rates by 70% in the US. The document then discusses screening guidelines, techniques for Pap tests, interpreting results, HPV vaccination, and screening special populations like immunocompromised women.
The document discusses adenomyosis, a benign condition where endometrial tissue grows within the uterine wall. It defines adenomyosis and describes associated symptoms like pelvic pain and abnormal bleeding. Diagnosis can only be confirmed by pathology after hysterectomy, though other imaging methods like ultrasound and MRI can provide clues. TVUS shows heterogeneous myometrial texture while MRI may detect increased thickness or consistency changes in the myometrium.
This document discusses gestational trophoblastic disease (GTD), specifically hydatidiform moles. It defines a hydatidiform mole as a pregnancy characterized by vesicular swelling of placental villi, usually with the absence of an intact fetus. Molar pregnancies can be complete or partial based on whether there is a fetus present. Complete moles have no fetus and are diploid, while partial moles may contain defective fetuses and are usually triploid. Symptoms include vaginal bleeding and an enlarged uterus. Diagnosis involves beta-hCG levels and ultrasound showing a "snowstorm" pattern. Treatment is surgical evacuation followed by chemotherapy for high-risk cases to prevent invasive tumors.
This document discusses visual inspection techniques for cervical cancer screening in developing countries. It begins by explaining the limitations of Pap smear screening in developing countries due to infrastructure and resource constraints. It then describes visual inspection with acetic acid (VIA) and visual inspection with Lugol's iodine (VILI) as alternative screening methods that are simpler, cheaper, and do not require a laboratory. The document provides details on the procedures for VIA and VILI, including how to interpret the results. It finds that VIA and VILI have reasonable sensitivity and specificity for detecting precancerous lesions compared to Pap smears, making them effective screening tools for developing world contexts.
Rh isoimmunization occurs when an Rh-negative mother carries an Rh-positive fetus. During pregnancy or delivery, fetal red blood cells can enter the mother's circulation, stimulating her immune system to produce antibodies against the Rh antigen. These antibodies can then cross the placenta during subsequent pregnancies and destroy fetal red blood cells, causing hemolytic disease of the newborn. Effects range from mild anemia to severe jaundice, hydrops fetalis, or fetal death. Management involves monitoring maternal antibody levels and fetal well-being through amniocentesis and ultrasound. At-risk pregnancies may require intrauterine transfusions or early delivery. Prevention relies on administering Rh immunoglobulin to the mother during
Cervical cancer is a major health problem worldwide, especially in developing countries like Egypt where it is the second most common cancer in women. Screening is important for early detection and treatment of pre-cancerous lesions to prevent the development of invasive cancer. The document discusses various screening methods for cervical cancer including cytology-based tests like Pap smears and HPV testing as well as visual inspection methods. It also reviews the prevalence of pre-cancerous lesions in Egypt and limitations of screening in low resource settings.
The document discusses cervical histology and screening for cervical cancer. It describes the squamocolumnar junction (SCJ) and transformation zone of the cervix. The location of the SCJ changes with age due to regenerative changes. Screening guidelines from ACOG and WHO are provided regarding what ages to screen and what tests to use. Screening methods like Pap smear, HPV testing, visual inspection with acetic acid are outlined. Management of abnormal screening results including follow up testing and treatment options like cryotherapy, LEEP, and hysterectomy are summarized.
The document discusses cervical cancer screening and treatment methods. It covers:
1. Premalignant stages of cervical cancer including cervical intraepithelial neoplasia grades 1-3 (CIN 1-3).
2. Screening methods for developing countries including visual inspection with acetic acid (VIA) and HPV testing, which are effective and affordable options.
3. Treatment of precancerous lesions generally involves cryotherapy, cold coagulation, or loop electrosurgical excision procedure (LEEP) depending on the severity, with a "see and treat" single visit approach recommended.
This document discusses cervical cancer screening. It begins with the epidemiology of cervical cancer, noting it is the 3rd most common gynecologic cancer in the US but 2nd most common in countries without screening. Risk factors include early sexual activity, multiple partners, HPV infection, and low socioeconomic status. Screening with Pap tests has reduced cervical cancer rates by 70% in the US. The document then discusses screening guidelines, techniques for Pap tests, interpreting results, HPV vaccination, and screening special populations like immunocompromised women.
The document discusses adenomyosis, a benign condition where endometrial tissue grows within the uterine wall. It defines adenomyosis and describes associated symptoms like pelvic pain and abnormal bleeding. Diagnosis can only be confirmed by pathology after hysterectomy, though other imaging methods like ultrasound and MRI can provide clues. TVUS shows heterogeneous myometrial texture while MRI may detect increased thickness or consistency changes in the myometrium.
This document discusses gestational trophoblastic disease (GTD), specifically hydatidiform moles. It defines a hydatidiform mole as a pregnancy characterized by vesicular swelling of placental villi, usually with the absence of an intact fetus. Molar pregnancies can be complete or partial based on whether there is a fetus present. Complete moles have no fetus and are diploid, while partial moles may contain defective fetuses and are usually triploid. Symptoms include vaginal bleeding and an enlarged uterus. Diagnosis involves beta-hCG levels and ultrasound showing a "snowstorm" pattern. Treatment is surgical evacuation followed by chemotherapy for high-risk cases to prevent invasive tumors.
This document discusses visual inspection techniques for cervical cancer screening in developing countries. It begins by explaining the limitations of Pap smear screening in developing countries due to infrastructure and resource constraints. It then describes visual inspection with acetic acid (VIA) and visual inspection with Lugol's iodine (VILI) as alternative screening methods that are simpler, cheaper, and do not require a laboratory. The document provides details on the procedures for VIA and VILI, including how to interpret the results. It finds that VIA and VILI have reasonable sensitivity and specificity for detecting precancerous lesions compared to Pap smears, making them effective screening tools for developing world contexts.
Rh isoimmunization occurs when an Rh-negative mother carries an Rh-positive fetus. During pregnancy or delivery, fetal red blood cells can enter the mother's circulation, stimulating her immune system to produce antibodies against the Rh antigen. These antibodies can then cross the placenta during subsequent pregnancies and destroy fetal red blood cells, causing hemolytic disease of the newborn. Effects range from mild anemia to severe jaundice, hydrops fetalis, or fetal death. Management involves monitoring maternal antibody levels and fetal well-being through amniocentesis and ultrasound. At-risk pregnancies may require intrauterine transfusions or early delivery. Prevention relies on administering Rh immunoglobulin to the mother during
This document discusses abnormal uterine bleeding (AUB). It defines AUB and normal menstruation. It describes various clinical types of AUB and potential causes. Evaluation involves history, examination, and investigations. Treatment options include medical approaches like hormonal therapies and surgical procedures like endometrial ablation. Dysfunctional uterine bleeding is discussed in depth as the most common cause of AUB.
