Abnormal Pap Smears

Information about LLETZ (Large Loop Excision of the Transformation Zone)
    
Introduction
You have probably been told that you have abnormal cells on the cervix.  THAT DOES NOT MEAN THAT YOU HAVE CANCER.  In many cases the abnormal cells may go away on their own, but in some cases you may require treatment.  Abnormal cells on the cervix can sometimes, if left alone for long enough without treatment, develop into cancer of the cervix.  That is why follow up is so important, and treatment is sometimes necessary.  Cancer usually takes years to develop.  Proper follow up with a gynaecologist is the best way of ensuring that a cancer does not occur.    

HPV
The abnormal cells on the cervix occur in the presence of a virus, known as the Human Papilloma Virus or HPV.  HPV belongs to the wart virus family and is a very common virus.  As many as 80% of sexually active people carry the virus at some time in their life.  Like many other viruses HPV can be cleared by your body’s immune system.  HPV many sub-types, some of which are known as “high risk sub-types” and can be associated with abnormal cells on the cervix.

Smoking
When you smoke (even passively) the toxins in cigarettes are concentrated 50-fold in the cervical mucus.  This can contribute to the actions of the high risk HPV subtypes in causing abnormal cells to form.

CIN
The abnormal cervical cells are classified into grades of abnormality, known as CIN (Cervical Intra-epithelial Neoplasia) 1, 2 or 3.  The presence of HPV effect or CIN 1 is known as Low Grade Epithelial Abnormality (LGEA) or Low-grade Squamous Intra-epithelial Lesion  (LSIL) and the presence of CIN 2 or CIN 3 is known as High Grade Epithelial Abnormality (HGEA) or High-grade Squamous Intra-epithelial Lesion – (HSIL).  Low-grade abnormalities are usually monitored rather than treated because they may go away without treatment.  High-grade abnormalities are usually treated.

Treatment
There are several types of effective treatment for high-grade abnormalities, however the most common is the Large Loop Excision of the Transformation Zone or LLETZ.  This is also known as LEEP.  Other treatments include knife cone biopsy and laser cone.  These procedures can sometimes be done awake, but are usually done under general anaesthetic, so that you are asleep.  Low-grade abnormalities usually do not required treatment, however they can be treated with LLETZ, laser ablation, diathermy (burning) or cryotherapy (freezing), especially if they persist.

LLETZ
The transformation zone is the area of the cervix where the abnormal cells occur.  The LLETZ procedure is performed as a day case at the Royal Hospital for Women or Prince of Wales Private Hospital in Randwick.  It is performed under General Anaesthetic, so you will be asleep.  If you wish to have the procedure done under local anaesthetic then you can be referred to the colposcopy clinic at the Royal Hospital for Women.

A wire loop with an electric cutting current is used to remove the tip of the cervix.  A burning current is then used to cauterise the base of the cervix.  This both stops the bleeding, and extends the depth of the treatment without removing more of the cervix.  A special solution, known as Monsel’s solution is then applied to the treated area to help prevent bleeding and to help it to heal.

Precautions Following the Procedure
The treated area of the cervix must be allowed to heal.  The initial healing takes 4 weeks.  During this time the cervix is very vulnerable to damage and to infection, especially viruses.  It is very important that for the first 4 weeks following a LLETZ procedure you DO NOT PUT ANYTHING INTO THE VAGINA.  That means do not have sexual intercourse, do not use tampons and do not go swimming or have baths for 4 weeks after the procedure.  You should also avoid any vigorous exercise, which may dislodge blood clots and cause bleeding.   You should then have a check-up with me, to check that the cervix is healing before resuming normal activities.

What to Expect Following the Procedure
You will notice quite a heavy vaginal discharge following the procedure.  This may also be blood-stained initially, and is quite normal.  You may also experience period-like cramping for the first few days following the procedure.  Anti-inflammatory tablets, such as Naprosyn, may be helpful if the cramping is severe and you are not allergic.  Remember always to take them with food.

Short Term Complications
The most common short-term complication is infection, which occurs in under 5% of cases.  The symptoms to look out for are worsening bleeding, fevers, an offensive-smelling vaginal discharge, and cramping, lower abdominal pain.  If these occur then you should contact my rooms immediately for advice.  After hours you should come to the emergency department at Prince of Wales Hospital in Randwick.

Long Term Complications
The two main long-term complications are cervical stenosis and cervical incompetence.  Cervical stenosis is narrowing of the entrance to the cervix due to scarring.  It may cause more painful menstrual periods, if the blood flow during a period is obstructed.  It may cause more difficulty becoming pregnant, if the sperm cannot pass through the canal to fertilise the egg.  It may also cause difficulty with dilatation of the cervix during labour.

Cervical incompetence is where the cervix is weakened, and can increase the risk of miscarriage or premature delivery.  Multiple procedures increase the risk of cervical incompetence. Traditional procedures, such as knife cone biopsies tend to weaken the cervix more than the new procedures, such as LLETZ.  Nowadays only a small tip of the cervix is removed, so the increase in miscarriage rate is small.  Similarly the pre-term delivery risk occurs mainly after 34 weeks of pregnancy, when the consequences to the baby from being born prematurely are not so severe.
    
Follow Up
You initial visit will be 4 weeks following the procedure.  You will be given the results of the cervical biopsy.  We hope for “clear margins”, which indicates that all the abnormal cells have been removed.  Do not worry if the margins are not clear, however, as the abnormal cells are still likely to have been treated.  Close follow up will determine whether the abnormal cells have all gone and whether further treatment is required.

You will generally return for repeat colposcopy and Pap smear at 6 months and 12 months post procedure.  A high risk HPV DNA test will generally be performed at 6 and 12 months, which will help in our assessment of whether you have been fully treated and how closely you need to be followed up in the future.

Prepared by Dr Rahul Sen, February 2011