Comparison of diagnostic value of visual inspection with Lugol’s iodine to conventional Paps smear in detection of colposcopic biopsy proved CIN: a tertiary care experience

Manisha Bajaj, Shamshad Ahmad, Shubha S. Trivedi


Background: An organized cytological screening (Pap smear) is the mainstay for cervical cancer prevention and control programme. Financial and logistic burden of operating such a program is considerable. This has prompted the evaluation of alternative feasible techniques. It appeared from the earlier studies that visual inspection with lugol’s iodine (VILI) could be a potential alternative to cervical cytology. VILI is a low cost, easy to apply and highly sensitive technique. It gives result immediately thus allows doctors to “see and treat” at first visit. Objective of present study was to evaluate the performance of visual inspection with lugol’s iodine and its comparison with cytology in cervical cancer screening.  

Methods: 400 non-pregnant reproductive age women were subjected to Paps and VILI in this prospective study done in a tertiary-care centre in Delhi. Reference standard used for all was colposcopy and colposcopic-directed biopsy (when required).

Results: Of 400 Pap smears done 11.75% were normal, 77.5% inflammatory, 5.5% had ASCUS, 0.25% ASC-H, 0.5% AGUS, 2% LSIL, 1.5% HSIL and invasive cancer in 0.5%. With LSIL and above smears as significant, the sensitivity and specificity of Paps were 50% and 97.66% respectively. VILI was positive in 12.8% of cases. Sensitivity and specificity of VILI was 85.5% and 89.9% respectively. Overall accuracy of VILI in detecting pre-invasive lesion was 89.7% while with pap smear it was 96%.

Conclusions: Accuracy of VILI and Pap smear in detecting pre-invasive cervical lesion was comparable. At tertiary-care centers VILI can be used effectively to screen the patients with significant lesions. Patients can be directly subjected to further treatment at the earliest thus reducing loss to follow-up.


Cervical cancer, Colposcopy, Screening, Sensitivity, Specificity

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Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012 v1.0. Available at

Forouzanfar MH, Foreman K, Lozano R. The Challenge Ahead: Progress and Setbacks in Breast and Cervical Cancer | Institute for Health Metrics and Evaluation. Available at

Hakama M, Chamberlain J, Day NE, Miller AB, Prorok PC. Evaluation of screening programmes for gynaecological cancer. Br J Cancer. 1985 Oct;52(4):669-73.

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. J Indian Soc Med Paediatr Oncol. 2012 Jul;33(3):161-5.

Sarian LO, Derchain SF, Naud P, Roteli-Martins C, Longatto-Filho A, Tatti S, et al. Evaluation of visual inspection with acetic acid (VIA), Lugol’s iodine (VILI), cervical cytology and HPV testing as cervical screening tools in Latin America. This report refers to partial results from the LAMS (Latin AMerican Screening) study. J Med Screen. 2005;12(3):142-9.

Parkin DM, Bray F, Ferlay J, Pisani P. Global Cancer Statistics, 2002. CA Cancer J Clin. 2005 Mar 1;55(2):74-108.

Bhatla N, Mukhopadhyay A, Joshi S, Kumar A, Kriplani A, Pandey RM, et al. Visual inspection for cervical cancer screening; evaluation by doctor versus paramedical worker. Indian J Cancer. 2004 Jan 1;41(1):32.

Chou P, Chen V. Mass screening for cervical cancer in taiwan from 1974 to 1984. Cancer. 1989 Aug 15;64(4):962-8.

Lazcano-Ponce EC, Rascón-Pacheco RA, Lozano-Ascencio R, Velasco-Mondragón HE. Mortality from Cervical Carcinoma in Mexico. Acta Cytol. 1996;40(3):506-12.

Syrjänen K, Naud P, Derchain S, Roteli-Martins C, Longatto-Filho A, Tatti S, et al. Comparing PAP smear cytology, aided visual inspection, screening colposcopy, cervicography and HPV testing as optional screening tools in Latin America. Study design and baseline data of the LAMS study. Anticancer Res. 2005 Oct;25(5):3469-80.

Sankaranarayanan R, Wesley R, Thara S, Dhakad N, Chandralekha B, Sebastian P, et al. Test characteristics of visual inspection with 4% acetic acid (VIA) and Lugol’s iodine (VILI) in cervical cancer screening in Kerala, India. Int J Cancer. 2003 Sep 1;106(3):404-8.

