VIAC and how it works

Visual Inspection with Acetic Acid and Camera, or VIAC, is an effective way to prevent cervical cancer in women age 30-50 years old. It involves examining the opening of the womb, or the cervix, for changes that might lead to cancer. If these changes are detected early, the cells can be eliminated before they become cancerous. The cells are usually removed using a method called cryotherapy, or another method called LEEP. Both treatments are briefly described below.

VIAC examinations can also reveal possible advanced cervical cancer and certain noncancerous conditions such as chronic cervitis, pelvic inflammatory disease, and cervical polyps.

Visual inspection with acetic acid and treatment using cryotherapy or LEEP has been well-studied and is endorsed by the World Health Organization. WHO recommends using this “screen-and-treat” approach as an effective, low-cost way to reduce the incidence of cervical cancer in low-income countries. The disease is caused by the human papillomavirus (HPV), and it is the leading cancer killer of women in Zimbabwe and other sub-Saharan African countries.

The Zimbabwe Ministry of Health and Child Care has an established cervical cancer prevention program that offers VIAC screening and treatment at several of the nation’s major hospitals.

The VIAC procedure

  • VIAC begins by swabbing the cervix with a vinegar-like solution of dilute acetic acid.
  • If precancerous cells are present, the vinegar-like solution turns the abnormal cells white. This portion of the exam is the VIA—”visual inspection with acetic acid”—in VIAC.
  • Next, a camera with a special lens is used to photograph the cervix. The photo helps identify the presence of abnormal, precancerous cells.

Figure 1. Left, the location of the cervix in the body. Right, a photo of a healthy cervix taken during a VIAC examination at St. Albert’s Mission Hospital.

Cervical cancer arises in the transformation zone of the cervix

The opening of the cervix is a place where two different types of cells meet. The cells that line the cervical canal (the “endocervix”) are tall, narrow, columnar epithelial cells. The cells that cover the surface of the cervix (the “ectocervix”), on the other hand, are squamous epithelial cells, which are very flat.

The place where the columnar cells meet the squamous epithelium is called the transformation zone. Cell division occurs at this junction, and it is in this junction that cervical cancer

Figure 2. This photo of a cervix taken during a VIAC examination at St. Albert’s shows the white patches formed by precancerous cells.

occurs. Abnormal cells can arise here spontaneously or they can be induced by exposure to carcinogens such as certain strains of hPV or the chemicals produced during tobacco use. If these abnormal cells are not cleared by the immune system, they can progress to cervical cancer.

Why precancerous cells appear white after swabbing with dilute acetic acid

When precancerous cells arise, they have particular characteristics. They have larger nuclei and less cytoplasm, which is evidence of increased cell division (i.e., mitosis). When the cervix is swabbed with dilute acetic acid, the acid denatures the proteins in the precancerous cells, causing them to clump. It also dehydrates the cells. Light cannot penetrate these dense cells and instead is reflected back, making the cells appear white.

Figure 3. Photo taken during a VIAC examination at St. Albert’s showing a cervix with suspected cervical cancer. A definite diagnosis of cervical cancer requires further study of the tissue.

A nurse trained in VIAC can perform the screening exam, but if the exam reveals precancerous changes, possible cancer, or an inconclusive finding, the patient must be seen by a doctor for further care. If the precancerous cells are detected early enough, they are removed using either cryotherapy or LEEP, depending on their extent.

Cervical cancer develops over many years, passing through several stages. The earliest of these is the period in which abnormal cells are present but not yet cancerous. This precancerous stage is called cervical intraepithelial neoplasia (CIN). It is divided into three parts according to the degree of change present in the abnormal cells: CIN 1, CIN 2, and CIN3.

  • CIN 1: The cells are mildly abnormal; they are not treated because they often clear up when left alone;
  • CIN 2: The cells are moderately altered;
  • CIN 3: The cells show a severe degree of change.

Women identified through VIAC screening as having CIN 2 and CIN 3 stage precancer should receive treatment, usually using cryotherapy or LEEP.

Cryotherapy

Cryotherapy, also called cryocautery, destroys precancerous cells by freezing them with ice-cold gas. It is used when the acetic-acid-induced white areas cover less than 75% of the ectocervix and do not extend into the endocervix. It is a simple outpatient procedure, and clients can go home the same day.

Note: After cryotherapy, a disharge from the vagina might continue for two to four weeks. It is generally a mild discharge and does not need treatment.  But if it persists, the woman should see a doctor and a vaginal swab taken for culturing.

LEEP (Loop Electrical Excision Procedure)

LEEP removes abnormal areas from the cervix using a thin heated electrical wire that is  passed through transformation zone. It is done under local anesthetic on outpatient basis. The affected tissue is sent for histological review. The margin of the excision is coagulated during the procedure, resulting in minimal bleeding. LEEP is used when the white areas cover more than 75% of the transformation zone or extend into the endocervix.

