Least morbidity with LEEP. Morbidity was compared with one-on-one trials of different techniques ( TABLE 1 ). The review noted that LEEP has the least morbidity (such as hemorrhage, infection, cervical stenosis, and midtrimester pregnancy loss) while providing the most reliable histology by excising tissue without causing thermal artifact ( FIGURE ).
Higher rate of hemorrhage with cone biopsy. Another systematic review of 21 controlled trials comparing treatments for CIN 2 or 3 found a similar efficacy of all the modalities, including cone biopsy, cryotherapy, laser ablation, and LEEP. However, it also found a trend toward a higher rate of significant hemorrhage among women who received cone biopsies compared with women who received either laser ablation or LEEP.2
FIGURE
CIN 2 and 3 and its treatment by LEEP
TABLE 1
CIN 2 and 3 treatment options: An outcomes comparison
| COMPARISON OF TREATMENTS | OUTCOME/MORBIDITY | ODDS RATIO (95% CI) |
|---|---|---|
| Laser ablation vs cryotherapy | Laser ablation had more perioperative severe bleeding | 7.45 (1.68–33) |
| Laser ablation had higher rates of future adequate colposcopy | 4.64 (2.98–7.27) | |
| Laser conization vs knife conization | Laser conization had higher rates of future adequate colposcopy | 2.73 (1.47–5.08) |
| Laser conization had less cervical stenosis | 0.39 (0.25–0.61) | |
| Laser conization vs LEEP | Laser conization had more severe pain during procedure | 5.36 (1.02–17.2) |
| LEEP had fewer inadequate future colposcopies | 0.27 (0.08–0.89) | |
| Source: Martin-Hirsch et al, Cochrane Database Syst Rev 2000.1 | ||
Surgical treatment raises obstetric risks
There is a concern regarding future obstetric outcomes for women who have undergone surgical treatment of a high-grade cervical lesion. A recent meta-analysis of 27 controlled cohort studies found that cold knife conization and LEEP were associated with increased obstetrical risks, such as delivery at less than 37 weeks’ gestation and a birth weight <2500 g ( TABLE 2 ). Any resection that was more than 10 mm deep increased the risk of prematurity with future pregnancies (pooled relative risk=2.6; 95%] CI, 1.3–5.3).3
TABLE 2
Obstetrical outcomes for CIN 2 and 3 treatment options
| TREATMENT TYPE | OBSTETRICAL OUTCOME | RELATIVE RISK (95% CI) |
|---|---|---|
| Cold knife conization | Preterm delivery | 2.59 (1.80–3.72) |
| Low birth weight | 2.53 (1.19–5.36) | |
| Cesarean delivery | 3.17 (1.07–9.40) | |
| Laser conization | Preterm delivery | 1.71 (0.93–3.14) |
| LEEP | Preterm delivery | 1.70 (1.24–2.35) |
| Low birth weight | 1.82 (1.09–3.06) | |
| Preterm premature rupture of membranes | 2.69 (1.62–4.46) | |
| Source: Kyrgiou et al, Lancet 2006.3 | ||
Recommendations from others
Consensus guidelines from the American Society for Colposcopy and Cervical Pathology (ASCCP) and a practice bulletin from the American College of Obstetricians and Gynecologists (ACOG) both recommend immediate removal of the entire transformation zone, with either ablative or excisional treatment as initial treatment of CIN 2 and 3 for patients who are not pregnant.4,5
Value of excisional treatment. The ASCCP guidelines note that there is a benefit to excisional treatment, as it allows pathologic assessment of the excised tissue. Some of the ASCCP guideline authors recommend excisional procedures for the management of large CIN 2 and 3 lesions, which are at increased risk of having microinvasive disease.4
For women with unsatisfactory colposcopy and biopsy-proven CIN 2 or 3, there is up to a 7% risk for an occult invasive cervical carcinoma.1,4 Performing a diagnostic excisional procedure is recommended on these patients.4,6
ASCCP and ACOG make special recommendations for both adolescents and pregnant women.
For adolescent patients with biopsy-proven CIN 2, a recent ACOG Committee Opinion recommends close follow-up—with Pap smears or colposcopies every 4 to 6 months—due to the high rates of resolution of CIN 2 in adolescents.7
For pregnant patients, diagnostic excisional procedures are associated with complications such as bleeding and preterm delivery, while there is minimal risk of CIN 2 or 3 progressing to invasive cervical cancer.4,8 In pregnancy, follow CIN 2 and 3 with colposcopy each trimester, and reevaluate at 6 to 12 weeks postpartum. Limit any diagnostic excisional procedures to cases where you cannot rule out invasive cancer.4,5