Tissue analysis by the pathologist divides precancerous changes into low grade or high grade squamous intraepithelial lesions (SIL). If the abnormality occupies the first third of the cervical skin it is called CIN I (cervical intraepithelial neoplasia) and two thirds CIN II. If the precancerous cells occupy full thickness it is called CIN III - the old name for this was "carcinoma in situ".
For women who have CIN II, CIN III or persistant CIN I precancerous changes the most common treatment is called Large Loop Excision of the Transformation Zone (LLETZ), also called Loop Electro-Excision Procedure (LEEP).
A loop of wire through which a specially blended electric current flows is used to shave off the abnormal cells. Like a tiny cheesewire, the loop cuts out the abnormal piece of skin from the cervix and seals up the area as it passes through. Any residual abnormal tissue can be destroyed by another pass of the loop or more cautery.
Many women who have the LLETZ/LEEP procedure prefer to have local anaesthesia if the operation is carried out in a warm, friendly, custom-designed outpatient suite. Women having treatment in an operating theatre, or those who are fairly nervous, may prefer to have treatment under general anaesthesia i.e. fully asleep after an intravenous injection.
Those women who prefer local anaesthesia will have an injection of local anaesthetic (as used by dentists) into the cervix before the loop is passed through the cervix to remove the abnormal cells.
Healing is usually very rapid and complete. The small "crater" left behind after the abnormal tissue is removed fills up quickly and normal skin grows over without delay.
Usually healing is complete after two or three weeks. Following the operation there is no pain, but most women experience some discharge and/or bleeding for up to two weeks and may need to wear a sanitary towel on or off for a couple of weeks.
Usually the cervix heals completely normally with no scarring or damage. Fertility is not affected, and because the tissue removed is relatively small there is usually no damage produced which could cause problems with subsequent pregnancy or childbirth.
Some doctors, especially in the public health service, offer treatment at the same time as the investigating colposcopy examination. This saves a second visit, but may leave the woman unprepared. Other doctors like to do the colposcopy examination at one visit and then plan the treatment at a second visit when the woman will not mind wearing a sanitary towel on and off for a week or two afterwards.
A very small number of women will have very heavy bleeding after the operation and will need to contact their gynaecologists immediately for help. Advice varies after loop excision procedures, although many gynaecologists recommend their patients to avoid swimming, intercourse and tampons for two or three weeks after the operation.
The piece which is removed from the cervix is sent for microscopic analysis by a pathologist. The pathologist will ensure that all the changes seen are not cancerous but pre-cancerous. He or she will report to the gynaecologist the grade of precancerous change found (CIN I, CIN II or CIN III) and the likelihood that all of the abnormal cells have been removed.
Before the introduction of the LLETZ/LEEP operation in the early 1990s, laser treatment was very popular in removing precancerous cells from the cervix. After confirming the diagnosis of CIN/SIL with a small punch biopsy, a laser beam (high-energy light) was used to vaporise the abnormal area, or the laser beam was used to cut a cone of tissue out similar to the LLETZ/LEEP procedure. Tissue healing after laser treatment was very good and a big improvement on using a surgical knife (scalpel) to cut out the abnormal tissue.
However, laser treatment has largely been replaced by the LLETZ/LEEP. Whereas the equipment for LLETZ/LEEP is much cheaper to buy, use and is easier to maintain than laser generators, it is the safety aspect of sending a large amount of tissue for pathological analysis after a LLETZ/LEEP procedure to ensure that a small, invasive cancer has not been missed which attracts gynaecologists to favour LLETZ/LEEP over small biopsy/laser.
Occasionally, when microinvasion or early invasion is suspected, a gynaecologist will recommend that the abnormal tissue is removed using a surgical knife which may require stitches to be put into the cervix in an attempt to prevent bleeding. Long knife cones may damage the ability of the cervix to hold babies in the womb during pregnancy and a few women may rquire a big stitch (cervical suture) to be inserted in pregnancy to prevent premature delivery.