Via

1. VIA

2. Cervical cancer is a preventable disease
Primary prevention:
Education to reduce high risk sexual behaviour
Measures to reduce/avoid exposure to HPV and other STIs
Secondary prevention:
Treatment of precancerous lesions before they progress to cervical
cancer (implies practical screening test)

3. “Down staging”
 A good screening method
Alternatives to Pap Smear

4. CERVIX

5. Types of visual inspection tests:
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).
Visual inspection with Lugol’s iodine (VILI), also known as Schiller’s
test, uses Lugol’s iodine instead of acetic acid.

6. Colposcopy / Digital Colposcopy
Cervicography
Automated pap smears
Molecular (HPV/DNA) tests

7. Naked eye (or low power magnification) inspection of cervix to detect
acetowhite abnormalities after applying dilute (3-5%) acetic acid
Cervix with
ACETO-WHITE lesionNegative

8. “VIA ..represents a proven, simple means of identifying cervical
intraepithelial neoplasia in developing countries.”
Commentary: P. Blumenthal. Detection of cervical intraepithelial
neoplasia in developing countries. The Lancet March 13, 1999

9. Unmagnified Visual inspection of the cervix to detect abnormalities
after applying acetic acid
Acetic acid is used to enhance and “mark” the acetowhite change of a
precancerous lesion or actual cancer
Sensitivity and specificity of VIA - 70-92%
Positive Predictive Value - 15-20%

10. The screening method before advent of Pap Smear
Due to expense & inconvenience VIA can be adjunct to cytology
patients in need of colposcopy could be identified more effectively and
efficiently
Cheaper , Easier & Effective means to identify a “normal”
transformation zone or detecting “precancerous” lesions of the cervix
Studies conducted to compare the efficacy of “naked eye” inspection
& “Colposcopy magnification” as a primary screening method

11. VIA IMAGES
NORMAL CERVIX
Cervix with
ACETO-WHITE lesion

12. VIA Category Clinical Findings
Test-negative No acetowhite lesions or faint
acetowhite lesions; polyp, cervicitis,
inflammation, Nabothian cysts.
Test-positive Sharp, distinct, well-defined, dense
(opaque/dull or oyster white) acetowhite
areas—with or without raised margins
touching the squamocolumnar junction
(SCJ); leukoplakia and warts.
Suspicious for cancer Clinically visible ulcerative, cauliflower-
like growth or ulcer; oozing and/or
bleeding on touch.

13. World Health Organization (WHO) supported a study in India between
1988 and 1991 in which unmagnified visual inspection with acetic acid
washing was evaluated as a "down staging" technique.
VIA was found to be effective in identifying women with cancer
at an earlier, more treatable stage.

14. SQJ
Squamous epithelium is smooth and pink
Columnar epithelium appears red
There are no aceto white changes

15. Squamocolumnar Junction with
Squamous Metaplasia
Normal Junction
Minimal white ring at junction
Squamous Metaplasia
normal variant

16. Categories for VIA tests results:
Suspicious for cancer
Photo source: PAHO, Jose Jeronimo

17. Aceto-white area far from squamocolumnar junction (SCJ) and not
touching it is insignificant.
Aceto-white area adjacent to SCJ is significant.
Negative Positive
Photo source: JHPIEGO

18. "VIA is a safe, simple and effective adjunct to the Papanicolaou
smear for cervical cancer screening” and can be helpful in reducing
referrals for colposcopy without compromising quality of care

19. Requirements:
VIA can be performed easily in any clinical setting
Examination table
Good light source / torch
Sterile gloves
Cusco’s speculum
Cotton swabs
Acetic acid in dilution 3-5 %

20. VIA is not performed:
During menses
During treatment with vaginal pessary
When suspicious mass is seen, acetic acid application is avoided &
patient referred for further oncology management

21. Procedure:
Informed consent
Relevant OBG history
Reassure pt – painless procedure
Ensure pt is fully relaxed
Modified lithotomy position
 Observed
Vaginal discharge
Ext genitalia
Introduce speculum
Adjust light Source

22. Under adequate light & under all aseptic precautions Cusco’s
speculum is inserted to visualise the cervix clearly
Fix the cusco’s so that cervix is stabilized
Any excess mucous or discharge is cleaned with sterile swab using
normal saline
Cervix is Inspected & looked at for any abnormality