Both treatments have a healing period of two to four weeks, with certain restrictions on a woman’s activity during that time. Complete healing generally takes about a month.

A few women might experience after-effects that must be treated at a health facility. Following either procedure, a woman should return to the treatment location after about six weeks to be checked and to receive her laboratory report.

After any of these treatments

  • Ask the doctor or nurse what to expect during the period of healing. Should you expect a discharge and how long will it last?
  • What activities is it OK for you do and what activities should you avoid?
  • What signs should you watch for that tell you you should return to the doctor?

58 Responses to VIAC and how it works

  1. Patience Matereke says:

    Hie . I live Overseas and have been having pap smears . Some are saying VIAC is the modern way of checking for cancer. I went to my doctor requesting for a VIAC and she stated that they dont do it here its outdated. Please help. Am confused now. Thanks. Patience

  2. Darrell Ward says:

    Hello, Patience, and thank you for your question. You have no cause for worry. Pap testing, also called “cytology,” is a highly effective test that is used to screen women for early signs of cervical cancer. It is the oldest screening test used to prevent cervical cancer. The test involves gently scraping the cervix to collect a sample of cells. The sample is placed on a microscope slide and specially stained to reveal the cells. That preparation is called a Pap smear. A doctor (that is, a pathologist) examines the cells in the sample using under a microscope. He or she looks for abnormal cells that show signs of being pre-cancerous or cancerous. Pap testing usually requires a woman to return to the doctor to repeat the test over a number years to monitor her for the appearance of pre-cancerous cells.

    In addition to the Pap test, two other methods are used to screen women and prevent cervical cancer. One of these is VIAC, which stands for visual inspection with acetic acid and cervicography (photographing the cervix as part of the test for quality control). VIAC reveals the presence of abnormal cells that might be precancerous. The presence of those cells is revealed immediately, and the woman can be treated during the same visit using cryotherapy or another therapy that destroys the abnormal cells. VIAC is a relatively inexpensive and effective method for preventing cervical cancer. Unlike Pap testing, it usually does not require the preparation microscope slides that must be examined by a pathologist. (However, when a VIAC exam suggests that cancer might be present on the cervix, a biopsy of the abnormal cervical cells will be taken and the sample sent to a pathologist to confirm that cancer is present.)

    VIAC is therefore a relatively inexpensive screening method, compared to Pap testing, and screening and treatment are possible during one visit to the clinic, making it more convenient for women who must travel long distances and have little or no money. Studies have shown that VIAC does prevent cervical cancer, and the method is endorsed by the World Health Organization for preventing cervical cancer in under-resourced countries. But VIAC is less precise than Pap testing. Abnormal cells that are revealed by VIAC might not truly be pre-cancerous; they might be abnormal of other reasons. However, the incidence of cervical cancer is very high in Zimbabwe and the region, in part because of the high rate of HIV infection, so treating all abnormal cells revealed by VIAC as pre-cancer can save many lives of women, keep families together and prevent children from becoming orphans.

    The third and newest method of preventing cervical cancer is to test women for the presence of HPV infection. HPV, the human papillomavirus, causes nearly all cases of cervical cancer. If a woman is not infected with HPV, she is unlikely to develop cervical cancer. Unfortunately, HPV testing remains too expensive for most under-resourced countries, but we hope it will one day be available worldwide. (Use of HPV vaccination can also protect girls, boys, women and men from HPV infection to start with and thereby prevent cervical cancer.)

    Thanks, Patience, and keep well…Darrell

  3. Patience Matereke says:

    Thanks Darrell . I recently had the HPV testing. All good.

  4. Darrell Ward says:

    That is great news, Patience. Thank you for writing back.
    Keep well…Darrell

  5. kim says:

    hie what are the effects of having sex a week after cryo

  6. Darrell Ward says:

    Hello, Kim, and thank you for your question. Zimbabwe Ministry of Health and Child Welfare guidelines say that a woman should not have sexual intercourse for one month after cryotherapy so as to avoid infection while the cervix is healing.
    Keep well…Darrell

  7. munemo c says:

    hello doctor when a cervix is diagnosed as clinically suspicious ,who long can one wait before the colonoscopy.what are the effects of delay?

  8. Darrell Ward says:

    Hello, and thank you for your question. I am not a doctor, but I have forwarded your question to a doctor in Zimbabwe. I will add his reply here after I receive it. In the meantime, I will say that when abnormal cells on the cervix are classified as suspicious of cancer, a sample of your cells — a biopsy — would have been taken and sent to a pathology lab. There a specialist will examine them under a microscope and confirm whether or not they are cancer cells. If the pathologist confirms that they are cancer cells, your doctor, nurse or midwife at the VIAC clinic will tell you and refer you to a clinic that specializes in treating cancer patients. You should try to learn whether your cells were cancerous or not as soon as possible and seek treatment as soon as possible. Thank you and I hope all goes well for you…Darrell

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