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Schiller's test

Schiller's test, also known as the Schiller iodine test, is a diagnostic procedure primarily used in gynecology for the visual inspection of the uterine cervix to identify areas of abnormal epithelium, particularly in the context of cervical cancer screening. The test involves applying Lugol's iodine solution—a mixture of elemental iodine and potassium iodide in water—to the cervical surface; normal squamous epithelial cells, which contain glycogen, absorb the iodine and stain a characteristic mahogany brown color, whereas abnormal cells lacking sufficient glycogen, such as those in dysplasia or malignancy, fail to stain and appear pale yellow, white, or ocher.^[1]^[2] The test was developed in the late 1920s by Walter Schiller (1887–1960), an Austrian-born pathologist who emigrated to the United States, as a simple, non-invasive method to detect early squamous cell carcinoma of the cervix. Building on observations by W. Lahm in 1928 that anaplastic cells exhibit reduced glycogen content, Schiller evaluated nearly 200 dyes and determined that Lugol's solution, originally formulated in 1829 by French physician Jean Guillaume Lugol for therapeutic purposes, provided the optimal vital staining for cervical epithelium. First described in Schiller's 1928 publication in Zentralblatt für Gynäkologie, the test leverages the biochemical affinity of iodine for glycogen, a principle tracing back to early work by Paul Ehrlich in the 19th century on glycogen staining in tissues.^[3]^[2] Despite its historical significance as one of the earliest targeted screening tools for cervical pathology, Schiller's test has notable limitations, including low specificity due to false positives from inflammation, atrophy, or infection, and variable sensitivity influenced by factors like iodine concentration and application technique. It has largely been supplanted in high-resource settings by more accurate methods such as Papanicolaou (Pap) cytology and human papillomavirus (HPV) testing since the mid-20th century. However, it remains relevant in colposcopic examinations to delineate lesion margins for biopsy or excision and is integral to visual inspection with Lugol's iodine (VILI) programs in low-resource regions, where studies report sensitivities around 87% and specificities near 85% for detecting high-grade lesions.^[2]^[4]

Background

Definition and Purpose

Schiller's test, also known as Schiller's iodine test or visual inspection with Lugol's iodine (VILI), is a simple, low-cost screening procedure applied to the cervix to highlight areas lacking glycogen, which may indicate precancerous or cancerous changes.^[1]^[5] The test involves applying an iodine-based solution, such as Lugol's iodine, directly to the cervical surface during a pelvic examination.^[6] Introduced by pathologist Walter Schiller in 1928, it serves as a visual diagnostic aid in gynecology.^[3] The primary purpose of Schiller's test is to detect early cervical intraepithelial neoplasia (CIN) or invasive cervical cancer by staining the transformation zone of the cervix, thereby guiding targeted biopsies for further histopathological evaluation.^[3]^[6] It enables clinicians to identify suspicious lesions in real time without requiring laboratory processing, facilitating prompt intervention in at-risk populations.^[7] The mechanism relies on the biochemical interaction between iodine and glycogen present in normal squamous epithelial cells of the cervix, which produces a distinct mahogany-brown color change upon staining.^[5]^[1] In contrast, glycogen-depleted areas, such as those affected by dysplasia, inflammation, or malignancy, remain unstained, appearing pale yellow or white, thus delineating potential abnormal regions.^[5]^[8] Within the broader context of cervical screening, Schiller's test was developed as a bedside method particularly suited for resource-limited settings, where it offers an accessible alternative to more resource-intensive techniques like cytology-based screening.^[9]^[7] This approach supports early detection efforts in low- and middle-income countries by requiring minimal equipment and training.^[9]

Historical Development

Schiller's test was introduced in 1928 by Austrian pathologist Walter Schiller (1887–1960), who was working at the University of Vienna, as a vital staining method to visualize early cervical cancer by highlighting areas of abnormal epithelium.^[2] Schiller developed the test amid growing interest in detecting precancerous cervical lesions, drawing on prior observations of iodine's affinity for glycogen in healthy tissues, including Paul Ehrlich's 19th-century work on glycogen staining and W. Lahm's 1928 observation that the glycogen content of squamous epithelial cells decreases as anaplasia increases.^[3]^[2] In his seminal 1928 publication, "Zur histologischen Frühdiagnose des Portiokarzinoms," in Zentralblatt für Gynäkologie, he described applying the test to 533 cervical scrapings, demonstrating its utility in identifying non-staining regions indicative of dysplasia or malignancy. He followed this with an English-language article, "Early Diagnosis of Carcinoma of the Cervix," in Surgery, Gynecology & Obstetrics in 1933, detailing the process after evaluating nearly 200 different dyes and selecting Lugol's solution for its strong affinity for glycogen-rich normal squamous epithelium while leaving glycogen-poor abnormal areas unstained.^[3]^[2] The test gained popularity in the 1930s through 1950s, particularly in Europe, where it was integrated into colposcopy-assisted examinations by figures like Hans Hinselmann, influencing the evolution of visual inspection methods for cervical screening.^[2] Adoption spread to Scandinavia, France, Italy, Spain, and Latin America via Hinselmann's trainees, though uptake was slower in the United States and English-speaking countries until the 1960s.^[2] Its prominence waned after the 1960s with the widespread implementation of the Papanicolaou (Pap) smear, which offered higher specificity and enabled mass screening programs.^[2] The method experienced a revival in the 1990s as visual inspection with Lugol's iodine (VILI), adapted for low-resource settings to address barriers to cytological screening in developing countries. Pioneered by researchers like R. Sankaranarayanan, VILI was evaluated in large-scale studies, such as a 2003 trial in India demonstrating its feasibility for community-based programs. The World Health Organization has since endorsed VILI as an acceptable screening option in resource-limited contexts, particularly where Pap smear infrastructure is unavailable.^[10]

