We have now for many years been offering cervical screening to all sexually active women to look for abnormal changes on the neck of the womb (cervix) that may increse the risk of her developing cervical cancer. We can then offer treatment that hopefully will help in preventing the progression to cancer.
The two most common abnormalities of interest detected are
- Cervical dysplasia , also known as cervical intraepithelial neoplasia (CIN)
- Adenocarcinoma in situ (ACIS)
Of course it is also to pick up cancer of the cervix but by and large, this is less common, and hopefully getting less so.
Both of the above conditions can be considered pre cancerous. However, with CIN, it is only those with grade 2 or 3 that we would consider treating. This is because CIN 1, considered low grade change, can spontaneously resolve over time. So in CIN 1, it is usually conservative management with close observation that is used.
There have been over time many treatments evolved for treating these conditions. All involve trying to remove the area of abnormality. Most involve a limited removal of the skin covering the cervix. Some may easily be done without an anaesthetic but most these days require either a local or general anaesthetic. This article is to discuss treatment of the above two conditions.
The various ways for treatment are as follows:
- Cervical cautery. At its simplest, this involves burning of the cervix either by electrical heat or sometimes by cold nitrogen cautery. I have not seen the latter for many years. Easy to do but it gives an uncertain degree of treatment. One cannot be sure how much tissue is removed. Furthermore, the tissue cannot be sent for further pathology testing.
This technique can be performed for other reasons where there is no concern about abnormalities. For example, some women complain of a persistent heavy vaginal discharge due to increased glandular tissue on the cervix. Too much glandular tissue leads to increase mucus production and a discharge. By doing this, it helps to eradicate the excess glandular tissue and can lead to a reduction in discharge.
- Laser therapy. This uses a CO2 laser to vapourise the tissue. Usually done under colposcopic (microscopic) control it is a very precise method of removing the affected tissue. It can also be done to precise depth that is required. Depending on the power of the Laser used, it can be quite slow. A good method, but again no tissue is conserved to be sent for further pathology testing. I used to use this technique but have ceased using this for a number of years in favour of the excision (LLETZ) technique.
- LLETZ. This involves using electrical cautery to excise out the affected area. It allows an accurate depth of tissue to be removed and importantly, the tissue can then be sent off for further pathology testing. This is important in my opinion as it can tell is there are changes more serious than what is suspected. Also it can, in most cases, tell if all the abnormal areas have been removed.
- Cone biopsy. In this method, a large area of the cervix is cut out. In fact when taken out, the tissue looks like the shape of an ice cream cone, hence the name. It is a much larger procedure and requires a general anaesthetic. The cone biopsy is important as it can remove tissue deep into the cervix, something that the above techniques cannot reliably do. In fact, many years ago, before the availability of colposcopy, it would be the technique used in all women with abnormal smears irrespective of age or pregnancy status.These days the cone biopsy is used mainly for women where there is concern that there would be significant abnormalities high in the cervix which cannot be seen on colposcopy or women who have ACIS. This is because removal of a large part of the cervix can weaken the cervix and this may lead to miscarriages in future pregnancy. Furthermore, for all the other women, a simple excision technique is sufficient to treat them.
- Hysterectomy. This is not usually performed as primary treatment for CIN or ACIS. However it may need to be considered if there is recurrent abnormalities despite other treatments. Where fertility is no longer required or the recurrence is becoming significant, then it may be a considered option. In ACIS, it would be a topic of discussion when fertility is no longer an issue due to the risk of recurrence of ACIS and the difficulty in picking this up.
Risks of therapy.
Apart from hysterectomy, the other techniques basically all have the same risks. These include:
- All operations cause bleeding. In this situation, the bleeding can go for a long time. Usually 1 week or so, and then there can be a discharge for over 6 weeks.
- Due to the raw area present, there is a risk of infection. Even with preventative antibiotics, this can happen. One particular time is 10 -14 weeks post surgery. It can lead to very heavy bleeding should that happen. In some, they may need readmission to Hospital and more surgery to settle the bleeding. For most this is not likely though it is unpredictable as to who it may affect.
- Cervical incompetence. This is where the cervix is weakened and in a future pregnancy, it can lead to miscarriage. More the issue with cone biopsies, it can also happen if repeated LLETZ or laser is done. If need be, a stitch can be inserted during the pregnancy to minimse the risk.
Long term outcomes
These are generally good. However, the cervical abnormalities can recur. It will depend on the type of Human papilloma virus present, the severity of the dysplasia and the extent of the affected area in the first instance. Other factors contributing to it will be one’s general health, use of medications that can affect the immune system and drugs like smoking etc.
These notes reflect my personal opinion and are intended for general advice only. It should not be relied upon for any one individual case. You should consult your own doctor to determine the appropriate management of your own individual situation.