Large Loop Excision of the Transformation Zone (LLETZ) and Cone Biopsy

What is an LLETZ Procedure?

Large Loop Excision of the Transformation Zone (LLETZ) is a minor surgical procedure used to remove abnormal or pre-cancerous cells from the cervix. It is also commonly known internationally as the Loop Electrosurgical Excision Procedure (LEEP).

The cervix is the lower part of the uterus that opens into the vagina. The transformation zone is the area on the cervix where two cell types meet. This area is particularly important because most cervical abnormalities and early cervical cancers develop here.

LLETZ uses a thin wire loop that carries a low-voltage electrical current. The loop gently removes abnormal tissue while sealing small blood vessels, thereby reducing bleeding.

Why is LLETZ Performed?

LLETZ is performed to:

• Remove high-grade abnormal cells: To prevent them from progressing to cervical cancer.
• Treat cervical intraepithelial neoplasia (CIN): Especially CIN 2 and CIN 3.
• Confirm diagnosis: The removed tissue is sent to a laboratory for detailed examination.
• Prevent future cancer risk: Early treatment significantly reduces the risk of invasive cervical cancer.

In Australia, cervical abnormalities are commonly detected through the National Cervical Screening Program, which now uses HPV testing as the primary screening method.

Who is Suitable for LLETZ and Cone Biopsy?

LLETZ and cone biopsy surgery is typically recommended for women with abnormal cervical cells, also known as cervical dysplasia. Cervical dysplasia is most commonly caused by a viral infection called human papillomavirus (HPV), which can lead to precancerous changes in the cervical cells.

Surgery may be  recommended for women who have:

• Abnormal cervical cell changes found during a Pap smear test or cervical screening test (CST)
• A cervical biopsy that shows cervical dysplasia
• Cervical intraepithelial neoplasia (CIN)
• Atypical squamous cells of undetermined significance (ASCUS)

Additionally, the surgery may be recommended for women who have previously had an LLETZ and have recurrent abnormal cervical cells.

Benefits of Surgery

The main benefit of the surgery is that it can remove abnormal cervical tissue and effectively treat cervical dysplasia, preventing the development of cervical cancer.

Some other benefits include the following:

• It is a relatively quick procedure that can be performed as day surgery, typically taking approximately 30 minutes.
• Recovery time is usually short; patients can resume normal activities within a few days.
• LLETZ preserves the patient's fertility, removing only the abnormal cervical tissue and leaving the healthy cervical tissue and uterus intact.

Alternative Options to LLETZ

Depending on your situation, alternatives may include:

• Observation: For low-grade abnormalities.
• Cold knife cone biopsy: A surgical procedure performed in a hospital.
• Laser treatment: In selected cases.

Dr Wong will recommend the most appropriate option based on your biopsy results and overall health.

What Should Be Done Before a LLETZ Procedure?

Preparing for a LLETZ procedure involves several important steps:

• Discuss with Your Doctor: Talk to your doctor about the procedure, its benefits, risks, and what to expect.
• Medical History: Ensure your doctor has your complete medical history, including any allergies and current medications.
• Review Medications: Inform your doctor about all your medications and supplements. Some may need to be paused before the procedure.
• Pain Relief: You may be advised to take an over-the-counter analgesic, such as ibuprofen or acetaminophen, approximately 30 minutes to an hour before the procedure.
• Avoid Vaginal Products: Do not use tampons, vaginal creams, or douches for at least 24 hours before the procedure.
• Abstain from Intercourse: Avoid sexual intercourse for 24 to 48 hours before the procedure to reduce the risk of irritation.
• Normal Eating: You can eat and drink as usual unless instructed otherwise by your doctor.
• Wear Comfortable Clothing: Choose clothes that are easy to remove and comfortable.
• Bring Support: Consider bringing a friend or family member for emotional support and to drive you home if needed.

LLETZ Procedure

The LLETZ procedure typically follows these steps:

• Visual Access: A speculum is gently inserted into your vagina to hold it open and allow access to your cervix.
• Local Anaesthesia: A local anaesthetic is injected into the cervix to numb the area and minimise discomfort.
• Magnification: A colposcope (a special microscope) is positioned outside the vagina to provide a magnified view of the cervix.
• Loop Electrode: A thin wire loop heated by an electric current removes the abnormal tissue from the cervix.
• Tissue Removal: The loop cuts away the transformation zone of the cervix, where abnormal cells are located.
• Control Bleeding: Any bleeding is controlled using a special paste or cauterisation (applying heat to seal blood vessels).

 

Cone Biopsy

This is necessary when the abnormal cells are deeper in the cervix. This is similar to LLETZ, but a deeper area is removed.

What to Expect After the Procedure?

After the procedure, you can expect the following:

• Immediate Aftermath:
• Discomfort: Some mild cramping or discomfort, similar to menstrual cramps, is normal.
• Discharge: You may experience a watery or slightly bloody discharge for up to 4 weeks, especially if a large area was treated.
• Activities:
• Rest: Rest for the remainder of the day. Most women can return to their normal activities within a day or two.
• Avoid Strenuous Activities: Avoid heavy lifting and vigorous exercise for a few days.
• Pain Management:
• Over-the-counter Pain Relief: Use over-the-counter pain relievers like ibuprofen or acetaminophen as needed for any discomfort.
• Avoiding Irritation:
• Hygiene: Avoid using tampons, douches, or vaginal creams for about four weeks to prevent infection and allow healing.
• Intercourse: Refrain from sexual intercourse for at least four weeks or as advised by your doctor.
• Signs of Complications:
• Infection: Watch for signs of infection, such as heavy bleeding, foul-smelling discharge, fever, or severe pain, and contact your doctor if they occur.

LLETZ Aftercare

• You will have vaginal discharge for up to three weeks
• Avoid intercourse and the use of tampons for three weeks
• Avoid swimming pools, spas, and baths – use the shower for three weeks
• Avoid heavy exercise, running and jumping for four weeks.
• Most women can resume normal daily activities within 1-2 days.

LLETZ Follow-up

Follow-up care is essential.

• HPV testing: Usually at 6 months post-procedure.
• Repeat cervical screening: As advised under Australian guidelines.
• Ongoing monitoring: Even after successful treatment.

Regular follow-up ensures early detection if abnormalities recur.

Prognosis

The success rate of LLETZ is very high.

• High cure rate: Approximately 90–95% for high-grade cervical abnormalities.
• Reduced cancer risk: Significantly lowers the risk of cervical cancer.
• Follow-up required: Ongoing HPV testing and cervical screening are essential.

Most women do not require further treatment after one procedure.

Risks

The surgery is generally safe, but as with any procedure, risks exist.

• Bleeding: Usually mild, rarely heavy.
• Infection: Uncommon but possible.
• Cervical stenosis: Narrowing of the cervix (rare).
• Impact on pregnancy: Slightly increased risk of preterm birth in future pregnancies, particularly if large amounts of tissue are removed.

Your doctor will balance the benefits of treatment against any potential risks, particularly if you are planning pregnancy.

What if Treatment is Delayed?

This can have significant implications, particularly if abnormal cervical cells are present:

• Progression to Cancer: The most serious risk of delaying treatment is the potential progression of cervical dysplasia to cervical cancer. Early treatment of abnormal cells is crucial to prevent this.
• Increased Severity: If abnormal cells are not removed, they may become more severe, requiring more extensive treatment in the future.
• Symptoms: Delaying treatment can also lead to symptoms such as abnormal bleeding, pain, and discharge.