This document discusses pre-cancerous lesions of the cervix. It begins by defining premalignant lesions and explaining the multi-step process of carcinogenesis. It then discusses specific pre-cancerous lesions including hyperplasia, metaplasia, dysplasia, and cervical intraepithelial neoplasia (CIN). High-risk HPV infection plays a key role in the development of these lesions. Screening methods like the Pap test and HPV testing can detect pre-cancerous lesions early. Colposcopy is used to examine the cervix in more detail when abnormalities are found. Biopsies of suspicious lesions allow diagnosis and treatment if needed to prevent progression to invasive cancer.
Rh negative pregnancies can lead to isoimmunization of the mother if she has a Rh positive baby. This occurs due to a fetomaternal hemorrhage which allows the fetus's Rh positive blood cells to enter the mother's circulation and trigger an immune response. Testing for isoimmunization involves indirect Coombs testing of the mother. Unsensitized Rh negative mothers receive anti-D immunoglobulin injections to prevent isoimmunization. Sensitized pregnancies require careful monitoring and may involve amniocentesis, intrauterine transfusions or early delivery to prevent fetal complications like hydrops fetalis. The baby may also require treatments like phototherapy or exchange transfusion if affected by hemolytic anemia or
This document discusses vesicovaginal fistula (VVF), including:
1. VVF is an abnormal opening between the bladder and vagina, causing continuous urinary incontinence.
2. VVF has various classifications based on location, size, and complexity.
3. Treatment involves conservative management or surgical repair, with the surgical approach depending on the fistula characteristics.
Gestational trophoblastic disease is a heterogeneous group of lesions arising from abnormal placental trophoblast proliferation. It includes premalignant conditions like complete and partial hydatidiform moles, as well as malignant gestational trophoblastic neoplasia (GTN). GTN has varying potential for local invasion and metastasis. While rare, GTN is highly curable even with widespread dissemination. Treatment involves chemotherapy, with single or multi-agent regimens depending on risk factors and disease stage according to the FIGO scoring system. Careful monitoring of beta-hCG levels is important for diagnosis and follow-up.
A molar pregnancy occurs when abnormal placental tissue develops instead of a fetus. There are two types: complete and partial moles. A complete mole shows trophoblastic proliferation throughout the placenta and no fetal tissue, while a partial mole shows slight, focal proliferation and may contain some fetal tissue. Clinical features can include vaginal bleeding, uterine enlargement beyond dates, and very high hCG levels in the case of a complete mole. Diagnosis is made through histopathological examination of tissue.
This document discusses previous cesarean delivery and a woman's options for her current pregnancy. It outlines the risks and benefits of an elective repeat cesarean section (ERCS) versus a trial of labor after cesarean (TOLAC), which could result in a vaginal birth after cesarean (VBAC). Key factors that influence the likelihood of a successful VBAC are described, such as the number and type of previous c-sections, prior vaginal delivery, and inter-delivery interval. Guidelines for candidacy and contraindications for TOLAC are provided. Continuous fetal monitoring and careful assessment of labor progress are recommended for women attempting VBAC.
1. Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial or venous thrombosis or pregnancy morbidity in the presence of antiphospholipid antibodies.
2. The diagnosis requires one clinical criterion of vascular thrombosis or pregnancy complications and one laboratory criterion of positive testing for antiphospholipid antibodies on two occasions at least 12 weeks apart.
3. Treatment during pregnancy involves low-dose aspirin and heparin starting at a positive pregnancy test through 34 weeks gestation to reduce the risk of pregnancy complications like miscarriage, preeclampsia, and intrauterine growth restriction.
A 19-year-old woman presented with left lower abdominal pain and a history of ovarian cysts seen on prior imaging. On examination, she had tenderness in her lower abdomen. Ultrasound showed a new 5 cm hemorrhagic cyst on her left ovary. She underwent a laparoscopic cystectomy which found a hemorrhagic cyst with clots but no torsion. Her postoperative course was uncomplicated. Ovarian cysts are common and most are functional, resolving without treatment. Evaluation involves history, exam, ultrasound and considering tumor markers or laparoscopy if concerned for a neoplasm.
This document provides an overview of endometrial carcinoma, including its epidemiology, risk and protective factors, classification, clinical presentation, diagnosis, staging, treatment, prognosis, and prevention. Endometrial carcinoma is the most common gynecological cancer and occurs most often in postmenopausal women. Risk factors include older age, early menarche, late menopause, nulliparity, obesity, and unopposed estrogen exposure. Treatment involves surgery, with additional chemotherapy, radiation, or hormonal therapy depending on the stage and grade of cancer. Prognosis depends on histologic grade and stage, with 5-year survival rates ranging from 83% for stage I to 27% for stage IV disease.
Endometrial hyperplasia is an overgrowth of the endometrium that is most common in postmenopausal women exposed to unopposed estrogen, but can occur in women of any age. The most common symptoms are abnormal uterine bleeding, vaginal discharge, and lower abdominal pain. It is classified by the WHO into two categories: hyperplasia without atypia and atypical hyperplasia. Diagnosis involves endometrial biopsy or dilation and curettage to sample the endometrial tissue. Treatment depends on the classification and symptoms, and may involve hormone therapy, progestins, or hysterectomy in severe cases.
Amenorrhea refers to the absence of menstrual periods. It can be classified based on cause, onset, and presence of secondary sexual characteristics. Primary amenorrhea is the absence of periods by age 16, secondary amenorrhea is the cessation of periods after they have started. Causes include anatomical issues, endocrine disorders, and genetic conditions. Evaluation involves history, exam, hormone levels, imaging, and genetic testing to determine the underlying cause and guide treatment.
This document discusses the diagnosis and management of adnexal masses. It provides information on the normal size and variation of ovaries and lifetime risk of ovarian neoplasms. Differential diagnoses of adnexal masses are outlined based on patient age. Diagnostic evaluation includes physical exam, ultrasound, CT or MRI if needed. Common ovarian tumors at different life stages are described. Functional cysts, endometriomas, benign and borderline tumors are discussed. Complications, clinical presentation, imaging and tumor markers are summarized. Guidelines for management of asymptomatic cysts and indications for surgery are provided.
The document discusses Bartholin glands cysts and abscesses. It begins with an introduction and overview of the anatomy and embryology of the Bartholin glands. It then describes pathological conditions such as cysts and abscesses of the Bartholin glands. The document discusses the clinical presentation and various treatment approaches for Bartholin glands cysts and abscesses, including expectant management, conservative treatment with antibiotics, and more invasive procedures like incision and drainage, catheter placement, marsupialization, and ablative therapies using silver nitrate or alcohol.
This document discusses the management of genital herpes in pregnancy. It notes that genital herpes is a common sexually transmitted infection caused by HSV-1 or HSV-2. For pregnant women with primary genital herpes infection in the third trimester, caesarean section is recommended due to the high risk of neonatal transmission. For women with recurrent genital herpes or primary infection acquired earlier in pregnancy, the risk of transmission is low and vaginal delivery can be considered. Babies born to mothers with herpes require evaluation and may need antiviral treatment depending on their condition and test results.
