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ORIGINAL RESEARCH |
From the Departments of Obstetrics and Gynecology and Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Address reprint requests to: Annekathryn Goodman, MD Massachusetts General Hospital Department of Obstetrics and Gynecology Boston, MA 02114 E-mail: agoodman{at}partners.org
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Abstract |
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Methods: We reviewed outpatient charts of women treated by loop excision for cervical dysplasia between August 1996 and January 1998 in the colposcopy clinic at Massachusetts General Hospital. One hundred sixty-four women were evaluated for cervical stenosis during follow-up. Stenosis was considered present if manual dilation was required to allow endocervical sampling with an endocervical currette 3 mm wide. Multivariable analysis with stepwise logistic regression was used to evaluate age, parity, tobacco use, hormonal status, use of oral contraceptives, pathology, previous loop excision, performance of additional endocervical excision, and dimensions of excision specimens as predictors of cervical stenosis.
Results: The average age was 32 years. Cervical stenosis occurred in ten of 164 women (6%, 95% CI 3%, 11%). Among factors analyzed, previous loop excision and volume of excision specimen were the only independent predictors of stenosis.
Conclusion: Cervical stenosis correlated with history of loop excision and volume of tissue removed, suggesting that women who have second excisions or large excisions should be counseled that their risk of stenosis might be higher.
Loop electrocautery excision procedure is used increasingly for evaluation and treatment of cervical intraepithelial neoplasia (CIN). Several studies found loop excision to be comparable to cold knife conization for treatment of severe dysplasia.1–3 See-and-treat strategies by loop excision for women with cervical dysplasia at their initial examinations have been gaining favor because of cost-effectiveness and patient preference.4–6 Convenience, diagnostic ability, and high patient acceptability have led to widespread use of loop excision, but negative consequences have not been well studied. With increasing numbers of women undergoing loop excision, information on long-term morbidity is needed.
Bleeding is the most frequent complication immediately after loop excision, and cervical stenosis and cervical incompetence are the main long-term consequences.7,8 Few studies have specifically addressed the risk of cervical stenosis, and quantifying the risk has been difficult because of the lack of a clear and consistent definition. The term "cervical stenosis" has been used to describe a variety of cervical scarring, from subjective impression of narrowing to a completely obliterated os. The clinically significant consequences of stenosis include obstruction of menstrual flow with resulting amenorrhea or dysmenorrhea, inadequate colposcopy during follow-up for dysplasia, and potential interference with fertility caused by inability of sperm to enter the upper genital tract.9,10 Understanding risk factors for cervical stenosis after loop excision would help practitioners make decisions regarding treatment, and allow patients to be better informed of their risk of developing long-term sequelae.
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Materials and Methods |
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After colposcopic viewing of lesions, paracervical block of 2% lidocaine with epinephrine was injected. The excision procedure was done with an electrosurgiscal generator at 140 W on blended current. The size of the loop varied from 10 x 10 mm to 21 x 10 mm depending on the lesion. An additional endocervical excision was done if a deep endocervical lesion was suspected. Specimens were labeled, fixed in formalin, and measured in the pathology department. Follow-up consisted of colposcopic examination, cytology, and endocervical curretage every 3 to 4 months for 1 year.
Clinically significant stenosis was defined as that requiring dilation to collect endocervical samples; subjective assessment of a stenotic exocervical os was not sufficient. According to the policy of the colposcopy clinic, cytologic sampling was done using a spatula and cytobrush, and endocervical sampling was done with a sterilized metal endocervical currette. Women with significant stenosis had cervical os diameters of less than 3 mm, corresponding to the end of an endocervical currette.
Two hundred forty-seven women who had loop excision were identified. Charts were reviewed for patient criteria, stenosis on initial examination before treatment and during the 1-year follow-up after the procedure. Sixty-nine women were excluded because they were not followed up at the colposcopy clinic. Two women with cervical stenosis before the procedure and two with histories of cold-knife cone biopsies also were excluded, as were six who had cold-knife cones or hysterectomies during follow-up from their initial loop excisions, leaving 164 eligible women. Information on age, smoking history, parity, hormonal status, use of oral contraceptives (OCs), indications for the procedure, pathology, additional endocervical excisions, and dimensions of excision specimen(s) were recorded for each woman. Measurements of excision specimens were not done for four women. In cases in which additional endocervical excisions were done, total depth of excisions was determined by adding the depths of initial excision and deeper endocervical excision. Surface area was taken as the exocervical area of the initial excision. Volume was calculated from the dimensions of the specimen(s). In 27 cases (16%), initial excisions resulted in more than one specimen. In those cases the volumes of the specimens were added together to determine total volume removed. Charts were examined with attention to follow-up examinations, to identify women who had cervical stenosis and whether dilation had been used to obtain endocervical samples.