Performing the Test

Preparation and Materials

Schiller's test, also known as visual inspection with Lugol's iodine (VILI), is performed as part of a routine pelvic examination in an outpatient clinic or colposcopy room equipped with good lighting to ensure clear visualization of the cervix.^[7] The patient is positioned in the lithotomy position, with legs supported in stirrups, to allow access to the vaginal canal and cervix via a speculum.^[7] Prior to the test, the healthcare provider should obtain informed consent, review the patient's obstetric and gynecological history, and inform her of potential mild discomfort from speculum insertion.^[7] The test should be avoided in cases of active vaginal infection, heavy vaginal bleeding, or known iodine allergy, as these conditions may compromise accuracy or cause adverse reactions.^[11] For patients with known iodine allergy, the test should be avoided; an allergy history assessment is recommended.^[11] In pregnant patients, the test may be performed if clinically necessary, with caution advised.^[6] Essential materials include a bivalve speculum (such as Cusco's or Graves'), examination gloves, cotton swabs or ring forceps for application, and a bright light source like a halogen lamp.^[7] The key reagent is Lugol's iodine solution, prepared by dissolving 5 grams of iodine crystals and 10 grams of potassium iodide in 100 ml of distilled water to achieve a 5% iodine concentration, which is stored in a sealed brown bottle and usable for up to one month.^[7] Some protocols use a stronger variant akin to Schiller's solution with approximately 5% iodine for enhanced staining, though standard Lugol's is preferred to minimize irritation.^[7] If combining with visual inspection with acetic acid (VIA), 3-5% acetic acid solution is also required for prior application.^[7] Safety measures involve decontaminating instruments with 0.5% chlorine solution for 10 minutes followed by high-level disinfection, such as boiling in water for 20 minutes, to prevent infection transmission.^[7] If irritation occurs post-application, the area should be rinsed with water to alleviate symptoms.^[11] The provider must ensure the iodine solution does not stain the patient's clothing or skin excessively during the procedure.^[7]

Procedure and Interpretation

The procedure for Schiller's test begins after the cervix is exposed using a vaginal speculum. Excess mucus or discharge is gently cleaned with saline-soaked gauze if necessary to ensure clear visualization.^[12] Lugol's iodine solution is then applied evenly to the entire ectocervix and vaginal fornices using a cotton swab or applicator, covering the transformation zone and squamocolumnar junction.^[6] The solution is allowed to react for 1 to 2 minutes, during which the patient may experience a mild warming or stinging sensation.^[13] Observation is performed under adequate lighting, with optional magnification using a colposcope for enhanced detail; the entire process typically takes 5 to 10 minutes.^[6] Interpretation relies on the staining patterns resulting from iodine's affinity for glycogen in healthy squamous epithelial cells. Normal, glycogen-rich squamous epithelium stains a uniform mahogany brown, indicating healthy tissue.^[12] Iodine-negative areas appear pale, white, or unstained, suggesting a lack of glycogen and potential dysplasia, cervical intraepithelial neoplasia (CIN), or invasive cancer; these regions are targeted for further evaluation.^[6] Columnar epithelium in the endocervical canal may stain pale yellow, while patterns such as iodine-negative mosaic (fine, net-like borders) or punctation (dot-like unstained spots) can indicate abnormal vascular changes associated with lesions.^[13] Following observation, unstained or suspicious areas are marked and sampled via directed biopsy, such as punch biopsy for focal lesions or cone biopsy for extensive involvement, to confirm pathology.^[6] In some protocols, the test is combined with visual inspection with acetic acid (VIA), where acetic acid is applied first to highlight acetowhite areas, followed by iodine for confirmatory staining.^[12]