This document discusses premature rupture of membranes (PROM), which is the spontaneous rupture of membranes before the onset of labor. It defines PROM as occurring beyond 28 weeks of gestation but before labor, and preterm PROM (PPROM) as occurring between 28-37 weeks.
The document outlines the risk factors, symptoms, diagnosis, and management of PROM depending on gestational age. Evaluation involves history, physical exam including speculum exam, and tests like nitrazine, ferning, fetal fibronectin, and ultrasound. Management often involves expectant monitoring, antibiotics, corticosteroids, and tocolytics to prolong the pregnancy if it is prior to 34 weeks. The goals are
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
This document discusses the management of preterm labor in cases of placenta previa and abruption placentae. It describes placenta previa as when the placenta is located over or near the internal os, and notes four degrees. For placenta previa, the expectant management using Macafee-Johnson's regime aims to continue the pregnancy for lung maturity up to 37 weeks without risking maternal health. For abruption placentae, where the placenta prematurely separates, active management through immediate delivery is usually indicated due to risks of further separation and fetal death. Lower segment c-section is often used for placenta previa, while vaginal delivery may be possible if the
This document provides information about hysteroscopy, including:
- A hysteroscope is an endoscope used to visualize the uterine cavity and perform procedures.
- It describes the historical development of hysteroscopy from the 19th century to modern techniques.
- The types of hysteroscopes and instrumentation used are outlined, including distention media, electrodes, sheaths, and cameras.
- The document discusses the procedures, indications, contraindications and complications of diagnostic and operative hysteroscopy.
This document discusses occiput posterior position, its definition, causes, diagnosis, and management. It defines occiput posterior position as the fetal head descending into the pelvis with the sagittal suture in the transverse plane. Causes include pelvic abnormalities and fetal positioning. Diagnosis involves vaginal examination to feel head position. Management includes careful assessment, cesarean for modern obstetrics, or manual rotation and assisted delivery if vaginal is possible. Manual rotation involves inserting the hand into the vagina to rotate the fetal head to the occiput anterior position, and can be done with the whole or half hand.
The document discusses the Loop Electrosurgical Excision Procedure (LEEP). It begins by outlining eligibility criteria and contraindications. It then explains that LEEP uses electrosurgical current to cut or coagulate cervical tissue. The procedure involves local anesthesia, applying iodine to outline lesions, and using a loop electrode at varying power settings to remove lesions. Follow up advice is given, including expected discharge and restrictions. Complications are less than 2% but can include bleeding. A follow up after 9-12 months is needed to check for persistent lesions.
Cervical Cancer Prevention in Poor Resource areas : See & treatapproach dr. ...Lifecare Centre
This document discusses cervical cancer prevention through a "see and treat" approach using visual inspection with acetic acid (VIA) screening in low-resource areas. It provides background on cervical cancer epidemiology in India, the rationale for screening, and details on performing VIA screening. A large cluster randomized controlled trial in Mumbai, India found that four rounds of VIA screening conducted by primary health workers reduced cervical cancer mortality by 31% compared to a control group that received only cancer education. The results demonstrate that VIA screening by primary health workers can effectively reduce cervical cancer deaths in low-resource settings.
This document discusses abnormal uterine bleeding (AUB). It defines AUB and normal menstruation. It describes various clinical types of AUB and potential causes. Evaluation involves history, examination, and investigations. Treatment options include medical approaches like hormonal therapies and surgical procedures like endometrial ablation. Dysfunctional uterine bleeding is discussed in depth as the most common cause of AUB.
This document discusses pre-cancerous lesions of the cervix. It begins by defining premalignant lesions and explaining the multi-step process of carcinogenesis. It then discusses specific pre-cancerous lesions including hyperplasia, metaplasia, dysplasia, and cervical intraepithelial neoplasia (CIN). High-risk HPV infection plays a key role in the development of these lesions. Screening methods like the Pap test and HPV testing can detect pre-cancerous lesions early. Colposcopy is used to examine the cervix in more detail when abnormalities are found. Biopsies of suspicious lesions allow diagnosis and treatment if needed to prevent progression to invasive cancer.
Rh negative pregnancies can lead to isoimmunization of the mother if she has a Rh positive baby. This occurs due to a fetomaternal hemorrhage which allows the fetus's Rh positive blood cells to enter the mother's circulation and trigger an immune response. Testing for isoimmunization involves indirect Coombs testing of the mother. Unsensitized Rh negative mothers receive anti-D immunoglobulin injections to prevent isoimmunization. Sensitized pregnancies require careful monitoring and may involve amniocentesis, intrauterine transfusions or early delivery to prevent fetal complications like hydrops fetalis. The baby may also require treatments like phototherapy or exchange transfusion if affected by hemolytic anemia or
This document discusses vesicovaginal fistula (VVF), including:
1. VVF is an abnormal opening between the bladder and vagina, causing continuous urinary incontinence.
2. VVF has various classifications based on location, size, and complexity.
3. Treatment involves conservative management or surgical repair, with the surgical approach depending on the fistula characteristics.
Gestational trophoblastic disease is a heterogeneous group of lesions arising from abnormal placental trophoblast proliferation. It includes premalignant conditions like complete and partial hydatidiform moles, as well as malignant gestational trophoblastic neoplasia (GTN). GTN has varying potential for local invasion and metastasis. While rare, GTN is highly curable even with widespread dissemination. Treatment involves chemotherapy, with single or multi-agent regimens depending on risk factors and disease stage according to the FIGO scoring system. Careful monitoring of beta-hCG levels is important for diagnosis and follow-up.
A molar pregnancy occurs when abnormal placental tissue develops instead of a fetus. There are two types: complete and partial moles. A complete mole shows trophoblastic proliferation throughout the placenta and no fetal tissue, while a partial mole shows slight, focal proliferation and may contain some fetal tissue. Clinical features can include vaginal bleeding, uterine enlargement beyond dates, and very high hCG levels in the case of a complete mole. Diagnosis is made through histopathological examination of tissue.
This document discusses previous cesarean delivery and a woman's options for her current pregnancy. It outlines the risks and benefits of an elective repeat cesarean section (ERCS) versus a trial of labor after cesarean (TOLAC), which could result in a vaginal birth after cesarean (VBAC). Key factors that influence the likelihood of a successful VBAC are described, such as the number and type of previous c-sections, prior vaginal delivery, and inter-delivery interval. Guidelines for candidacy and contraindications for TOLAC are provided. Continuous fetal monitoring and careful assessment of labor progress are recommended for women attempting VBAC.
1. Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial or venous thrombosis or pregnancy morbidity in the presence of antiphospholipid antibodies.
2. The diagnosis requires one clinical criterion of vascular thrombosis or pregnancy complications and one laboratory criterion of positive testing for antiphospholipid antibodies on two occasions at least 12 weeks apart.
3. Treatment during pregnancy involves low-dose aspirin and heparin starting at a positive pregnancy test through 34 weeks gestation to reduce the risk of pregnancy complications like miscarriage, preeclampsia, and intrauterine growth restriction.
