Original studies
Characteristics of a Group of Adolescents Undergoing Loop Electrical Excision Procedure (LEEP)

https://doi.org/10.1016/S1083-3188(02)00209-7Get rights and content

Abstract

Study Objective: To describe the sociodemographic characteristics of a cohort of adolescents undergoing loop electrosurgical excision procedure (LEEP) of the cervix, and to determine if LEEP is a safe and effective procedure for evaluation and treatment of high-grade squamous intraepithelial lesions (HSIL) of the cervix in adolescents.

Setting: Case series of all adolescents who underwent LEEP between 1995 and 1997 at Children's Hospital, Boston, MA.

Design: Medical and laboratory records were reviewed to assess baseline characteristics and the following outcomes: (1) LEEP pathology results, (2) postoperative complications, (3) pregnancy outcomes, (4) compliance with follow-up appointments, and (5) recurrence of disease over a 12- to 37-month period.

Participants: Thirty-five adolescents underwent LEEP. The mean age of the adolescents at the time of LEEP was 17.9 ± 1.5 yrs.

Results: The mean interval between coitarche and LEEP was 3.69 ± 2.09 yrs. On preoperative colposcopy, 28 (80%) had HSIL on biopsy, 3 (8.6%) had HSIL on Pap smear with a discordant biopsy demonstrating low-grade squamous intraepithelial lesion (LSIL), 1 (2.9%) had a persistent LSIL, 2 (5.6%) had diffuse LSIL with an unsatisfactory colposcopy, and 1 (2.9%) had a HSIL Pap smear with a normal biopsy. LEEP specimen histopathology results were: HSIL in 19 (54%), LSIL in 10 (29%), SIL difficult to grade in 3 (9%), and no residual disease in 3 (9.0%). Postoperative complications were bleeding in 2 (5.7%), pain in 1 (2.9%), vaginal discharge in 1 (2.9%), cervicitis in 3 (8.6%), and endometritis in 2 (5.7%). Fourteen pregnancies were diagnosed after LEEP; no spontaneous abortions occurred. Mean follow-up period was 21.1 ± 9.4 months. Compliance with follow-up appointments was 51% in the first 12 months post-LEEP and 26% in the second 12 months post-LEEP. Of the 28 patients followed for 12 months or more, there was one recurrence of HSIL confirmed by colposcopy and biopsy.

Conclusions: Outcome and complications of LEEP in adolescent females are similar to those reported in larger series of adult women. LEEP appears to be a safe and effective procedure for the evaluation and treatment of HSIL of the cervix in adolescents, but additional long-term data are needed.

Introduction

Although the incidence of invasive cervical cancer has been steadily decreasing over the last several years, it is still a significant public health problem in the United States. Approximately 13,000 new cases of invasive cervical cancer occur in this country annually, making it the third most frequent malignancy of the female lower genital tract.1, 2 In 2000, 4600 deaths resulted from cervical neoplasia.1 The reduction in the incidence of invasive cervical cancer can be attributed to the widespread use of cytology screening, which can result in early diagnosis and treatment of premalignant cervical lesions (squamous intraepithelial lesions).3

Intraepithelial lesions of the cervix occur more frequently in younger women, with peak incidence in the early thirties, but more recent data suggest that this incidence may be increasing in even younger woman.4, 5, 6 Possible explanations for this increase in cervical dysplasia are: (1) earlier initiation of sexual intercourse leading to increased exposure to sexually transmitted diseases, particularly to human papillomavirus (HPV) infection, (2) increased number of sexual partners, and (3) vulnerability of the adolescent cervix during the process of squamous metaplasia.4, 5, 6, 7, 8, 9, 10 Sadeghi and colleagues,11 analyzing 796,337 Pap smears performed in the United States during 1981, found a prevalence rate for cervical intraepithelial neoplasia (CIN) of 18.8 per 1000 for teenagers aged 15 to 19 yrs and 28.8 per 1000 for women aged 20 to 24 yrs. Among girls aged 15 to 19 yrs, 104 cases of grade CIN 2 and 60 cases of CIN 3 carcinoma in situ diagnosed by biopsy were detected.

