A LEEP is one of the diagnostic excisional procedures for the removal of high grade cervical dysplasia.1,2 A thin, loop-shaped wire attached to an electrosurgical generator is used to pass around and under the transformation zone, excising the abnormal portion of the cervix using thermal energy. The electrical current allows the loop tool to both cut and coagulate at the same time, although its use is followed by a ball electrode to complete the coagulation. The removed specimen is sent to a pathology laboratory for further analysis to help determine the extent of the lesion. In this way, LEEP is both a treatment and a diagnostic procedure.
The procedure is often done at the doctor’s office and is brief, usually taking less than 30 minutes.1 It begins very similarly to a colposcopy, in which the patient is placed in lithotomy position, a speculum is placed, and a colposcope may be used to better visualize the cervix. Local anesthetic and a vasoconstrictive solution are administered to minimize discomfort and bleeding. Application of local anesthetic is often associated with an initial burning sensation that fades as the anesthetic begins to work.
Some patients worry that treatment for high grade lesions can be associated with adverse pregnancy outcomes or infertility. There is minimal evidence that cervical treatments, whether ablative or excisional, negatively affect the ability to get pregnant. Although a small risk of certain negative pregnancy events is present, incidence is low, so the benefits of high-grade lesion treatment exceed the risk in most cases.
A 2014 systematic review and meta-analysis of 15 studies (n=38,050) found that pregnancy rates were higher among women who received either excisional or ablative treatment for cervical intraepithelial neoplasia than those who went untreated (n=31155) (43% vs 38%).3 The overall rate of miscarriage and miscarriage in the first trimester were similar between the treated and untreated groups. Overall miscarriage rates were 4.6% (350/7660) among treated group and 2.8% (886/31,844) in the untreated group (Relative Risk [RR]=1.04, 95% Confidence Interval [CI]=0.90-1.21). Miscarriages in the first trimester occurred at a rate 9.8% (51/519) in the treated group vs 8.4% (49/584) in the untreated group (RR=1.16, 95% CI=0.80-1.69). Cervical treatment was significantly associated with increased risk of second trimester miscarriage with a rate of 1.6% (258/16,558) in the treated group vs 0.4% (8520/2,165,710) in the untreated group (RR 2.60,95% CI = 1.45-4.67). Ectopic pregnancies were more common in the treated arm (1.6% [114/6985] vs 0.8% (239/31,208) with a RR of 1.89 (95% CI=1.50-2.39) compared to untreated controls. Pregnancy termination was more common among women with a history of treatment (12.2%, 852/6990) as opposed to untreated individuals (7.4%, 2320/31,218) (RR=1.71, 95% CI=1.31-2.22).
A 2014 retrospective cohort study (n=1,355) found that comparing women who had received an excisional procedure and those who had not, there was no significant difference in rate of pregnancy (88.4% vs 89.7%), time to conception (median of 3 months for both), or perceived difficulty getting pregnant (17.2% vs 19.2%).4 Within a subset of the study population who had significant surgery (cold knife conization or repeat LEEP, n=59), there was more discrepancy in rate of pregnancy (72.7% vs 89.7%) and perceived difficulty getting pregnant (25% vs 19.2%).
A 2011 meta-analysis of 30 cohort studies found that those who received treatment for precancerous cervical lesions experienced higher rates of preterm birth.5 Those who had excisional treatment (n=17,344) had 8.9% incidence of preterm birth and those who had ablative treatment (n=6,355) had 6.8% incidence compared to the comparison group (n=1,227,449) which had 4.4% incidence of preterm birth (RR=2.19 for excisional treatment and RR=1.47 for ablative treatment).
A population-based retrospective cohort study taking place from 2001-2004 in Wales found that risk of preterm birth was similar among those who only received a colposcopy and those who received both a colposcopy and treatment, suggesting that the presence of abnormal cervical cells is likely the cause of increased risk rather than treatment.6 Those with a negative smear were used as comparison (n=38,983) and had 7.2% incidence of preterm birth (5.9% <37 weeks, 1.0% <32 weeks, 0.3% <28 weeks), those who received only a colposcopy (n=2,534) had 10.5% (8.5% <37 weeks, 1.5% <32 weeks, 0.5% <28 weeks), and those who had cervical treatment (n=2,202) had 11.1% (9.0% <37 weeks, 1.5% <32 weeks, 0.6% <28 weeks). Birth rate was similar among all groups (25% for negative smear, 29% for colposcopy only, and 28% for colposcopy and cervical treatment).
References:
- WHO Guidelines Approved by the Guidelines Review Committee. Comprehensive Cervical Cancer Control: A Guide to Essential Practice. World Health Organization; Copyright © World Health Organization 2014.; 2014.
- Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. Apr 2020;24(2):102-131. doi:10.1097/LGT.0000000000000525
- Kyrgiou M, Mitra A, Arbyn M, et al. Fertility and early pregnancy outcomes after treatment for cervical intraepithelial neoplasia: systematic review and meta-analysis. BMJ. Oct 28 2014;349:g6192. doi:10.1136/bmj.g6192
- Martyn FM, McAuliffe FM, Beggan C, Downey P, Flannelly G, Wingfield MB. Excisional treatments of the cervix and effect on subsequent fertility: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol. Feb 2015;185:114-20. doi:10.1016/j.ejogrb.2014.12.004
- Bruinsma FJ, Quinn MA. The risk of preterm birth following treatment for precancerous changes in the cervix: a systematic review and meta-analysis. Bjog. Aug 2011;118(9):1031-41. doi:10.1111/j.1471-0528.2011.02944.x
- Reilly R, Paranjothy S, Beer H, Brooks CJ, Fielder HM, Lyons RA. Birth outcomes following treatment for precancerous changes to the cervix: a population-based record linkage study. Bjog. Jan 2012;119(2):236-44. doi:10.1111/j.1471-0528.2011.03052.x