A 19-year-old woman presented with left lower abdominal pain and a history of ovarian cysts seen on prior imaging. On examination, she had tenderness in her lower abdomen. Ultrasound showed a new 5 cm hemorrhagic cyst on her left ovary. She underwent a laparoscopic cystectomy which found a hemorrhagic cyst with clots but no torsion. Her postoperative course was uncomplicated. Ovarian cysts are common and most are functional, resolving without treatment. Evaluation involves history, exam, ultrasound and considering tumor markers or laparoscopy if concerned for a neoplasm.
This document provides an overview of endometrial carcinoma, including its epidemiology, risk and protective factors, classification, clinical presentation, diagnosis, staging, treatment, prognosis, and prevention. Endometrial carcinoma is the most common gynecological cancer and occurs most often in postmenopausal women. Risk factors include older age, early menarche, late menopause, nulliparity, obesity, and unopposed estrogen exposure. Treatment involves surgery, with additional chemotherapy, radiation, or hormonal therapy depending on the stage and grade of cancer. Prognosis depends on histologic grade and stage, with 5-year survival rates ranging from 83% for stage I to 27% for stage IV disease.
Endometrial hyperplasia is an overgrowth of the endometrium that is most common in postmenopausal women exposed to unopposed estrogen, but can occur in women of any age. The most common symptoms are abnormal uterine bleeding, vaginal discharge, and lower abdominal pain. It is classified by the WHO into two categories: hyperplasia without atypia and atypical hyperplasia. Diagnosis involves endometrial biopsy or dilation and curettage to sample the endometrial tissue. Treatment depends on the classification and symptoms, and may involve hormone therapy, progestins, or hysterectomy in severe cases.
Amenorrhea refers to the absence of menstrual periods. It can be classified based on cause, onset, and presence of secondary sexual characteristics. Primary amenorrhea is the absence of periods by age 16, secondary amenorrhea is the cessation of periods after they have started. Causes include anatomical issues, endocrine disorders, and genetic conditions. Evaluation involves history, exam, hormone levels, imaging, and genetic testing to determine the underlying cause and guide treatment.
This document discusses the diagnosis and management of adnexal masses. It provides information on the normal size and variation of ovaries and lifetime risk of ovarian neoplasms. Differential diagnoses of adnexal masses are outlined based on patient age. Diagnostic evaluation includes physical exam, ultrasound, CT or MRI if needed. Common ovarian tumors at different life stages are described. Functional cysts, endometriomas, benign and borderline tumors are discussed. Complications, clinical presentation, imaging and tumor markers are summarized. Guidelines for management of asymptomatic cysts and indications for surgery are provided.
The document discusses Bartholin glands cysts and abscesses. It begins with an introduction and overview of the anatomy and embryology of the Bartholin glands. It then describes pathological conditions such as cysts and abscesses of the Bartholin glands. The document discusses the clinical presentation and various treatment approaches for Bartholin glands cysts and abscesses, including expectant management, conservative treatment with antibiotics, and more invasive procedures like incision and drainage, catheter placement, marsupialization, and ablative therapies using silver nitrate or alcohol.
This document discusses the management of genital herpes in pregnancy. It notes that genital herpes is a common sexually transmitted infection caused by HSV-1 or HSV-2. For pregnant women with primary genital herpes infection in the third trimester, caesarean section is recommended due to the high risk of neonatal transmission. For women with recurrent genital herpes or primary infection acquired earlier in pregnancy, the risk of transmission is low and vaginal delivery can be considered. Babies born to mothers with herpes require evaluation and may need antiviral treatment depending on their condition and test results.
This document discusses premature rupture of membranes (PROM), which is the spontaneous rupture of membranes before the onset of labor. It defines PROM as occurring beyond 28 weeks of gestation but before labor, and preterm PROM (PPROM) as occurring between 28-37 weeks.
The document outlines the risk factors, symptoms, diagnosis, and management of PROM depending on gestational age. Evaluation involves history, physical exam including speculum exam, and tests like nitrazine, ferning, fetal fibronectin, and ultrasound. Management often involves expectant monitoring, antibiotics, corticosteroids, and tocolytics to prolong the pregnancy if it is prior to 34 weeks. The goals are
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
This document discusses the management of preterm labor in cases of placenta previa and abruption placentae. It describes placenta previa as when the placenta is located over or near the internal os, and notes four degrees. For placenta previa, the expectant management using Macafee-Johnson's regime aims to continue the pregnancy for lung maturity up to 37 weeks without risking maternal health. For abruption placentae, where the placenta prematurely separates, active management through immediate delivery is usually indicated due to risks of further separation and fetal death. Lower segment c-section is often used for placenta previa, while vaginal delivery may be possible if the
This document provides information about hysteroscopy, including:
- A hysteroscope is an endoscope used to visualize the uterine cavity and perform procedures.
- It describes the historical development of hysteroscopy from the 19th century to modern techniques.
- The types of hysteroscopes and instrumentation used are outlined, including distention media, electrodes, sheaths, and cameras.
- The document discusses the procedures, indications, contraindications and complications of diagnostic and operative hysteroscopy.
This document discusses occiput posterior position, its definition, causes, diagnosis, and management. It defines occiput posterior position as the fetal head descending into the pelvis with the sagittal suture in the transverse plane. Causes include pelvic abnormalities and fetal positioning. Diagnosis involves vaginal examination to feel head position. Management includes careful assessment, cesarean for modern obstetrics, or manual rotation and assisted delivery if vaginal is possible. Manual rotation involves inserting the hand into the vagina to rotate the fetal head to the occiput anterior position, and can be done with the whole or half hand.
The document discusses the Loop Electrosurgical Excision Procedure (LEEP). It begins by outlining eligibility criteria and contraindications. It then explains that LEEP uses electrosurgical current to cut or coagulate cervical tissue. The procedure involves local anesthesia, applying iodine to outline lesions, and using a loop electrode at varying power settings to remove lesions. Follow up advice is given, including expected discharge and restrictions. Complications are less than 2% but can include bleeding. A follow up after 9-12 months is needed to check for persistent lesions.
Cervical Cancer Prevention in Poor Resource areas : See & treatapproach dr. ...Lifecare Centre
This document discusses cervical cancer prevention through a "see and treat" approach using visual inspection with acetic acid (VIA) screening in low-resource areas. It provides background on cervical cancer epidemiology in India, the rationale for screening, and details on performing VIA screening. A large cluster randomized controlled trial in Mumbai, India found that four rounds of VIA screening conducted by primary health workers reduced cervical cancer mortality by 31% compared to a control group that received only cancer education. The results demonstrate that VIA screening by primary health workers can effectively reduce cervical cancer deaths in low-resource settings.