Denny L, Kuhn L, Pollack A, Wainwright H, Wright TC. Evaluation of alternative methods of cervical cancer screening for resource-poor settings. Cancer. 2000 Aug 15;89(4):826-33.

Denny L, Kuhn L, Pollack A, Wright TC. Direct visual inspection for cervical cancer screening. Cancer. 2002 Mar 15;94(6):1699-707.

Sankaranarayanan R, Nene BM, Dinshaw K, Rajkumar R, Shastri S, Wesley R, et al. Early detection of cervical cancer with visual inspection methods: a summary of completed and on-going studies in India. Salud Pública México. 2003 Jan;45:399-407.

Belinson JL, Pretorius RG, Zhang WH, Wu LY, Qiao YL, Elson P. Cervical cancer screening by simple visual inspection after acetic acid. Obstet Gynecol. 2001 Sep 1;98(3):441-4.

of Zimbabwe U, Project JC. Visual inspection with acetic acid for cervical-cancer screening: test qualities in a primary-care setting. The Lancet. 1999 Mar 13;353(9156):869-73.

Mitchell MF, Schottenfeld D, Tortolero-Luna G, Cantor SB, Richards-Kortum R. Colposcopy for the diagnosis of squamous intraepithelial lesions: a meta-analysis. Obstet Gynecol. 1998 Apr 1;91(4):626-31.

Luthra UK, Prabhakar AK, Seth P, Agarwal SS, Murthy NS, Bhatnagar P, et al. Natural history of precancerous and early cancerous lesions of the uterine cervix. Acta Cytol. 1987;31(3):226-34.

ADDIS I. Intraepithelial disease of the cervix, vagina, and vulva. Berek Novaks Gynecol. 2007;576-8.

Sankaranarayanan R, Nene BM, Dinshaw KA, Mahe C, Jayant K, Shastri SS, et al. A cluster randomized controlled trial of visual, cytology and human papillomavirus screening for cancer of the cervix in rural India. Int J Cancer. 2005 Sep 10;116(4):617-23.

Miller AB, Nazeer S, Fonn S, Brandup-Lukanow A, Rehman R, Cronje H, et al. Report on consensus conference on cervical cancer screening and management. Int J Cancer. 2000 May 1;86(3):440-7.

Ghosh P, Gandhi G, Kochhar PK, Zutshi V, Batra S. Visual inspection of cervix with Lugol’s iodine for early detection of premalignant and malignant lesions of cervix. Indian J Med Res. 2012 Aug;136(2):265-71.

Saleh HS. Can visual inspection with acetic acid be used as an alternative to Pap smear in screening cervical cancer? Middle East Fertil Soc J. 2014 Sep 1;19(3):187-91.

Sankaranarayanan R, Basu P, Wesley RS, Mahe C, Keita N, Mbalawa CCG, et al. Accuracy of visual screening for cervical neoplasia: Results from an IARC multicentre study in India and Africa. Int J Cancer. 2004 Jul 20;110(6):907-13.

Shastri SS, Dinshaw K, Amin G, Goswami S, Patil S, Chinoy R, et al. Concurrent evaluation of visual, cytological and HPV testing as screening methods for the early detection of cervical neoplasia in Mumbai, India. Bull World Health Organ. 2005 Mar;83(3):186-94.

Sangwa-Lugoma G, Mahmud S, Nasr SH, Liaras J, Kayembe PK, Tozin RR, et al. Visual inspection as a cervical cancer screening method in a primary health care setting in Africa. Int J Cancer. 2006 Sep 15;119(6):1389-95.

Li N, Ma CP, Sun LX, Zhang YZ, Shao SL, Xing JX, et al. Evaluation on the visual inspection with Lugol’s iodine in cervical cancer screening program. Zhonghua Liu Xing Bing Xue Za Zhi Zhonghua Liuxingbingxue Zazhi. 2006 Jan;27(1):15-8.

Mandelblatt JS, Lawrence WF, Gaffikin L, Limpahayom KK, Lumbiganon P, Warakamin S, et al. Costs and benefits of different strategies to screen for cervical cancer in less-developed countries. JNCI J Natl Cancer Inst. 2002 Oct 2;94(19):1469-83.

Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, Gordillo-Tobar A, Levin C, Mahé C, et al. Cost-effectiveness of cervical-cancer screening in five developing countries. N Engl J Med. 2005 Nov 17;353(20):2158-68.

Juneja A, Sehgal A, Sharma S, Pandey A. Cervical cancer screening in India: Strategies revisited. Indian J Med Sci. 2007 Jan;61(1):34-47.