LARGE LOOP EXCISION OF THE …

1 LARGE LOOP EXCISION OF THE transformation ZONE(LLETZ) Dr Scott SalisburyObstetrician & GynaecologistWatkins Medical Centre Level 3 225 Wickham TerraceBrisbane Q 4000 Appointments 07 3010 2121 After Hours 07 3899 4455 Dr Scott Salisbury 2010 LARGE LOOP EXCISION OF THE transformation ZONE(LLETZ)This refers to a method of treating the cervix of women who have had abnormal smears and whom there is felt to be a risk eventually developing cancer of the cervix. WHAT IS THE CERVICAL transformation ZONEThis is part of the outer surface of the normal cervix and represents the junction in between two different types of epithelium (skin or surface cover). At this junction, the cells that make up the epithelium are in a state of change as the acidic environment of the vagina and its more robust cells (squamous cells) try to replace the more sensitive lining (columnar cells) that lines the inner part of the uterus that extends to the outer part of the cervix.

2 This junction between the sensitive (columnar ) cells and robust cells (squamous cells) is called the squamo-columnar junction. It is during this state of change that they may become vulnerable to various events that can cause these cells to become abnormal or pre-cancerous. These processes of transformation only ever occurs in this zone and is collectively known as dysplasia (this is a technical term for pre-cancer). It is believed that dysplasia may eventually progress to cause cancer of the cervix. HOW ARE THESE CHANGES RECOGNISED Because these changes are often confined to a small part of the cervix and only involved the surface layer, women are totally unaware that they have dysplasia or pre-cancerous changes in the cervix. It does not cause bleeding, it does not cause pain nor does it cause a discharge.

3 The only way in which it can be discovered is by having a cervical smear test. This test gently removes the top few layers of cells from the cervix. The cells are then spread onto a microscope slide and by examining them, it is possible to suspect that dysplasia is present. Trained observers can recognise the presence of dysplasia by the appearance of the cells. This is an abnormal smear and usually means that further investigations should be performed, but not necessarily treated as sometimes the smear can become normal without intervention. Dr Scott Salisbury 2010 WHAT FURTHER TESTS? Because this process of dysplasia is by no means always going to become cancer and even if it should, then it generally takes years, there is no need for every woman or doctors to rush into complicated tests.

4 In some cases, the cervix might return to normal without any further tests or treatment, particularly if the abnormality seen on the smear test is only very slight. In this situation, it is quite correct just to repeat the smear test in about 6 months. If a smear test remains abnormal or if the initial test showed more worrying changes, then an investigation called colposcopy should be arranged. WHAT IS COLPOSCOPY? In this test, the cervix is carefully examined with a specially designed low power microscope. After careful inspection of the cervix, especially the transformation zone, and then by the application of special solutions, I can tell if any part of the cervix shows features suggestive of dysplasia. The area exhibits certain characteristics to determine if this is the case, but it still often needs taking a biopsy (a small piece of cervical skin) in the area that seems the most suspicious.

5 This biopsy can then be examined at much greater detail in the laboratory so that a firm diagnosis is then made. It is only possible to make a diagnosis of dysplasia (often called pre-cancer), by taking a biopsy. A smear test and colposcopy can both suspect the disease, only a biopsy can confirm it. SO WHAT IS A LLETZ? This is treatment for women with abnormal smears. As it removes the transformation zone and provides a good tissue sample to send to the laboratory, it can be used to treat women with abnormal smear tests. As it cuts a piece of cervix out rather than destroying it, a better biopsy is obtained to confirm the original biopsy and to be sure that the area of abnormality is completely removed. WHAT IS A LLETZ LOOP AND HOW WILL IT WORKA loop is a specially designed insulated fine stainless steel wire (about lOOth of an inch thick).

6 By attaching the loop to a diathermy machine (a machine that delivers a specially modulated current) and by connecting you to another part of the machine. The loop when touching the cervix completes an electric circuit and generates heat just around the edge of the fine wire. This heat allows the fine wire to cut easily through the tissues and also seals off all of the very small blood vessels. A smooth cut can be easily obtained with virtually no bleeding and removes all of the transformation zone in a matter of minutes. Before treatment is started, general anaesthetic is usually utilised and obviously makes the procedure painless. It is possible to treat most women in this way. Dr Scott Salisbury 2010 WHAT HAPPENS AFTER LOOP EXCISION ?

7 In the first 6 weeks, most women will notice a discharge that might be blood stained initially. This is because the area from which the piece of cervix was taken is trying to heal. During the first 6 weeks, it is advisable to avoid sexual intercourse, not to use tampons or anything else that may cause irritation to the cervix. This is a relatively standard procedure following all treatment methods. After 6 weeks a check of the cervix is undertaken to ensure that the cervix is healed. After 4-6 months, a smear test will be performed and often a colposcopy as well. In 90% of cases, all has returned to normal at this visit. By 12 months, 95% of treated women will have a normal smear test. ARE THERE ANY COMPLICATIONS The procedures invariably leave a raw area on the cervix, responsible for postoperative vaginal bleeding and discharge that may last for up to 4 weeks.

8 The bleeding should not exceed that usually associated with a period. During this time you are advised not to have intercourse, use tampons or take a bath so as to reduce the likelihood of infection being introduced into the area. Pads may be used in place of tampons. If you are taking the oral contraceptive pill you should continue to do so on a daily basis without altering your place in the cycle, despite the fact that you may now be bleeding due to the operation. It is also common to experience period-like cramping abdominal pain in the first 24 hours postoperatively. Should the pain become severe or persistent or should a fever or heavy vaginal bleeding develop then infection is likely and antibiotics will be required, The incidence of postoperative infection in the first 2 weeks is 1 %.

9 Oral antibiotics are usually sufficient treatment although occasionally readmission to hospital, intravenous antibiotics, vaginal packing and/or further surgery to control the bleeding are required. Other complications that may occur are: -Cervical stenosis (or scarring) preventing normal dilatation of the cervix in labour and making pap smear collections and cervical examinations difficult in the future (<1% risk). It equally may make menstruation more incompetence (or weakness) leading to miscarriage or premature delivery in the middle third of a future pregnancy (low risk). -Anaesthetic complications of which there are a number of uncommon but serious possibilities. Your anaesthetist can elaborate upon heat transfer or burns to surrounding tissues requiring further TREATMENT AFFECT PERIODS?

10 There is no evidence to suggest that this type of treatment will alter the periods in any way and any trouble with menstruation following treatment would usually indicate a separate problem. CAN TREATMENT AFFECT LOVEMAKING? Once the cervix has been allowed to heal women can enjoy a normal sex life. Treatment of the cervix neither alters enjoyment or makes sex unsafe in terms of future health. It is important to ensure that adequate contraceptive measures are used unless you wish to become pregnant. HOW LONG SHOULD A PREGNANCY BE DELAYED? Theoretically a couple could embark upon a pregnancy as soon as the cervix is healed. I would advise that a pregnancy is avoided if possible until after the first check up in 4-6 months. If any treatment is required (unlikely) this could them be performed.