Cinnamon has been used for centuries as a spice and for medicinal purposes. Recent scientific research has explored cinnamon's potential health benefits. Some studies have found cinnamon may help lower blood sugar levels and reduce risk factors for conditions like diabetes and heart disease. However, more high-quality human studies are still needed to confirm cinnamon's effectiveness for specific medical uses. The FDA has granted cinnamon GRAS status as a food additive.
The document provides guidelines for managing women diagnosed with adenocarcinoma in-situ (AIS) from an excisional procedure. It recommends hysterectomy as the preferred treatment but notes conservative management is acceptable if future fertility is desired. For those undergoing conservative management, re-excision is recommended if margins are involved or endocervical curettage is positive, while re-evaluation at 6 months is acceptable if margins are negative. Long-term follow-up is recommended for those undergoing re-evaluation.
Lugol's solution is an aqueous solution of elemental iodine and potassium iodide. It was invented in 1829 by French physician J.G.A. Lugol and is used as an antiseptic, disinfectant for water, and reagent for starch detection. It has also been used to treat hyperthyroidism and replenish iodine deficiency. The solution turns dark blue/black in the presence of starches. It stains cell nuclei, glycogen in tissues, and mucogingival junction. Lugol's solution has various medical, laboratory, and aquarium applications and comes in concentrations of 1-5% iodine. Higher concentrations can cause irritation
Recommended Thromboprophylaxis for Pregnancies Complicated by Inherited Throm...Asha Reddy
This document provides recommendations for anticoagulation therapy during pregnancy and postpartum for women with different risk factors for venous thromboembolism. It recommends therapeutic anticoagulation for women with acute thromboembolism during pregnancy or those at high risk, such as those with mechanical heart valves. For women with a history of idiopathic thrombosis or transient risk factors, it recommends either antepartum prophylactic anticoagulation or surveillance without anticoagulation. It provides a table outlining recommended thromboprophylaxis for different clinical scenarios based on the presence or absence of thrombophilia and previous venous thromboembolism episodes.
Single dose Methotrexate- Monitoring : Medical treatment ectopicAsha Reddy
The document describes two protocols for treating ectopic pregnancies with methotrexate (MTX): a multiple-dose protocol and a single-dose protocol.
The multiple-dose protocol administers MTX and leucovorin over 8 days, monitoring hCG levels after each dose. If hCG levels decline by at least 15%, treatment continues until levels fall below 5 mIU/mL. If decline is insufficient, treatment is stopped and surveillance begins.
The single-dose protocol administers a single dose of MTX on day 1 and day 7, if needed. hCG is monitored on days 1, 4, and 7 to assess the 15% decline threshold. Complete resolution usually takes 2-3
The document describes a multiple-dose methotrexate (MTX) treatment protocol for ectopic pregnancy. On treatment days 1, 3, 5, and 7, patients receive MTX injections if their human chorionic gonadotropin (hCG) levels have declined by less than 15% from the previous measurement. Leucovorin is administered on days 2, 4, 6, and 8. hCG is measured before starting treatment and on each treatment day to assess the decline. If hCG declines by more than 15%, treatment is stopped and surveillance begins. Surveillance involves weekly hCG testing until levels fall below 5 mIU/mL.
This document discusses colposcopy, which is a medical examination of the cervix and vagina. It describes the colposcopy procedure, which uses a colposcope to magnify and illuminate the vaginal walls and cervix. The colposcope allows the doctor to closely examine the cervix for any abnormalities. The document also mentions that colposcopy is usually performed after an abnormal Pap smear to further evaluate any suspicious lesions found on the cervix.
The Accuracy of Diagnostic Colposcopy using IFCPC 2011 TerminologySujoy Dasgupta
This paper was presented in the Annual Conference of Bengal Obstetric and Gynaecological Society (BOGSCON) 2014 held at ITC Sonar, Kolkata- January, 2014
Dindigul district cervical screening study, india acceptability, effectivenes...Asha Reddy
Dindigul district cervical screening study, india acceptability, effectiveness and safety of treatment of cervical precancerous lesions by nurses using cryotherapy
Medical treatment of ectopic pregnancy is discussed. Ectopic pregnancies, which occur when a fertilized egg implants outside the uterus, most often in the fallopian tubes, can be treated medically with methotrexate (MTX) or surgically. The guidelines provide criteria for use of MTX including hemodynamic stability, no severe pain, commitment to follow up, and normal liver and kidney function. Success rates of MTX treatment are high at 78-96% for appropriately selected patients, though certain risk factors like high beta-hCG levels or large ectopic mass size can increase risk of MTX treatment failure. Close monitoring of beta-hCG levels is required after MTX treatment to ensure complete resolution
Dr. nisreen cervical cancer screening in park hayatTariq Mohammed
The document discusses cervical cancer prevalence, incidence, and mortality worldwide and in Saudi Arabia. It notes that cervical cancer is the second leading cause of cancer death in women globally, with over 500,000 new cases and 288,000 deaths annually. In Saudi Arabia specifically, the incidence is very low at 1.9 cases per 100,000 women, accounting for 152 new cases and 55 deaths annually. However, little is known about HPV prevalence and transmission patterns in the country. The challenges in addressing cervical cancer in Saudi Arabia include understanding HPV and abnormal cytology prevalence, sexual practices, implementing screening programs, determining vaccine cost-effectiveness, and ensuring quality screening and colposcopy.
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Given the availability of a colposcope and a trained colposcopist this method is an essential tool for effective secondary prevention of female reproductive organ diseases. Colposcopic guided procedures enable a preceise diagnostic and consequent treatments with eventually organ preserving means. This power point presentation highlights the range of opportunities offered by Colposcopy.
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This document discusses the principles and procedures of colposcopy examinations. It begins by defining a colposcope and its main uses. The most common reason for referral is abnormal cervical screening tests indicating possible precancerous lesions. During the exam, the cervix is examined under magnification with saline, acetic acid, and Lugol's iodine to identify any abnormal white lesions that could indicate precancer or cancer. The document outlines the proper colposcopy instrumentation, examination steps including the principles behind using acetic acid and Lugol's iodine, how to interpret the results, and the importance of thoroughly documenting findings.
VIA is an attractive alternative to cytology-based cervix uteri screening in low-resource settings. Cryotherapy is the treatment option for test-positive individuals. Hereby a “Screen and Treat” approach can be integrated into existing reproductive health services in low-resource countries.
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Ovarian hyper stimulation syndrome (OHSS) is an exaggerated response to ovulation induction that is usually associated with exogenous gonadotropin stimulation. It is typically a self-limiting condition, but can progress to become severe and be associated with increased pregnancy complications. OHSS is classified based on severity of symptoms and managed through prediction, prevention strategies like using a GnRH antagonist protocol or cryopreserving all embryos, and treatment of symptoms for mild-moderate cases or intensive care for critical OHSS. Further research aims to reduce OHSS risk while allowing for fresh embryo transfers.