Clinical Relevance

Diagnostic Value

Schiller's test, also known as visual inspection with Lugol's iodine (VILI), demonstrates variable diagnostic performance in detecting high-grade cervical intraepithelial neoplasia (CIN2+) or invasive cancer, with reported sensitivity ranging from 60% to 90% across studies. A meta-analysis of 23 studies involving over 101,000 women found pooled sensitivity of 88% (95% CI: 82–93%) and specificity of 86% (95% CI: 83–89%) for CIN2+ detection.^[14] Specificity is generally lower, typically 40–70% in broader evaluations, leading to false-positive results that necessitate confirmatory testing.^[15] The test excels at visualizing lesions in the transformation zone, particularly when combined with colposcopy, with some studies reporting sensitivity over 90% for high-grade abnormalities.^[16] In low-resource settings, Schiller's test provides immediate results without requiring laboratory infrastructure, making it a valuable tool for primary screening and triage to biopsy.^[17] WHO-supported trials in the 2000s, such as those conducted in India, demonstrated that VILI's accuracy for CIN2+ detection is comparable to conventional Pap smears, with sensitivity around 87% versus 82%.^[18] Studies and reviews through the 2020s support its utility in reducing cervical cancer mortality in developing regions, where positive predictive values range from 10% to 20% for significant pathology, supporting scalable screen-and-treat approaches.^[19]^[20] It is often integrated adjunctively with HPV testing or cytology to improve overall diagnostic precision and confirm suspicious iodine non-uptake areas observed during the procedure.^[17]

Limitations and Alternatives

Schiller's test exhibits poor specificity, often leading to false-positive results that prompt unnecessary biopsies, as benign conditions such as inflammation, nabothian cysts, atrophy, metaplasia, and columnar epithelium fail to stain with iodine, mimicking abnormal areas.^[21]^[12] Interpretation of the test is inherently subjective and varies among examiners due to its reliance on visual assessment of staining patterns, which can be influenced by factors like lighting and experience. Additionally, the test is ineffective for detecting endocervical lesions, as it primarily visualizes the ectocervix and transformation zone.^[4] The procedure carries risks of mild vaginal irritation from the iodine application and, in rare cases, severe allergic reactions, including anaphylaxis, particularly in patients with iodine sensitivity.^[22]^[23] It is contraindicated in individuals with known iodine allergy and should be used with caution during pregnancy due to theoretical risks of iodine absorption affecting fetal thyroid function, though generally considered safe with minimal systemic effects.^[24] In high-resource settings, these limitations and risks, combined with the availability of more accurate methods, have rendered the test outdated, often resulting in over-treatment from false positives.^[4] Contemporary alternatives have largely supplanted Schiller's test. The Papanicolaou (Pap) smear, introduced in the 1940s, offers higher specificity through cytological examination and remains a standard screening tool.^[4] Human papillomavirus (HPV) DNA testing, widely adopted since the 2000s, provides superior sensitivity exceeding 90% for detecting high-grade precancerous lesions, enabling earlier intervention.^[25]^[26] Colposcopy followed by biopsy serves as the gold standard for confirmatory diagnosis, offering magnified visualization and targeted sampling.^[27] Visual inspection with acetic acid (VIA) provides a simpler, non-iodine-based visual alternative suitable for low-resource environments.^[4] As of 2025, Schiller's test is rarely employed in developed countries, where it has been replaced by cytology and primary HPV testing for improved accuracy and reduced subjectivity.^[4] In contrast, its variant, visual inspection with Lugol's iodine (VILI), persists in global health initiatives for low-income areas lacking laboratory infrastructure, as recommended by organizations like the Alliance for Cervical Cancer Prevention for its low cost and immediacy.^[12] Unlike Schiller's test, modern approaches such as liquid-based cytology and HPV assays minimize interpretive variability through standardized laboratory analysis and enhance detection of early HPV-related cervical changes.^[4]^[25]