23. Inspection of cervix done & findings described as
Hypertrophy
Redness or congestion
Irregular surface
Distortion
Simple erosions (do not bleed on touch)
Cervical polyps (with smooth surface)
Abnormal discharge: foul smelling, dirty / greenish, cheesy
white, blood stained
Nabothian follicles

24. After noting the abnormalities, it is washed liberally with diluted 5 %
acetic acid using a cotton swab on a sponge holding forceps or
sterile stick with cotton
5 % acetic acid = 5ml glacial acetic acid + 95ml distilled water
Wait for 1 whole minute
Inspect cervix for aceto white areas

25. Normal VIA
Normal appearing cervix
No aceto-white changes seen
Minimal translucent or very pale white epithelium at SCJ is normal
and may indicate squamous metaplasia
Record result
No further testing needed

26. Acetic Acid – Aceto-white Areas
Acetic acid
Dissolves mucus
Induces intracellular dehydration
Causes coagulation of protein
As a result cells with increased
Nuclear / Cytoplasmic ratio ratio
Nuclear density
Chromosomal aneuploidy
Become opaque – aceto-white area – test positive

27. Acetic Acid
Helps locate Squamocolumnar junction
Identifies the lesion & its limits
Decide whether the lesion is CIN
Determine whether invasion is possible
Select a site or sites for biopsy if appropriate

28. Result

29. After application - Note
Aceto–white areas
Margins
Surface
Gland openings
Mosaic & punctations
Abnormal vessels

30. Interpretation of “Aceto-white”
Following epithelial changes become aceto-white
Healing or regenerating epithelium
Congenital transformation zone
Inflammation
Immature squamous metaplasia
HPV infection
CIN / CGIN
Adenocarcinoma
Invasive squamous cell carcinoma

31. Reporting in VIA
Naked eye Visualisation of cervix is described as
Normal
Appearance-smooth, pink
Discharge-clear mucoid
External OS
In postmenopausal-atrophic

32. Abnormal
Hypertrophy
Redness or congestion
Irregular surface
Distortion
Simple erosions (do not bleed on touch)
Cervical polyps (with smooth surface)
Abnormal discharge: foul smelling, dirty / greenish, cheesy
white, blood stained
Nabothian follicles

33. Interpretation of “ABNORMAL”
Infection
Ectopy
Benign tumour
Suspicious Of Malignancy:
Erosion that bleeds on touch or friable
Growth, with an irregular surface or friable

34. Cervical Dysplasia
Opaque white epithelium
Occurs at SCJ

35. Cervical Dysplasia
Aceto white epithelium surrounds cervical OS
Internal margins of more densely white epithelium

36. Cervical Dysplasia
Diffuse aceto white changes
Most prominent at 6 & 10’o clock

37. Severe Dysplasia
Marked aceto-white epithelium
Abnormal raised contour

38. Carcinoma in Situ

39. Features of early cancer lesions
Oyster shell white
Rolled edges
Abnormal vessels
Friable
Uneven surface

41. Invasive Cancer
Raised lesion
Rolled edges
Raised white epithelium
Abnormal vessels
Important to biopsy

42. VIA test performance (n=7):
* Weighted median and mean based on study sample size
Source: Adapted from Gaffikin, 2003
Sensitivity Specificity
Minimum 65% 64%
Maximum 96% 98%
Median* 84% 82%
Mean* 81% 83%

43. Management – VIA Positive
If infection is suspected /present
Take a swab and send for analysis
Treat the patient accordingly
Re-examine after six weeks
If no signs of infection:
Perform Pap-smear and / or Colposcopy
Pap-smear / Colposcopy negative: re call for follow-up in
6-12 months
Pap-smear / Colposcopy positive: call the patient for
appropriate treatment

44. Limitations of VIA:
Moderate specificity results in resources being spent on
unnecessary treatment of women who are free of precancerous
lesions in a single-visit approach
No conclusive evidence regarding the health or cost implications of
over-treatment, particularly in areas with high HIV prevalence
There is a need for developing standard training methods and
quality assurance measures
Likely to be less accurate among post-menopausal women
Rater dependent

45. VIA Advantages
Non invasive, quick
Easy to perform
Can be performed by all levels of health workers
No sophisticated gadgets required
No special skills / training required
Reporting is simple, results available immediately
Can be very useful for mass screening across the entire length &
breadth of our country
Requires only one visit
Excellent sensitivity

46. Thank You