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Visual inspection with Lugol’s iodine
1. Visual inspection withVisual inspection with
LugolLugol’’s iodine (s iodine (VILI):VILI):
Evidence to dateEvidence to date
Original source:
Alliance for Cervical Cancer Prevention (ACCP)
www.alliance-cxca.org
2. Overview:
❚ Description of VILI and how it works
❚ Infrastructure requirements
❚ What test results mean
❚ Test performance
❚ Strengths and limitations
❚ Program implications in low-resource settings
3. Types of visual inspection tests:
❚ Visual inspection with Lugol’s iodine (VILI),
also known as Schiller’s test, uses Lugol’s iodine
instead of acetic acid.
❚ Visual inspection with acetic acid (VIA) can be
done with the naked eye (also called cervicoscopy
or direct visual inspection, [DVI]), or with low
magnification (also called gynoscopy, aided VI, or
VIAM).
4. What does VILI involve?
❚ Performing a vaginal speculum exam during
which a health care provider applies Lugol’s
iodine solution to the cervix.
❚ Viewing the cervix with the naked eye to
identify color changes on the cervix.
❚ Determining whether the test result is positive
or negative for possible precancerous lesions or
cancer.
5. How VILI works:
❚ Squamous epithelium contains glycogen, whereas precancerous
lesions and invasive cancer contain little or no glycogen.
❚ Iodine is glycophilic and is taken up by the squamous epithelium,
staining it mahogany brown or black.
❚ Columnar epithelium does not change color, as it has no glycogen.
❚ Immature metaplasia and inflammatory lesions are at most only
partially glycogenated and, when stained, appear as scattered, ill-
defined uptake areas.
❚ Precancerous lesions and invasive cancer do not take up iodine (as
they lack glycogen) and appear as well-defined, thick, mustard or
saffron yellow areas.
6. What infrastructure does
VILI require?
❚ Private exam room
❚ Examination table
❚ Trained health professionals
❚ Adequate light source
❚ Sterile vaginal speculum
❚ New examination gloves, or HLD surgical gloves
❚ Large cotton swabs
❚ Lugol’s iodine solution and a small bowl
❚ Containers with 0.5% chlorine solution
❚ A plastic bucket with a plastic bag
❚ Quality assurance system to maximize accuracy
7. Categories for VILI test results:
Clinically visible ulcerative, cauliflower-
like growth or ulcer; oozing and/or
bleeding on touch.
Suspicious for
cancer
Well-defined, bright yellow iodine non-
uptake areas touching the squamo-
columnar junction (SCJ) or close to
the os if SCJ is not seen.
Test-positive
Squamous epithelium turns brown and
columnar epithelium does not change
color; or irregular, partial or non-
iodine uptake areas appear.
Test-negative
Clinical FindingsVILI Category
8. VILI: test-negative
❚ The squamous epithelium
turns brown and columnar
epithelium does not
change color.
❚ There are scattered and
irregular, partial or non-
iodine uptake areas
associated with immature
squamous metaplasia or
inflammation.
Photo source: IARC
9. VILI: test-positive
❚ Well-defined, bright
yellow iodine non-
uptake areas touching
the squamocolumnar
junction (SCJ).
❚ Well-defined, bright
yellow iodine non-
uptake areas close to
the os if SCJ is not
seen, or covering the
entire cervix.
Photo source: IARC
10. VILI: Suspicious for cancer
❚ Clinically visible
ulcerative, cauliflower-
like growth or ulcer;
oozing and/or bleeding
on touch.
Photo source: IARC
11. Management options if the VILI
result is positive:
❚ Offer to treat immediately, (without colposcopy
or biopsy, known as the “test-and-treat” or
“single-visit” approach).
❚ Refer for colposcopy and biopsy and then offer
treatment if a precancerous lesion is confirmed.
12. Management options if the VILI
result is suspicious for cancer:
❚ Refer for colposcopy and biopsy and further
management. Further management options
include:
❙ Surgery
❙ Radiotherapy
❙ Chemotherapy
❙ Palliative care
13. Test performance:
Sensitivity and Specificity
❚ Sensitivity: The proportion of all those
with disease that the test correctly
identifies as positive.
❚ Specificity: The proportion of all those
without disease (normal) that the test
correctly identifies as negative.
14. VILI test performance:
❚ Sensitivity = 87.2%
❚ Specificity = 84.7%
❚ These results are from a cross-sectional
study involving 4,444 women.
(Sankaranarayanan et al., 2003).
15. Strengths of VILI:
❚ Simple, easy-to-learn approach that is minimally
reliant upon infrastructure.
❚ Low start-up and sustaining costs.
❚ Many types of health care providers can perform
the procedure.
❚ High sensitivity results in a low proportion of
false negatives.
❚ Test results are available immediately.
❚ Decreased loss to follow-up.
16. Limitations of VILI:
❚ Moderate specificity may result in over-referral
and over-treatment in a single-visit approach.
❚ Less accurate when used in post-menopausal
women.
❚ There is a need for developing standard training
methods and quality assurance measures.
❚ Rater dependent.
17. Conclusions:
❚ VILI is a promising new approach.
❚ Adequate training and ongoing supervision are essential
to enable health care providers to evaluate the features
of a lesion and make accurate assessments.
❚ More research is needed to establish the most
appropriate and feasible approach to reducing false-
positives and over-treatment (when offered as part of a
single-visit, “test-and-treat” approach).
❚ Properly designed studies on VILI are essential to
evaluating the effectiveness in reducing cervical cancer
incidence and mortality.
18. References:
❚ ACCP. Visual screening approaches: Promising alterative screening
strategies. Cervical Cancer Prevention Fact Sheet. (October 2002).
❚ Sankaranarayanan R, Wesley R, Thara S, Dhakad N, Chandralekha
B, Sebastian P, Chithrathara K, Parkin DM, Nair MK. Test
characteristics of visual inspection with 4% acetic acid (VIA) and
Lugol's iodine (VILI) in cervical cancer screening in Kerala, India.
International Journal of Cancer 106(3):404-408. (September 1,
2003).
❚ Sankaranarayanan R,Rajkumar R, Arrossi S, Theresa R, Esmy PO,
Mahé C, Muwonge R, Parkin DM, Cherian J. Determinants of
participation of women in a cervical cancer visual screening trial in
rural south India. Cancer Detection and Prevention 27(6):415-523
(November-December 2003).
19. For more information on cervical
cancer prevention:
❚ The Alliance for Cervical Cancer Prevention (ACCP)
www.alliance-cxca.org
❚ ACCP partner organizations:
❙ EngenderHealth www.engenderhealth.org
❙ International Agency for Research on Cancer
(IARC) www.iarc.fr
❙ JHPIEGO www.jhpiego.org
❙ Pan American Health Organization (PAHO)
www.paho.org
❙ Program for Appropriate Technology in Health
(PATH) www.path.org
20. 1
Visual inspection withVisual inspection with
LugolLugol’’ss iodine (iodine (VILI):VILI):
Evidence to dateEvidence to date
Original source:
Alliance for Cervical Cancer Prevention (ACCP)
www.alliance-cxca.org
Slide overview: This presentation provides a summary of the latest evidence, as of
2003, on visual inspection with Lugol’s iodine (VILI) as a test for cervical cancer.