References

[1]
Definition of Schiller test - NCI Dictionary of Cancer Terms
A test in which iodine is applied to the cervix. The iodine colors healthy cells brown; abnormal cells remain unstained, usually appearing white or yellow.
[2]
https://doi.org/10.1016/j.ejogrb.2021.04.011
[3]
Walter Schiller (1887–1960) | Embryo Project Encyclopedia
Aug 12, 2021 · In 1928, Schiller invented what later became known as the Schiller test to diagnose cervical cancer in women. To do that, he used Lugol's ...
[4]
Cervical cancer screening tests: Visual inspection methods
May 16, 2025 · ... Schiller [1]. However, Schiller's test has poor specificity and was almost entirely replaced with the advent of cervical cytology. Current ...
[5]
[PDF] Visual inspection with Lugol's iodine (VILI): Evidence to date
How VILI works: ❚ Squamous epithelium contains glycogen, whereas precancerous lesions and invasive cancer contain little or no glycogen.
[6]
Colposcopy - StatPearls - NCBI Bookshelf - NIH
Nov 12, 2023 · This is referred to as a "Schiller's test." A positive Schiller test is an area that is nonstaining with iodine.[9] An endocervical speculum ...
[7]
[PDF] A practical manual on visual screening for cervical neoplasia
Naked-eye visual inspection of the uterine cervix, after application of 5% acetic acid (VIA) and/or of Lugol's iodine. (VILI), provides simple tests for the ...
[8]
Cervical Squamous Cell Carcinoma - StatPearls - NCBI Bookshelf
The cervix is then painted with Schiller's iodine, which differentiates darker glycogen-laden cells from the paler glycogen-free cells, which are abnormal.Missing: mechanism | Show results with:mechanism
[9]
Comparison of the Accuracy of Papanicolaou Test Cytology, Visual ...
VIA or VILI can be used as a stand-alone cervical cancer screening test when compared with Papanicolaou test cytology, particularly in resource-limited settings ...
[10]
Syntheses of evidence - WHO guideline for screening and treatment ...
Index test could include any of the following: visual Inspection methods including visual inspection using acetic acid (VIA), lugol's iodine (VILI), automated ...
[11]
Use of potassium iodide in Dermatology: updates on an old drug - NIH
The iodine solution, or Lugol's solution, used in Schiller's test stains glycogen-rich areas. ... KI is also contraindicated in patients with any type of allergy ...
[12]
[PDF] Visual inspection with Lugol's iodine (VILI): Evidence to date
❚ Visual inspection with Lugol's iodine (VILI), also known as Schiller's test, uses Lugol's iodine instead of acetic acid.Missing: history | Show results with:history
[13]
Colposcopy and treatment of cervical intraepithelial neoplasia
The step-by-step procedure of doing the colposcopic examination is described in the next chapter. ... Principles of Schiller's (Lugol's) iodine test. The ...
[14]
https://doi.org/10.1111/1471-0528.14783
[15]
and middle-income countries: A systematic review and meta-analysis
Objective. To evaluate the performance of visual inspection with acetic acid (VIA) testing, visual inspection with Lugol's iodine (VILI), primary HPV testing, ...
[16]
Test characteristics of visual inspection with 4% acetic acid (VIA ...
The sensitivities of low-threshold VIA, high-threshold VIA, VILI and cytology to detect CIN 2 or worse disease were 88.6%, 82.6%, 87.2% and 81.9%, respectively; ...Missing: accuracy | Show results with:accuracy
[17]
WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention
### Summary of WHO Recommendations on VILI and Visual Inspection Methods for Cervical Screening
[18]
Cervical Imaging in the Low Resource Setting: A Review - MDPI
The positive predictive value of VILI is 16.8%, and the negative predictive value of 99.7%, resulting in many false positives. The specificity and sensitivity ...
[19]
Detection of cervical neoplasia: Reducing the risk of error
Columnar epithelium, inflammatory areas, recent biopsy sites and metaplastic areas also failed to take the iodine stain. Despite these drawbacks, the Schiller.
[20]
Anaphylactic-like reaction to lugol solution during colposcopy
We report that during the Schiller test, a patient complained of an anaphylactic-like reaction to the Lugol solution with vaginal and generalized pruritus, ...Missing: pregnancy | Show results with:pregnancy
[21]
Lugol's solution and other iodide preparations - NIH
Oct 26, 2017 · However, an anaphylactic-like reaction has been reported when using LS in diagnosis of cervical cell alterations (Schiller's test) [55]. Other ...Iodide Effects In Healthy... · Mechanisms Of Iodide On The... · Treatment With Ls
[22]
Cervical Biopsy - University of Rochester Medical Center
What are the risks of a cervical biopsy? · You are allergic to or sensitive to medicines, iodine, or latex. · You are pregnant or think you could be pregnant.<|separator|>
[23]
7 Primary HPV screening for cervical cancer - ScienceDirect
HPV tests were found to have higher sensitivity than cytology (96.1% vs. 53.0%) but somewhat lower specificity (90.7% versus 96.3%) [3]. Thus, HPV testing was ...
[24]
Cervical Specimen Self-Collection Is Finally Here - AAFP
Sep 30, 2024 · The HPV test is 90% sensitive for identifying cervical precancers. A previous AFP editorial advocated for primary HPV screening over co-testing ...
[25]
Various Methods of Cervical Cancer Screening - Siloam Hospitals
May 27, 2025 · 1. Pap Smear · 2. Visual Inspection with Acetic Acid (VIA) · 3. Schiller's Test · 4. HPV DNA Test · 5. Colposcopy · 6. Endocervical Curettage · 7.