Statistical analysis was done using SAS software version 6.12 (SAS Institute, Cary, NC). Univariate analysis was done using t tests for normally distributed variables and Fisher exact tests for categoric variables. Variables with P < .2 were entered in a stepwise logistic regression model for multivariate analysis.
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Results |
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).
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). Among 39 women who had additional deep endocervical excisions, seven (18%) had stenosis compared with three of 125 (2.4%) who had not had additional excisions (P = .002). A history of loop excision also was a significant predictor of stenosis. Four of eight women who had previous loop excisions developed stenosis, compared with six of 156 who had not (P < .001). Specimen surface area and depth and volume of tissue removed were significantly correlated with stenosis (P = .001, .008, and < .001, respectively). Volumes of excisions were greatest for women with additional deep endocervical specimens or large surface areas or excision depths. Therefore, when analysis with a stepwise logistic regression model was done, neither additional endocervical excision nor depth was still an independent predictor when we controlled for volume. The only two significant independent predictors of stenosis based on the logistic regression models were volume of the tissue removed (OR 1.32, 95% CI 1.1, 1.67) and history of loop excision (OR 17.4, 95% CI 2.7, 112).
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Discussion |
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Previous studies found that morbidity after cold-knife cone biopsy correlated with excision size.16 After conization, stenosis rates of 6–40% were reported,17–19 with some authors advocating cervical stents as prophylaxis.20 There have been no published reports of the use of stents after loop electrocautery excision.
Although some investigators have suggested that postmenopausal women and those on progestin contraceptives are at higher risk of cervical stenosis because of a lack of estrogen, we did not find an association with age, menopausal status, or OC use with stenosis at loop excision to support a hormonal factor. However, the women in this series were relatively young (mean age 32 years), so our study did not have sufficient power to detect an effect among postmenopausal women. Further study is needed on postmenopausal women to determine whether systemic or topical estrogen replacement protects against stenosis in that group.
Information on the clinical effects of cervical stenosis is limited largely to case reports. Stenosis is a recognized contributing factor to infertility, and women have been treated with dilation, cervical shaving, and even surgical reconstruction of the cervical canal to achieve pregnancy.21–26 The degree of stenosis that would result in a significant decrease in fertility is not known. For women who have in vitro fertilization, stenosis to less than 2 mm would preclude the passage of most embryo transfer catheters. Amenorrhea and dysmenorrhea have been reported after loop excision, but none of the women in our study who developed stenosis were symptomatic at follow-up. Women in our study were treated at follow-up with endocervical curretage; however, recent data suggest that the cytobrush is equivalent in its ability to assess the endocervical canal, which would lessen the effect of cervical stenosis on follow-up for those women.27 Nevertheless, with increased use of loop excision by practitioners, future detection of dysplasia among high-risk women might be compromised by stenosis.
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Footnotes |
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Received March 15, 2000. Received in revised form May 25, 2000. Accepted June 15, 2000.
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2. Bigrigg A, Haffenden DK, Sheehan AL, Codling BW, Read MD. Efficacy and safety of large-loop excision of the transformation zone. Lancet 1994;343:32–4.[Medline]
3. Mathevet P, Dargent D, Roy M, Beau G. A randomized prospective study comparing three techniques of conization: Cold knife, laser, and LEEP. Gynecol Oncol 1994;54:175–9.[Medline]
4. Burger RA, Monk BJ, Van Nostrand KM, Greep N, Anton-Culver H, Manetta A. Single-visit program for cervical cancer prevention in a high-risk population. Obstet Gynecol 1995;86:491–8.[Abstract]
5. Holschneider CH, Ghosh K, Montz FJ. See-and-treat in the management of high-grade squamous intraepithelial lesions of the cervix: A resource utilization analysis. Obstet Gynecol 1999;94:377–85.