21. 2
Overview:
❚ Description of VILI and how it works
❚ Infrastructure requirements
❚ What test results mean
❚ Test performance
❚ Strengths and limitations
❚ Program implications in low-resource settings
Slide overview: In this presentation, we will discuss the following topics.
22. 3
Types of visual inspection tests:
❚ Visual inspection with Lugol’s iodine (VILI),
also known as Schiller’s test, uses Lugol’s iodine
instead of acetic acid.
❚ Visual inspection with acetic acid (VIA) can be
done with the naked eye (also called cervicoscopy
or direct visual inspection, [DVI]), or with low
magnification (also called gynoscopy, aided VI, or
VIAM).
Slide overview: This is a partial list of the types of vision-based tests available for
testing for cervical cancer or precancer. The key differences in these tests are
whether or not magnification is used, and whether acetic acid or some other
technique of highlighting abnormalities is used.
•Note for bullet 1: The screening test using iodine (VILI) is similar in approach to
the Schiller’s iodine test advocated in the 1930s and widely used early in the 20th
century before the development of cytology. Schiller’s test was well known for its
low specificity, however, it is noteworthy that experience gained through the use of
Lugol’s iodine application in colposcopy has helped refine VILI and avoided many
false-positive findings.
•Note for after last bullet: This talk focuses on VILI.
23. 4
What does VILI involve?
❚ Performing a vaginal speculum exam during
which a health care provider applies Lugol’s
iodine solution to the cervix.
❚ Viewing the cervix with the naked eye to
identify color changes on the cervix.
❚ Determining whether the test result is positive
or negative for possible precancerous lesions or
cancer.
Slide overview: VILI is simple to administer, and a range of types of health care
providers can perform the procedure with appropriate training.
Note fur bullet 3: Results of the test are available immediately and do not require
laboratory support.
24. 5
How VILI works:
❚ Squamous epithelium contains glycogen, whereas precancerous
lesions and invasive cancer contain little or no glycogen.
❚ Iodine is glycophilic and is taken up by the squamous epithelium,
staining it mahogany brown or black.
❚ Columnar epithelium does not change color, as it has no glycogen.
❚ Immature metaplasia and inflammatory lesions are at most only
partially glycogenated and, when stained, appear as scattered, ill-
defined uptake areas.
❚ Precancerous lesions and invasive cancer do not take up iodine (as
they lack glycogen) and appear as well-defined, thick, mustard or
saffron yellow areas.
Slide overview: Application of iodine results in brown or black color staining in
areas containing glycogen. In areas lacking glycogen, iodine is not absorbed and
such areas remain colorless or turn yellow.
Note for bullet 1: Glycogen is a sugar stored by normal cells.
Note after the last bullet: Gross cancerous lesions are usually apparent before the
application of iodine.
25. 6
What infrastructure does
VILI require?
❚ Private exam room
❚ Examination table
❚ Trained health professionals
❚ Adequate light source
❚ Sterile vaginal speculum
❚ New examination gloves, or HLD surgical gloves
❚ Large cotton swabs
❚ Lugol’s iodine solution and a small bowl
❚ Containers with 0.5% chlorine solution
❚ A plastic bucket with a plastic bag
❚ Quality assurance system to maximize accuracy
Slide overview: The supplies and equipment required to provide VILI testing are
listed here. Most of these supplies are available at even the most basic levels of the
health care system in low-resource countries, although not always.
Note for bullet 4: Preferably, a bright halogen lamp that can be easily directed at
the cervix. The light source needs to be something other than daylight. It can be a
flashlight or torch, or a gooseneck lamp. The stronger and more consistent the light
source, the easier it will be for health care providers to identify abnormalities.
•Note for bullet 7: Cotton swabs can be handmade using cotton batting and
broomsticks or ring forceps.
Note for bullet 9: For decontamination, an aluminium/steel/plastic container is
used for immersing the gloves, and a plastic bucket or container for
decontamination of instruments.
Note for bullet 10 (second to last): A bucket is used to dispose of contaminated
swabs and other waste items.
Note for last bullet: Elements of a quality assurance system include (but are not
limited to) supervision, periodic refresher trainings, evaluation of on-going program
activities and long-term impact, a mechanism for constructive feedback from
women and health care providers, and an effective information system.
Note at the end: Other necessary supplies that should be available at any clinic
setting include cotton balls, gauze, and rubber or plastic sheets for the table.
26. 7
Categories for VILI test results:
Clinically visible ulcerative, cauliflower-
like growth or ulcer; oozing and/or
bleeding on touch.
Suspicious for
cancer
Well-defined, bright yellow iodine non-
uptake areas touching the squamo-
columnar junction (SCJ) or close to
the os if SCJ is not seen.
Test-positive
Squamous epithelium turns brown and
columnar epithelium does not change
color; or irregular, partial or non-
iodine uptake areas appear.
Test-negative
Clinical FindingsVILI Category
Slide overview: There are three categories of test results. Each is described in more
detail on the following slides.
27. 8
VILI: test-negative
❚ The squamous epithelium
turns brown and columnar
epithelium does not
change color.
❚ There are scattered and
irregular, partial or non-
iodine uptake areas
associated with immature
squamous metaplasia or
inflammation.
Photo source: IARC
Slide overview: Patterns associated with a normal or inflamed cervix are visible
during VILI.
Note for bullet 1 and photo: In the top photo, squamous epithelium turns black in
color (due to presence of glycogen) and the columnar epithelium does not change
color (due to lack of glycogen). No well-defined yellow areas are observed in the
transformation zone.
Note for bullet 2 and photo: In the bottom photo, scattered, discontinuous yellow
spots are seen all over the cervix and the vaginal fornices due to localized thinning
caused by inflammation.
28. 9
VILI: test-positive
❚ Well-defined, bright
yellow iodine non-
uptake areas touching
the squamocolumnar
junction (SCJ).
❚ Well-defined, bright
yellow iodine non-
uptake areas close to
the os if SCJ is not
seen, or covering the
entire cervix.
Photo source: IARC
Slide overview: The well-defined, mustard-yellow lesions in the transformation zone
indicate cervical intraepithelial neoplasia.
Note for bullet 1: The squamocolumnar junction (SCJ) is the point at which
columnar cells meet ectocervical squamous cells on the cervix. This junction marks
the furthest extent of the transformation zone towards or, in the case of post-
menopausal women, into the cervical canal.
29. 10
VILI: Suspicious for cancer
❚ Clinically visible
ulcerative, cauliflower-
like growth or ulcer;
oozing and/or bleeding
on touch.
Photo source: IARC
Slide overview: Because invasive cervical cancer lacks glycogen, the growth does
not stain with iodine and turns yellow. Gross cancerous lesions can be apparent
before the application of iodine.
30. 11
Management options if the VILI
result is positive:
❚ Offer to treat immediately, (without colposcopy
or biopsy, known as the “test-and-treat” or
“single-visit” approach).
