From the information obtained from the smear, colposcopy and biopsy, the gynaecologist can advise on appropriate treatment options. Mild degrees of abnormality (mild dyskaryosis / CIN I) may return to normal and there are times when they may be left untreated but kept under careful review by repeated smears and colposcopy.

The more severe abnormal areas will probably need to be destroyed. This can be achieved by removing them surgically (knife cone biopsy) or with a heated loop removing a cone (LLETZ is a large loop excision of the transformation zone-Figure 21.11). The cervix may be frozen (cryotherapy;Figure 21.4) or destroyed by cautery, cold coagulation (this still involves heat) or laser.

Figure 21.11

Figure 21.4

Historically diathermy knife cone biopsy and were the preferred treatments. The advent of laser allowed colposcopically directed ablation of the abnormal area. The disadvantage of laser was that it destroyed all the abnormality but there was no excised tissue for analysis.

The LLETZ has become popular because it treats the abnormality and the removed tissue can be analysed histologically (microscope examination. It has allowed a see and treat policy with assessment and treatment at the first visit. With ablative treatment a colposcopically directed biopsy is required before treatment.

There has been accumulating evidence that LLETZ is associated with subsequent premature delivery and this in turn increases the risk of damaging or losing the baby. There may, therefore, be a trend to return to ablative treatments. There may also be a case for less treatment of low grade abnormality. The chance of a CIN I lesion becoming malignant is 1% and 5% for CIN 2 - 5%.9801 The appropriate treatment of premalignant conditions of the cervix requires review. Ultrasound assessment of the cervix may be appropriate in pregnancy for those who have had excision operations on the cervix to determine those at risk and perhaps consideration of a cervical circlage procedure. One study, however, showed no reduction of premature delivery with prophylactic cervical cerclage.9801The majority of CIN 1 lesions regress within 2 years.9902 At one time after treatment local antibiotic vaginal cream was prescribed to be used as this was thought to reduce the chance of infection and promote healthy healing. A study, however, has shown no benefit.9801 Sexual activity should be avoided for at least three weeks and internal sanitary protection for four weeks.

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