6. Das SS, Elias AH. Diagnosis and treatment of cervical intraepithelial neoplasia in a single visit. Aust N Z J Obstet Gynaecol 1998;38:246–50.[Medline]
7. Moinian M, Andersch B. Does cervix conization increase the risk of complications in subsequent pregnancies? Acta Obstet Gynecol Scand 1982;61:101–3.[Medline]
8. Vejerslev LO, Schouenborg L, Sorensen F, Nielsen D, Sorensen SS, Juhl BR, et al. Loop diathermy or laser excisional conization for cervical intraepithelial neoplasia. Acta Obstet Gynecol Scand 1999; 78:900–5.[Medline]
9. Baldauf JJ, Dreyfus M, Wertz JP, Cuenin C, Ritter J, Philippe E. Consequences and treatment of cervical stenoses after laser conization or loop electrosurgical excision. J Gynecol Obstet Biol Reprod 1997;26:64–70.[Medline]
10. Pschera H, Kjaeldgaard A. Haematocervix after conization diagnosed by ultrasonography. Gynecol Obstet Invest 1990;29:309–10.[Medline]
11. Baldauf JJ, Dreyfus M, Ritter J, Meyer P, Philippe E. Risk of cervical stenosis after large loop excision or laser conization. Obstet Gynecol 1996;88:933–8.[Abstract]
12. Hallam NF, West J, Harper C, Edwards A, Hope S, Merriman H, et al. Large loop excision of the transformation zone (LLETZ) as an alternative to both local ablative and cone biopsy treatment: A series of 1000 patients. J Gynecol Surg 1993;9:77–82.[Medline]
13. Spitzer M, Chernys AE, Seltzer VL. The use of large loop excision of the transformation zone in an innercity population. Obstet Gynecol 1993;82:731–5.
14. Wright TC, Gagnon S, Richart RM, Ferenczy A. Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure. Obstet Gynecol 1992;79:173–8.
15. Keijser KG, Kenemans P, van der Zanden PH, Schijf P, Vooijs GP, Rolland R. Diathermy loop excision in the management of cervical intraepithelial neoplasia. Am J Obstet Gynecol 1992;166:1281–7.[Medline]
16. Luesley DM, McCrum A, Terry PB, Wade-Evans T, Nicholson HO, Mylotte MJ, et al. Complications of cone biopsy related to the dimensions of the cone and the influence of prior colposcopic assessment. Br J Obstet Gynaecol 1985;92:158–64.[Medline]
17. Hagen B, Skjeldestad FE, Bratt H, Tingulstad S, Lie AK. CO2 laser conization for cervical intraepithelial neoplasia grade II–III: Complications and efficacy. Acta Obstet Gynecol Scand 1998;77:558–63.[Medline]
18. Gilbert L, Saunders NJ, Stringer R, Sharp F. Hemostasis and cold knife cone biopsy: A prospective randomized trial comparing a suture versus nonsuture technique. Obstet Gynecol 1989;74:640–3.
19. Byrne GD. Cone biopsy: A survey of 100 cases. Aust N Z J Obstet Gynecol 1966;25:849–61.
20. Luesley DM, Redman CW, Buxton EJ, Lawton FG, Williams DR. Prevention of postcone biopsy cervical stenosis using a temporary cervical stent. Br J Obstet Gynaecol 1990;97:334–7.[Medline]
21. Noyes N. Hysteroscopic cervical canal shaving: A new therapy for cervical stenosis before embryo transfer in patients undergoing in vitro fertilization. Fertil Steril 1999;71:965–6.[Medline]
22. Groutz A, Lessing JB, Wolf Y, Yovel I, Azem F, Amit A. Cervical dilatation during ovum pick-up in patients with cervical stenosis: Effect on pregnancy outcome in an in vitro fertilization-embryo transfer program. Fertil Steril 1997;67:909–11.[Medline]
23. Zreik TG, Dickey KW, Keefe DL, Glickman MG, Olive DL. Fluoroscopically guided cervical dilatation in patients with infertility. J Am Assoc Gynecol Laparosc 1996;3(Suppl):S56.
24. Honore LH. Pathology of female infertility. Curr Opin Obstet Gynecol 1994;6:364–71.[Medline]
25. Frishman GN. The use of the stem pessary to facilitate transcervical embryo transfer in women with cervical stenosis. J Assist Reprod Genet 1994;11:225–8.[Medline]
26. Pittaway DE, Daniell J, Maxson W, Boehm F. Reconstruction of the cervical canal after complete postconization obstruction. A case report. J Reprod Med 1984;29:339–40.[Medline]
27. Mogensen ST, Bak M, Dueholm M, Frost L, Knoblauch NO, Praest J, et al. Cytobrush and endocervical curettage in the diagnosis of dysplasia and malignancy of the uterine cervix. Acta Obstet Gynecol Scand 1997;76:69–73.[Medline]
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