Fig. 3.1
VIA: Normal cervix and no acetowhite area
Fig. 3.2
VIA: Low-grade lesion; faint shady acetowhite areas are seen at 11 and 7 o’clock (biopsy done from these areas showed mild dysplasia)
Fig. 3.3
VIA: High-grade lesion-circumferential opaque acetowhite areas with well-defined margins
The rapid acetowhiteness of high-grade lesions can be explained by large number of dysplastic cells having more nucleoproteins in superficial layers of the epithelium.
Acetowhiteness may also occur in various conditions such as:
Immature squamous metaplasia
Congenital transformation zone
Leukoplakia
Condyloma
Inflamed, regenerating cervical epithelium
Acetowhiteness of these conditions is thin, less pale, translucent, and without well-defined margins and takes longer to appear and disappears more rapidly than CIN.
3.2.2 Procedure
For making freshly prepared 3–5 % acetic acid solution, 3–5 ml of glacial acetic acid is mixed with 95–97 ml of distilled water. After explaining the procedure to the woman, written content is taken. The perineum and external genitalia are inspected for lesions. The cervix is exposed by sterile speculum in good light, torch, or halogen lamp. The external os, columnar epithelium, squamous epithelium, squamocolumnar junction, and transformation zone are identified. Acetic acid is dabbed by sterile cotton swab and the cervix is inspected for acetowhite areas after 1 min. Acetic acid can be reapplied if in doubt, taking care not to induce bleeding. Several studies have found that VIA has a sensitivity of 76–97 % and specificity of 37–64 % [3, 4].
3.3 Visual Inspection with Lugol’s Iodine (VILI)
3.3.1 Principle
VILI involves the use of Lugol’s iodine to aid inspection of the cervix with the naked eye. Mature squamous cells store glycogen resulting in black or dark mahogany-brown staining. Immature squamous cells and metaplastic epithelium have small amounts of glycogen depending on the grade of maturity resulting in patchy staining. Neoplastic squamous epithelium contains little or no glycogen and does not stain with iodine.
3.3.2 Procedure
After explaining the procedure to the woman and taking written informed consent, the cervix is dabbed with Lugol’s iodine and inspected under bright light. Due to low glycogen content, premalignant and malignant lesions of the cervix are mustard yellow, while normal areas take up dark mahogany-brown stain (Figs. 3.4, 3.5, and 3.6).
Fig. 3.4
VILI: Normal cervix
Fig. 3.5
VILI: Low-grade lesion and iodine-negative area seen at 12–1 o’clock position (biopsy from this lesion showed mild dysplasia)
Fig. 3.6
VILI: High-grade lesion. Distinct iodine-negative areas are seen at 12 and at 6 o’clock positions (biopsy from these areas showed severe dysplasia)
3.4 Visual Inspection After Acetic Acid Application and Under Magnification (VIAM)
This is VIA done under low magnification using magnification devices. It is also called gynoscopy, aided visual inspection, or VIAM. VIAM has similar sensitivity and specificity as compared with VIA and does not have any added benefit over VIA as noted in the Mumbai cervix cancer trial [5].
3.5 VIA and VILI as a Screening Method
VIA has been analyzed as a promising alternative to more laboratory-dependent and expensive cytology. VIA has shown to have a low specificity compared to cytology and a high rate of false positives in several studies [10–12].
VIA clearly scores over cytology in low-resource settings, in terms of increased screening coverage, easy and improved follow-up care, and overall program quality [13]. As fewer specialized medical personnel and lesser infrastructure, training, and equipment are required in screening with VIA, cervical cancer screening can be easily performed successfully in more remote and less equipped health-care settings leading to higher coverage. Moreover, the results of VIA are available immediately, making it possible to screen-and-treat women during the same visit. This ensures the administration of treatment at the same visit and thus reduces the number of women who may miss out on treatment because they are not able to return to the clinic at another time. Certain benign conditions like inflammation, cervical condyloma, and leukoplakia can give false-positive results of VIA test [12, 14]. VIA has a low positive predictive value resulting in overdiagnosis and overtreatment [15].
The lesions above the endocervical canal which cannot be visualized represent a major problem especially for postmenopausal women where the transformation zone recedes inside the endocervical canal [16].
Various studies have demonstrated the low cost and ease of screening with acetic acid as an alternative to exfoliative cytology and human papillomavirus (HPV) DNA testing in areas where adequate infrastructure is not available.
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