INTRODUCTION

Several treatments are available for women with cervical abnormalities, often referred to as dysplasia, CIN (cervical intraepithelial neoplasia) or CIS (carcinoma in situ). Treatments including cryosurgery (freezing), laser (high-energy light), and excision (surgical removal of the abnormal area).

The tests performed to evaluate abnormal Pap smears are discussed separately. (See "Patient information: Management of atypical squamous cells (ASC-US and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL) (Beyond the Basics)" and "Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC) (Beyond the Basics)".)

CHOOSING THE BEST TREATMENT FOR ABNORMAL PAP SMEARS

Abnormal pap smears are treated by identifying the area of abnormal cervical tissue and removing it to prevent worsening or spread to other areas of the cervix. There are two main types of treatment for cervical abnormalities:

• Those that destroy the abnormal area (called ablative therapy) and
• Those that remove the abnormal areas (called excisional therapy).

Some abnormalities are best treated with one type of treatment while others can be treated with either type, depending upon the patient and physician's preference. There are some classes of abnormalities that can be followed without treatment, if the physician and patient are willing.

Excisional therapy — Excisional therapies include loop electrosurgical excision procedures (LEEP), also called large loop excision of the transformation zone (LLETZ), laser conization, and cervical conization procedures. Most clinicians prefer excisional therapy (see 'Excision' below).

Excisional therapy is recommended when the extent or type of cervical abnormality is not clear based upon colposcopy and biopsy. In this situation, excision is preferred because the abnormal tissue can be examined with a microscope. This allows the physician to determine if the entire abnormal area was removed and if a more serious condition (eg, cervical cancer) is present.

Ablative therapy — Ablative therapies include cryosurgery and laser ablation. Ablative therapy may be recommended when there is less concern about cancer or about the extent of the abnormal tissue.

EXCISION

Excision is a procedure that cuts out the abnormal area on the surface of the cervix; excision can also remove abnormalities that extend inside the cervical opening. Excision serves two purposes:

• It provides a sample of tissue to confirm the degree of an abnormality and check for cancerous or precancerous cells deep within the cervix.
• Excision helps to ensure that the abnormality is removed completely. If the edges of the tissue that is removed show evidence of the abnormality or precancer, further treatment may be needed.

Loop electrosurgical excision procedure (LEEP) — Excision can be done with a device that uses electrical current; this is called a LEEP procedure (loop electrosurgical excision procedure) or LLETZ (large loop excision of the transformation zone). A thin, wire loop is inserted through the vagina, where it uses an electric current to remove a cone-shaped portion of the cervix. This can also be performed with a laser knife, which uses high intensity energy from a light beam.

Excision can be done in the office or operating room after the cervix is injected with local anesthesia to prevent pain. The woman may feel a dull ache or cramp during the procedure. A brown paste is applied after the treatment to prevent bleeding; this often causes a dark vaginal discharge (similar to coffee grounds). Most women are able to return to work or school after the procedure.

Cervical cone biopsy (conization) — Excision can also be done with a scalpel instead of a loop; this is called a cervical conization or cone biopsy (figure 1). Conization is usually done in an operating room after the patient has received general anesthesia (medicine given to induce sleep) or regional anesthesia (eg, epidural or spinal).

Following LEEP or conization, most women have mild to moderate vaginal bleeding and discharge for one to two weeks. The bleeding should not be heavy (eg, should not soak a pad in less than one hour). Care after excision is described below (see 'Post-procedure care' below).

Complications — As with any surgical procedure, complications can occur during excision. These include:

• Bleeding during the procedure — Bleeding is rarely serious, and can usually be managed with suturing or by applying cauterizing material (a liquid or treatment that helps the blood to clot) to the cervix.
• Bleeding after the procedure — Although light bleeding or spotting is normal, some women have heavy bleeding several days or weeks after the procedure. This can usually be treated in the office, but occasionally a procedure in an operating room is necessary.
• Infection — Infections occur rarely after cone biopsy, either on the cervix itself or elsewhere in the reproductive tract. Most infections can be treated with oral antibiotic therapy.
• Perforation of the uterus — This is an uncommon complication, and is more likely to occur in women who are postmenopausal or whose uterus is tipped forward. If the uterus is perforated, it usually heals without any need for treatment. Infrequently, laparoscopy or laparotomy is required to see and repair injuries to internal organs.
• Late complications — (see 'Pregnancy after treatment for abnormal Pap smear' below).

ABLATIVE TREATMENTS

Ablative treatment destroy, rather then cut away, abnormal cervical tissue.

Cryosurgery — Cryosurgery involves applying liquid nitrogen or carbon dioxide to the cervix. This causes the cervical tissue to freeze, which destroys the abnormal cells. Cryosurgery can be done in the office, similar to a pelvic examination, without any anesthesia. It may cause mild cramping or discomfort.

Cryosurgery is not recommended in certain situations, such as when the extent and type of cervical abnormality are not clear based upon colposcopy and/or biopsy. Excisional therapy is preferred in these cases.

