Information about LLETZ
(Large Loop Excision of the Transformation Zone)
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 essential, and why 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.
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. Up to 90% 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 has many sub-types, some of which are known as “high risk” sub-types, and can be associated with abnormal cells on the cervix.
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. Stopping smoking is important in helping prevent cervical and other cancers.
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) and the presence of CIN 2 or CIN 3 is known as High Grade Epithelial Abnormality (HGEA). Low-grade abnormalities are usually monitored rather than treated because they often go away on their own. High-grade abnormalities usually require 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. Other treatments include knife cone biopsy and laser cone. These procedures can usually be done awake, but I perform them while you are asleep, which is generally more pleasant for you. Low-grade abnormalities usually do not require treatment initially, however they can be treated with LLETZ, laser ablation, diathermy (burning) or cryotherapy (freezing), if they persist.
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 awake, under local anaesthetic, then I can refer you to the public colposcopy clinic at the Royal Hospital for Women.
A thin, wire loop with a cutting electric current is used to remove the very tip of your 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 heal.Precautions Following the Procedure
The treated area of the cervix must be allowed to heal properly. 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 LLETZ Procedure
You may 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 you are not allergic. Remember always to take them with food, otherwise they can irritate the stomach.
Short Term Complications
The most common short-term complication is infection, which occurs in less than 5% of cases. The symptoms to look out for are worsening bleeding, fevers, an offensive-smelling vaginal discharge, or 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, as you will usually need a course of antibiotics.
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 menstrual blood flow is obstructed. It may cause more difficulty becoming pregnant, if the sperm cannot pass through the cervical canal to fertilise the egg. It may also cause difficulty with dilatation of the cervix during labour and abnormal progress in labour.
Cervical incompetence is where the cervix is weakened, and can increase the risk of miscarriage or premature birth. Multiple procedures increase the risk of cervical incompetence. Traditional procedures, such as knife cone biopsies, tend to weaken the cervix more than the modern procedures, such as LLETZ. Nowadays only a small section of the tip of the cervix is removed, so the increase in miscarriage rate is small. Moreover 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, however there is a small increase in the risk of very preterm delivery.
Follow Up & Vaccination
Your follow-up initial visit will be 4 weeks after 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 majority of 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 my assessment of whether you have been fully treated, and how closely you need to be followed up in the future. Follow up is extremely important, as there remains a risk of recurrence.
The latest evidence suggests that the cervical cancer vaccination, Gardasil, reduces your risk of recurrence, so I recommend you request the vaccine from your GP, if you have not already had it. The cost is around $160 for each of the three injections. Gardasil covers two of the high risk sub-types. A vaccine covering more of the sub-types is being developed. In December 2017 Australia is going to replace conventional 2 yearly Pap smears with 5 yearly HPV DNA testing for everyone.
Prepared by Dr Rahul Sen. Updated 2017.