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Cervical cancer screening

Training Module 2

Aided Visual Inspection of the Cervix

"Acetic Acid Test"

Saloney Nazeer

WHO Collaborating Centre in Education and Research in Human Reproduction


The objective of the aided visual inspection is solely to be able to recognize clinically normal (Acetic Acid Test Negative) from abnormal cervix (Acetic Acid Test Positive) and refer abnormal looking cases for further evaluation and diagnosis and appropriate treatment.

The aim is to detect and treat cervical dysplasia in asymptomatic women, to prevent development of cervical cancer. It can also be used to complement Pap-smear screening, where that facility is available, albeit in limitation.

Equipment required
  1. Examination table, preferrably with stirrups or leg supports
  2. Sterile speculum, preferably Cusco's
  3. Sterile rubber gloves
  4. Source of light, a lamp or a torch
  5. Cotton swabs
  6. Forceps
  7. Syringe for acetic acid lavage
  8. Acetic Acid in dilutions of 3-5%
  9. Stationary, to record examination findings
The Examination
  1. The procedure and the reason for it should be carefully explained to the woman to be examined and she should be made as comfortable as possible. Take into consideration the privacy of the patient.
  2. Put patient in lithotomy position (if possible) or suppine with legs bent at knees
  3. Good visualization is essential. Direct the light source to the genital area.
  4. Observe and record any abnormal findings in the external genitalia.
  5. Lubricate the speculum with warm water and insert into the vagina with the speculum closed.
  6. Open the speculum and adjust the light source so as to get a clear view of the cervix.
  7. If there is excess mucus or discharge, clean it with a cotton swab soaked in boiled water or normal saline solution.
  8. Observe any abnormal findings.
  9. Wash the cervix with the acetic acid (3-5%) with the help of the syringe.
  10. Wait for approximately 1 minute. Inspect the cervix for acetowhite area(s).


  • Do not perform the examination if the woman is having menstrual period or is using intravaginal medication. Advise her to come back when the mensus or the treatment is over.
  • Do not apply acetic acid if there is a gross lesion suspicious of malignancy, refer patient directly to oncology/tertiary care facility.
Reporting Visual Inspection Findings

The gross appearance of the cervix should be classified as follows:

Classification Appearance of the Cervix
BEFORE ACETIC ACID (see Unaided Visual Inspection of the Cervix "Clinical Downstaging" - Picture Atlas)

Clinical interpretation:
Can be;

  • 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
  • Prolapsed uterus
Suspicious of Malignancy
  • Erosion that bleeds on touch or friable
  • Growth, with an irregular surface or friable
(see Aided Visual Inspection of the Cervix "Acid Acetic Test" - Picture Atlas)
Acetic Acid Test Negative
  • Aceto-white area(s) not present
Acetic Acid Test Positive
  • Aceto-white area(s) present

Important: All findings, normal or abnormal, should be carefully recorded in the provided printed form. The patient should be informed and explained the follow-up procedure accordingly.

Referral Protocol
  1. Acetic Acid Test Negative ( Normal cervix): follow-up after 3-5 years according to the decided policy. Advise to come back if develops symptoms.
  1. Acetic Acid Test Positive (Abnormal cervix):
    If infection is suspected, take a swab and send for analysis. Refer the patient to the primary health clinic (PHC) for further evaluation and treatment.

At the PHC:

  • If signs of infection are present, treat the patient accordingly. Re-examine after six weeks.
  • If no signs of infection, perform Pap-smear (if available). Analyse smear on site, if not possible then follow-up cytology results in 1-2 weeks and inform patient accordingly.
    • Pap-smear negative: re call for follow-up in 6-12 months
    • Pap-smear positive: call the patient for appropriate treatment
  • Alternatively, if Pap-smear facility is not available perform Colposcopy:
    • Colposcopy negative: re call for follow-up in 6-12 months
    • Colposcopy positive : call for appropriate treatment