The best management strategies for adolescents with a squamous intraepithelial lesion (SIL) are controversial. Low-grade squamous intraepithelial lesions (LSIL) have increasingly been managed with a conservative approach, since spontaneous regression occurs in 50% or more of cases.12, 13 In contrast, a significant proportion of high-grade squamous intraepithelial lesions (HSIL) progress to invasive cervical carcinoma if left untreated.14 This has led to the use of more ablative treatment modalities even in the young teenager.

The use of colposcopy accompanied by biopsy has provided a more precise evaluation of cervical lesions in terms of size, distribution, and involvement of the endocervical canal.15 This approach has led to less-aggressive treatment of cervical cell changes, particularly in young women in whom preservation of childbearing potential is desired. There are many options for the management of intraepithelial lesions, varying from ablative methods, such as cryotherapy, electrocautery, and diathermy laser, to excisional methods such as laser conization, cold-knife conization, and, more recently, the loop electrosurgical excision procedure (LEEP). LEEP was introduced in the United Kingdom during the early 1980s as an alternative to cold-knife and laser conization in the treatment of premalignant cervical lesions. The procedure uses a low-voltage, high-frequency electrical current to excise the entire transformation zone using monopolar loop-shaped electrodes. The technique is relatively simple and very cost-effective since it is performed with local anesthesia as an outpatient procedure in the office or in a surgical center.16 Large series have shown over 90% cure rates for all grades of CIN and a lower rate of complications such as hemorrhage or cervical stenosis than reported with cold-knife conization.15, 17, 18

Although some studies of LEEP outcomes include young women in the study population, none has specifically examined an adolescent population. Since there is a paucity of data regarding the outcome of LEEP in adolescents, we examined the safety and effectiveness of LEEP in 35 adolescents focusing on postoperative complications, subsequent pregnancies or spontaneous abortions, compliance with follow-up, and recurrence of HSIL.

Section snippets

Materials and Methods

Thirty-five adolescents underwent LEEP between January 1, 1995 and December 31, 1997 at Children's Hospital, Boston, MA. All patients had been previously evaluated by colposcopy and biopsies as well as sexually transmitted disease (STD) testing in the Pap Smear Evaluation Center by the attending physician. Only those who had HSIL on biopsy or Pap smear, persistence of LSIL, or 4-quadrant LSIL or LSIL with unsatisfactory colposcopy were referred for LEEP.

LEEP was performed as an outpatient

Results

Table 1, Table 2 summarize the data on patient demographics. The mean age of the 35 patients at LEEP was 17.9 ± 1.5 yrs (range 15–21). Overall, 20 (57.2%) of the patients used at least one form of contraception; only 3 (28.6%) patients who were using hormonal contraception also reported consistent condom use.

Table 3 shows the Pap smear result that led to referral for biopsy. Table 4 shows the results of LEEP by colposcopic histopathology. The majority of LEEPs were performed for biopsy for

Discussion

This study is the first to review a series of adolescents undergoing LEEP, which is presently one of the primary modalities of treatment in this country for high-grade cervical dysplasia in adults. However, there is little published information regarding its appropriateness for the treatment of dysplasia in adolescents.

One of the advantages of LEEP is that in addition to effecting treatment for an abnormal lesion of the cervix, it can provide an excellent specimen for histologic evaluation,

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      Historical data suggest the compliance in adolescents is as low as 24% at 2 years, even after having an excisional procedure such as a LEEP.5,14 In our study, the noncompliance rate was 40% at 1 year, which is similar to previous reports.5,14 Noncompliance has been associated with younger age, lower educational level, unmarried status, lack of adequate health insurance, better overall health, lower-grade cervical lesions, as well as lack of understanding of the significance of their abnormality.7

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      The rationale is that because a significant proportion of HSIL in adolescents is likely to be CIN 2 or less, referral to colposcopy rather than immediate treatment is justified. One study found that only 54% of loop electrosurgical excision procedure (LEEP) specimens in adolescents referred for histologic or cytologic HSIL had confirmed CIN 2.41 This finding suggests that many of the lesions in adolescents, whether CIN 1, 2, or 3, regress spontaneously.

    • Status quo and prevention of overtreatment in cervical diseases

      2012, European Journal of Gynaecological Oncology
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    Dr. Perlman is now at the Department of Obstetrics and Gynecology, University of Louisville School of Medicine, Louisville, KY; Dr. Kahn is now with the Division of Adolescent Medicine, Children's Hospital Medical Center, Cincinnati, OH.

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