Most women have watery vaginal discharge for one week after cryosurgery. Care after cryosurgery is described below (see 'Post-procedure care' below).

Laser ablation — Laser ablation uses high intensity energy from a light beam to destroy abnormal areas of the cervix. The laser is directed to the abnormal area of the cervix through the vagina. This is usually performed in an operating room after the woman has received general anesthesia (medicine given to induce sleep) or regional anesthesia (eg, epidural or spinal). Laser treatment requires special training and equipment.

A disadvantage of laser ablation is that it destroys the abnormal tissue, similar to cryosurgery. Laser ablation is not recommended in certain situations, such as when the extent and type of cervical abnormality are not clear based upon colposcopy and/or biopsy.

Most women have vaginal discharge for one to two weeks after laser treatment. Care after laser treatment is described below (see 'Post-procedure care' below).

POST-PROCEDURE CARE

All women should ask about their ability to drive home from the procedure and when they can resume normal daily activities. Following treatment, most providers recommend avoiding sexual intercourse, not placing anything in the vagina (eg, douches, tampons), and not taking a bath or swim for a few weeks (showers are fine); other physicians may recommend a shorter period of "pelvic rest". This should be discussed in detail with the physician.

In general, a woman should call her provider if she has bleeding that is heavier than a normal menstrual period (defined as soaking a pad in less than one hour, especially if there are clots), severe or worsening pain, fever over 101º F (38.4º C), or a foul-smelling vaginal discharge.

Treatment efficacy — The treatments described above cure most women with abnormal cervical cells. Women that are not cured after a first treatment may have persistence, recurrence, or progression of the abnormality, especially if a high risk type of HPV (types 16 and 18) is present. Additional treatment is sometimes needed in this case. For this reason, lifelong follow up with cervical cytology smears (Pap smear) is important.

Follow up appointments — Typically, a woman is seen for a follow up examination several weeks after treatment to make sure the cervix is healing. A Pap smear (with or without colposcopy) is recommended approximately every six months. Colposcopy is recommended if atypical squamous cells or other abnormalities are found and HPV testing is positive. The time interval between subsequent tests will depend upon the results of the initial testing after treatment and the woman's age. Follow up is best discussed with a woman's individual provider since it may vary significantly from one woman to another.

Need for further treatment — Some women will require additional treatments to ensure that all abnormal areas are removed. This is especially true if excision was done and microscopic analysis showed a larger abnormality than was expected. The decision to have additional treatment is individualized, based upon the type of abnormality seen, the woman's risk of cervical cancer, and whether or not childbearing is completed. (See "Patient information: Cervical cancer treatment; early stage cancer (Beyond the Basics)".)

PREGNANCY AFTER TREATMENT FOR ABNORMAL PAP SMEAR

Many women are concerned about the risks of infertility and preterm labor after being treated for an abnormal Pap smear. The risk of these complications depends upon a number of factors, including the type and number of treatment(s) performed (ablation versus excision) and the time between the treatment and the pregnancy. Other factors, such as underlying medical conditions and a woman's age can also increase a woman's risk of these conditions.

Most women are advised to wait six to 12 months after conization before attempting to become pregnant to allow the tissue to heal fully. In general, the data suggest that excisional procedures slightly increase the risk of preterm delivery, but ablative procedures do not. The risk of infertility related to treatment is probably very small. More data are needed to better define these risks. (See "Patient information: Preterm labor (Beyond the Basics)", section on 'Cervical length'.)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Cervical cancer (The Basics)
Patient information: Pap tests (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Cervical cancer screening (Beyond the Basics)
Patient information: Management of atypical squamous cells (ASC-US and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL) (Beyond the Basics)
Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC) (Beyond the Basics)
Patient information: Cervical cancer treatment; early stage cancer (Beyond the Basics)
Patient information: Preterm labor (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cervical cancer screening tests: Techniques and test characteristics of cervical cytology and human papillomavirus testing
Cervical cytology: Evaluation of atypical and malignant glandular cells
Cervical cytology: Evaluation of atypical squamous cells (ASC-US and ASC-H)
Cervical cytology: Evaluation of high-grade squamous intraepithelial lesions (HSIL)
Cervical cytology: Evaluation of low-grade squamous intraepithelial lesions (LSIL)
Cervical intraepithelial neoplasia: Management of low-grade and high-grade lesions
Screening for cervical cancer: Rationale and recommendations

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Cancer Institute

     (www.nci.nih.gov)

• American Society for Colposcopy and Cervical Pathology

     (www.asccp.org)

• American Cancer Society

     (www.cancer.org, search for HPV)

• National HPV and Cervical Cancer Public Education Campaign

     Telephone: 1-866-280-6605
     (www.cervicalcancercampaign.org)

• Center for Disease Control and Prevention

     (www.cdc.gov/)

• American Social Health Association

     (http://www.ashastd.org/)

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