❚ Refer for colposcopy and biopsy and then offer
treatment if a precancerous lesion is confirmed.
Slide overview: Women testing positive may be offered further testing (colposcopy
or biopsy) or treatment, or both, immediately after testing.
Note after bullet 2: The different approaches to screening, diagnosis, and
treatment, based on VILI, are being evaluated in terms of safety, acceptability to
women, and effectiveness in preventing invasive cancer.
31. 12
Management options if the VILI
result is suspicious for cancer:
❚ Refer for colposcopy and biopsy and further
management. Further management options
include:
❙ Surgery
❙ Radiotherapy
❙ Chemotherapy
❙ Palliative care
Slide overview: If a VILI test result is suspicious for cancer, refer for further testing
(colposcopy or biopsy) and management.
32. 13
Test performance:
Sensitivity and Specificity
❚ Sensitivity: The proportion of all those
with disease that the test correctly
identifies as positive.
❚ Specificity: The proportion of all those
without disease (normal) that the test
correctly identifies as negative.
Slide overview: The test performance of each screening method is rated by its
sensitivity and specificity. Before discussing VILI’s test performance, it is important
to understand what sensitivity and specificity mean.
33. 14
VILI test performance:
❚ Sensitivity = 87.2%
❚ Specificity = 84.7%
❚ These results are from a cross-sectional
study involving 4,444 women.
(Sankaranarayanan et al., 2003).
Slide overview: VILI’s 87.2% sensitivity ensures that a large proportion of high-
grade disease is identified. Its specificity implies that about 15 percent of women
tested may be treated unnecessarily in a single-visit “test-and-treat” approach.
Note for bullet 1: High sensitivity in detecting high-grade lesions or cancer means
there are few false-negatives and most precancerous lesions are detected. The
diagnostic properties of VILI are being evaluated in 12 ACCP cross-sectional
studies established in India, Congo, Mali, Niger, Guinea, and Burkina Faso. The
screening tests are provided by a range of health care providers including trained
nurses, health workers, or graduate students. VILI’s performance in these ACCP
studies is consistent with the findings presented here.
Note for bullet 2: Further investigation with diagnostic procedures, such as
colposcopy and biopsy, may reduce over-treatment caused by VILI’s lower
specificity.
34. 15
Strengths of VILI:
❚ Simple, easy-to-learn approach that is minimally
reliant upon infrastructure.
❚ Low start-up and sustaining costs.
❚ Many types of health care providers can perform
the procedure.
❚ High sensitivity results in a low proportion of
false negatives.
❚ Test results are available immediately.
❚ Decreased loss to follow-up.
Slide overview: VILI has the following strengths as an alternative test for precancer
or cancer in low-resource settings.
•Note for bullet 1: Assuming sufficiently trained providers are available, VILI is a
simple approach. Health care providers can be trained in a short period of time (1 to
2 weeks).
•Note for bullet 2: In most settings, costs associated with launching and sustaining
VILI-based programs are lower than other methods (except VIA). VILI can be
performed in extremely low-resource settings.
Notes on bullet 3: In situations in which health care providers can receive adequate
and ongoing training, VILI has the potential for adequate population coverage.
Note for bullet 4: Therefore, a high proportion of precancerous lesions are
detected.
Note for bullet 5: Because results are available immediately, further investigations
(such as colposcopy and biopsy), and treatment (such as cryotherapy or LEEP) can
occur during the same visit, if appropriate.
Note for bullet 6: This means that additional visits for investigations and
treatments are reduced.
35. 16
Limitations of VILI:
❚ Moderate specificity may result in over-referral
and over-treatment in a single-visit approach.
❚ Less accurate when used in post-menopausal
women.
❚ There is a need for developing standard training
methods and quality assurance measures.
❚ Rater dependent.
Slide overview: VILI also has limitations.
Note for bullet 1: The single-visit “test-and-treat” approach results in over-referral
and over-treatment of women. Over-referral has important cost implications in
settings with scarce resources.
Note for bullet 2: It may be difficult to interpret the color patterns associated with
Lugol’s iodine application in post-menopausal women because of the degeneration
and atrophy of the epithelium. Menopause reduces the production of glycogen, and
the color pattern resulting from iodine application becomes confusing.
•Note for bullet 3: The Alliance for Cervical Cancer Prevention (ACCP) is currently
investigating these elements.
•Note for bullet 4: “Rater dependent” means the test's performance depends on the
abilities of the person doing the test (versus a machine, as for HPV testing). This
means that even when service providers have training, test performance may vary
depending on service delivery conditions and other factors.
36. 17
Conclusions:
❚ VILI is a promising new approach.
❚ Adequate training and ongoing supervision are essential
to enable health care providers to evaluate the features
of a lesion and make accurate assessments.
❚ More research is needed to establish the most
appropriate and feasible approach to reducing false-
positives and over-treatment (when offered as part of a
single-visit, “test-and-treat” approach).
❚ Properly designed studies on VILI are essential to
evaluating the effectiveness in reducing cervical cancer
incidence and mortality.
Slide overview: VILI is a promising, new approach to cervical cancer prevention,
however, it remains to be determined if VILI-based screening programs will result
in a reduced disease burden.
Note for bullet 2: The feasibility of utilizing VILI for wide-scale screening will be
determined, to a larger extent, by the capacity to maintain effective training and
monitoring efforts.
Note for bullets 3 and 4: Current ACCP research may provide valuable information
on VILI’s sensitivity and specificity, program effectiveness in detecting high-grade
lesions, and prevention of cervical cancer.
37. 18
References:
❚ ACCP. Visual screening approaches: Promising alterative screening
strategies. Cervical Cancer Prevention Fact Sheet. (October 2002).
❚ Sankaranarayanan R, Wesley R, Thara S, Dhakad N, Chandralekha
B, Sebastian P, Chithrathara K, Parkin DM, Nair MK. Test
characteristics of visual inspection with 4% acetic acid (VIA) and
Lugol's iodine (VILI) in cervical cancer screening in Kerala, India.
International Journal of Cancer 106(3):404-408. (September 1,
2003).
❚ Sankaranarayanan R,Rajkumar R, Arrossi S, Theresa R, Esmy PO,
Mahé C, Muwonge R, Parkin DM, Cherian J. Determinants of
participation of women in a cervical cancer visual screening trial in
rural south India. Cancer Detection and Prevention 27(6):415-523
(November-December 2003).
38. 19
For more information on cervical
cancer prevention:
❚ The Alliance for Cervical Cancer Prevention (ACCP)
www.alliance-cxca.org
❚ ACCP partner organizations:
❙ EngenderHealth www.engenderhealth.org
❙ International Agency for Research on Cancer
(IARC) www.iarc.fr
❙ JHPIEGO www.jhpiego.org
❙ Pan American Health Organization (PAHO)
www.paho.org
❙ Program for Appropriate Technology in Health
(PATH) www.path.org