Dr. Sheeba Farooqui, Dr. Manisha Sharma, Dr. Namrata

COMPARATIVE STUDY OF VISUAL INSPECTION OF
CERVIX USING ACETIC ACID AND LUGOL'S IODINE WITH

PAPANICOLAOU’S SMEAR FOR THE SCREENING OF
PREMALIGNANT AND MALIGNANT LESIONS OF CERVIX

Dr. Sheeba Farooqui, Dr. Manisha Sharma, Dr. Namrata

INTRODUCTION
 Cervical cancer is an important health problem.
 Fourth most common cancer in women worldwide1.
 Second leading cause of female cancer deaths in India.
 Contributes 23.2% and 25.2% to the global cervical cancer

incidence and mortality respectively2.
 Several screening tests are available.
 The present study is aimed to compare the

effectiveness of the Papanicolaou’s smear with
visual inspection of cervix using acetic acid (VIA)
and Lugol’s iodine (VILI).
AIMS AND OBJECTIVES
 To perform Pap smear and visual inspection of

cervix using 3- 5% acetic acid and Lugol’s iodine.
 To perform biopsy on the abnormal positive Pap
smear and suspicious lesions suggested by the visual
inspection methods.
 To compare the results
MATERIALS AND METHODS
 STUDY DESIGN: A Hospital based cross-sectional

observational study
 PERIOD OF STUDY: April 2015- March 2017.
 PLACE OF STUDY: Department of Obstetrics and
Gynaecology, Hindu Rao Hospital, Delhi.
 STUDY POPULATION: All the sexually active women
above the age of 21 attending the Gynaecology OPD and
fulfilling the case definition.
 SAMPLE SIZE : This study comprises of 400 women
attending the Gynaecology OPD of Hindu Rao Hospital and
fulfilling the inclusion criteria.
PARTICIPANTS
Inclusion Criteria:
 All the sexually active women in the reproductive
age group above the age of 21 years.
 Those giving consent to participate in the study

voluntarily.
Exclusion Criteria:
 Refuse to take part in the study

 Abnormal result from previous screening
 Pregnant women
 Active bleeding per vaginum
 Post hysterectomy
 Never been sexually active.
 Undergone prior treatment for cervical
intraepithelial neoplasia or cancer cervix
STUDY METHOD
 A brief history
 Verbal-informed consent
 Studied in detail for the demographic profile,
predisposing factors and any other complaint
 Cervix was visualised under good lighting
 Pap smear was taken
 Reporting as per 2014 Bethesda System
 Cervix was painted with 3-5% acetic acid.
 Later on, cervix was painted with Lugol’s iodine.
 All suspicious or visible lesions were then biopsied.
 Cervical biopsy was taken as the gold standard.
 Statistical testing was conducted with the
statistical package for the social science system
version SPSS 17.0.
 Sensitivity, specificity, PPV, NPV and accuracy
was calculated.
VISUAL INSPECTION OF CERVIX USING ACETIC
ACID(VIA)
FIG 1:NORMAL LOOKING FIG 2:ACETOWHITE AREA ABUTTING

CERVIX ON VIA THE SQUAMOCOLUMNAR JUNCTION
FIG 3: ACETOWHITE AREA ON THE
CERVIX AFTER THE APPLICATION
OF 3-5% ACETIC ACID
VISUAL INSPECTION OF CERVIX USING LUGOL’S
IODINE(VILI)
FIG 4: CERVICAL ECTROPION SEEN AFTER

THE APPLICATION OF LUGOL’S IODINE FIG 5: PARTIAL IODINE UPTAKE
FIG 6: IODINE NEGATIVE AREAS ABUTTING
THE SQUAMOCOLUMNAR JUNCTION
OBSERVATIONS AND RESULTS
 The mean age of the patients included in the study

was 39.16 ± 6.30 years.
 81.3 % of patients were illiterate.
 Mean age at first sexual contact was 18.94 ± 3.02
years.
 Most of the women had the complaint of vaginal
discharge (62.3 %) or pain abdomen (56%) or both
(31%)
FIGURE 7: DISTRIBUTION OF WOMEN ACCORDING TO
FREQUENCY OF COMPLAINTS
TABLE 1: DISTRIBUTION OF WOMEN ACCORDING TO FINDINGS
ON PAP TEST AS PER BETHESDA SYSTEM3
ON VISUAL INSPECTION OF CERVIX USING ACETIC ACID(VIA)
BASED ON CATEGORISATION OF VIA RESULTS BY IARC4
ON VISUAL INSPECTION OF CERVIX USING LUGOL’S IODINE(VILI)
BASED ON CATEGORISATION OF VILI RESULTS BY IARC 4
TABLE 4: DISTRIBUTION OF WOMEN ACCORDING TO
CERVICAL BIOPSY REPORTS
TABLE 5: COMPARISON BETWEEN PAP SMEAR AND CERVICAL
BIOPSY
TABLE 6: COMPARISON OF RESULTS OF PAP SMEAR,VIA AND
VILI WITH CERVICAL BIOPSY
TABLE 7: COMPARISON OF SENSITIVITY, SPECIFICITY,
PREDICTIVE VALUES AND ACCURACY OF PAP TEST, VIA
AND VILI IN OUR STUDY
DISCUSSION
 The mean age of the women was 39.16 ± 6.30 years which was
comparable to the studies conducted by Hend S. Saleh et al5 and
Khan M et al6, who also found the mean age of the subjects as 36.2
± 10.3 years and 35.74 ± 9.64 years respectively.
 The mean age at marriage or first sexual contact was 18.94 ± 3.02
years which was comparable to the study conducted by Rani SA et
al7 who found that most of the women (73%) got married between
15-20 years of age.
 Most common presenting complaint among the patients in the
present study was white discharge per vaginum (62.3%). Rani SA
et al7 also found white discharge per vaginum as the most common
presenting complaint (63%) in their study while Ghosh P et al8
found that 91% of the patients had chief complaint of vaginal
discharge.
Table 8: Comparison between the sensitivity, specificity,
positive predictive value and negative predictive value of
Pap test in the present study with other studies
Table 9: Comparison between the sensitivity, specificity, positive predictive
value and negative predictive value of VIA/VILI in the present study with
other studies
TABLE 10: CORRELATION BETWEEN VIA AND
PAP TEST
TABLE 11:CORRELATION BETWEEN
VILI AND PAP TEST
CONCLUSION
 Pap test can be replaced by inexpensive visual

inspection methods, in low resource settings
 High sensitivity and negative predictive value
with acceptable specificity.
 May be used as an adjunct to enhance the
sensitivity of cytology based screening tests.
References
1. Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena M, Gómez D et al. ICO

Information Centre on HPV and Cancer (HPV Information Centre). Human
Papillomavirus and Related Diseases in the World. Summary Report 19 May 2017.
2. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C et al.
GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer
Base No. 11.Lyon, France: International Agency for Research on Cancer; 2013
3. Nayar R, Wilbur DC. The Bethesda System for Reporting Cervical Cytology.
Switzerland: Springer International Publishing; 2015.p. xii- xv.
4. International Agency for Research on Cancer (IARC) Handbooks of Cancer Prevention:
Cervix Cancer Screening. Vol. 10. Lyon, France: IARC Press; 2005 .p. 59- 83.
5. Hend S. Saleh. Can visual inspection of cervix with acetic acid be used as an alternative
to Pap smear in screening cervical cancer? Middle East Fertility Society Journal.
2014; 19(3): 187-91.
6. Khan M, Sultana SS, Jabeen N, Arain U, Khan S. Visual inspection of cervix with acetic
acid: a good alternative to Pap smear for cervical cancer screening in resource-limited
setting. J Pak Med Assoc. 2015 Feb; 65(2):192-5.
7. Rani SA, Rama K. Comparative Analysis of Visual Inspection with Acetic Acid And Lugol’s
Iodine And Liquiprep TM in Cervical Cancer Screening with Cervical Biopsy As Gold Standard.
IOSR Journal of Dental and Medical Sciences. 2016; 15(7), 54-62.
8. Ghosh P , Gandhi G, Kochhar PK, Zutshi V, Batra S. Visual inspection of cervix with Lugol's
iodine for early detection of premalignant & malignant lesions of cervix. Indian J Med Res.
2012 Aug; 136(2): 265–271.
9 . Albert S, Oguntayo O, Samaila M. Comparative study of visual inspection of the cervix using
acetic acid (VIA) and Papanicolaou (Pap) smears for cervical cancer
screening. Ecancermedicalscience. 2012; 6: 262.
10. Sankaranarayanan R. Screening for Cancer in Low- and Middle-Income Countries. Annals of
Global Health. 2014; 80 (5): 412-417.
11.Consul S, Agrawal A, Sharma H, Bansal A, Gutch M, Jain N. Comparative
study of effectiveness of Pap smear versus visual inspection with acetic acid and visual
inspection with Lugol's iodine for mass screening of premalignant and malignant lesion of
cervix. Indian J Med Paediatr Oncol. 2012 Jul; 33(3):161-5
12.Qureshi S, Das V, Zahra F. Evaluation of visual inspection with acetic acid And Lugol's iodine
as cervical cancer screening tools in a low-resource setting. Trop Doct. 2010 Jan; 40(1): 9-12.
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COMPARATIVE STUDY OF VISUAL INSPECTION OF

CERVIX USING ACETIC ACID AND LUGOL'S IODINE WITH

Dr. Sheeba Farooqui, Dr. Manisha Sharma, Dr. Namrata

 Cervical cancer is an important health problem.

 Fourth most common cancer in women worldwide1.

 Second leading cause of female cancer deaths in India.

 Contributes 23.2% and 25.2% to the global cervical cancer

 The present study is aimed to compare the

 To perform Pap smear and visual inspection of

 STUDY DESIGN: A Hospital based cross-sectional

 Those giving consent to participate in the study

 Refuse to take part in the study

FIG 1:NORMAL LOOKING FIG 2:ACETOWHITE AREA ABUTTING

FIG 4: CERVICAL ECTROPION SEEN AFTER

 The mean age of the patients included in the study

 Pap test can be replaced by inexpensive visual

1. Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena M, Gómez D et al. ICO

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