Cervical abnormalities: CIN3 and CGIN
LLETZ (loop diathermy)
The most common treatment for CIN2 and CIN3 these days is loop diathermy also know as LLETZ – Large Loop Excision of the Transformation Zone (LEEP outside the UK – Loop Electro-Excision Procedure). Its aim is to remove all the abnormal cells from the cervix. A wire loop with an electric current (diathermy) is used to remove these cells. This leaves a raw area on the cervix, which heals very well. The healed cervix should then contain only healthy tissue, without any abnormal cells.
LLETZ is usually performed in a hospital as an outpatient. The procedure takes about five minutes and is carried out under local anaesthetic. Like colposcopy, LLETZ is not usually performed if a woman has her period.
Some of the women we interviewed had a colposcopy and LLETZ in the same appointment and were pleased to be treated there and then.
The doctor could see the area that needed treatment and Anna was pleased to be treated sooner...
On the first day that I saw them I explained that we were expecting to start IVF treatment and the delay was really scary. And the doctor said if he looked and it was obvious that I would need treatment, he would do the treatment there and then.
Fortunately my husband was with me because he’d had the day off that day. And he looked and he said, “Okay well, I’m going to take a biopsy but I can see that there is definitely an abnormality. And you’re going to need to have a loop diathermy. So I’ll just do it. And so he just did it there and then. So that was, I thought that was really good of him because that, you know, that meant I could have more IVF treatment sooner and also I’d know the answer quicker. And that was a weight off my mind that he did that.
The colposcopy is kind of nothing; it’s just like an extra long smear except they use a kind of a big camera-y thing. So that was a bit of a surprise, so I didn’t really need to see a close up of that area of my body. So I looked the other way.
But the treatment itself, I don’t know because I’d had a lot of treatment in that area because I’ve had fertility treatment, so I don’t really get embarrassed so much. And I’ve certainly had treatment that was a lot less comfortable, just doing that.
But I think the worst bit was the injection. And the second worst bit after that was them taking the speculum out. And, other than that, it really wasn’t at all painful.
Jo felt shocked and unprepared to be treated at colposcopy but her mum persuaded her to go ahead....
To be honest I was really, really shaken. Really, really shocked because I didn’t expect to have the treatment there and then. And I’ll be absolutely honest, I just burst into tears and said, “Right that’s it, I want to go home. I just don’t want to do it.” I felt like I wanted to be more prepared and go back to the doctors knowing what was going to happen. Rather than, it was just, all happened really quickly.
However, you know, to be honest if it wasn’t for my mum saying, “You know, just have it done, it’s over and done with then.” I probably would’ve walked out the doctor there and then if I was on my own. But, you know, I went ahead with the treatment.
They used the term the Loop Excision, I think. And they did explain to me that it was going to be taking away, you know burning away the cells. That there was going to be follow up after that, a follow up check.
They offered the choice to view it all on some TV screen, and I said, “I don’t want to look, don’t want to know.” I mean, to be honest I’m quite the person that doesn’t really want to know the detail. If, you know, if you need to do it what you need to do, then that’s fine.
Some of the women we talked to had LLETZ shortly after their colposcopy, while others had to wait several weeks. Many found that difficult and a few felt very anxious and isolated. On the day of treatment, some went to the hospital alone while others said they took their partner, mum or a friend with them for support. Some said it was helpful to have another person there to listen to the information they were given.
A doctor explains why some women are treated at the colposcopy appointment while others might be...
Some women were treated at the same appointment as their colposcopy appointment. Others had to come back later for treatment. Is there any particular reason for that?
It’s such a variation. It depends on the severity of the abnormality, depends on the woman’s wishes. And it depends on the judgement that the doctor makes at the time. The general rules are, if there is an abnormality that’s obvious, the full limit can be seen, and the women’s willing to be treated at the time, she can be offered treatment on the day.
Many of the women interviewed recalled signing a consent form and having the procedure explained. Some, though, said they would have liked more information beforehand. Most found the treatment painless, though a few felt a little stinging sensation when they were given the local anaesthetic. Two women said they took a paracetamol before going to the hospital and felt no pain at all. Several said that having the treatment was better than they’d expected.
Anna was nervous beforehand but the procedure was similar to a smear. Apart from a bit of...
Waiting to go in, very nervous because I wanted to know exactly what was going on. He’d explained everything to me, although I wasn’t quite taking it in at the time because my mind was just elsewhere.
When I went into the actual room where they were doing the treatment, I had to sit on a chair with stirrups up for my legs to go in, and slide my bum down a bit, so I was at a better angle. Very similar to a smear, maybe a bit more comfortable because you’re in a chair than laid on a couch. Which isn’t very pleasant.
And then he came in, obviously you need to be from the waist, stripped from the waist down, so ideally wear a skirt. And then it was, to start off with, it was pretty much like a smear. They insert the speculum, which is never very comfortable, and he explained that he obviously needed to numb the area, and put in a local anaesthetic. My cervix tilts a bit so that was a bit awkward, and it, a little painful. I think that was the most painful part I think for me. But it was bearable.
The nurse obviously then had to put the little plastic thing on your thumb to keep it, finger on to check your pulse. And then they put some plastic, I remember plastic, it felt like plastic stickers on my thighs. I can’t remember what that was for, maybe again to just monitor how I was.
And then you heard a buzzing noise, which I, well I think it was just something that helped them with the treatment when he got the wire rod to insert into me. Didn’t feel anything when it was being done, obviously because the anaesthetic was working.
There was an unpleasant smell in the air, which wasn’t very nice. I could feel myself burning up. I think that was more nerves than anything, feeling a bit light headed but the nurse was there to keep me talking, asking me questions about what I was doing at the weekend, just to keep my mind off it.
Didn’t last very long really, and they have removed everything there. My legs were obviously trembling, and with them being up in stirrups. That obviously make things easier and that he did have to stop at one point because I was getting a bit nervous. But yeah, I think it probably only took about five, ten minutes.
Some of the women we spoke with said they were interested in watching the procedure on the screen, while others felt that talking to the nurse helped to take their mind off it. A few women recommended wearing a skirt. Anna, who’d had her colposcopy while travelling abroad and a LLETZ in England, was happy with the treatment she’d been given and wrote to thank the medical staff afterwards.
The atmosphere was very relaxed. The procedure was painless and had little impact on Annas life...
As soon as I got to the hospital, she was, “No, no, it’s fine. Absolutely no problem. I can treat you here and now.” It was very relaxed. My boyfriend came with me as well, and while she was, I mean the procedure probably took about fifteen minutes or something. And it was the loop procedure where they just sort of burn it out with a loop thing.
And we were just chatting about our holiday, you know, it was all very relaxed. The nurse was very relaxed. There was all sorts of, almost a bit of a jokey atmosphere, it was fine. Obviously afterwards I couldn’t really exercise, have sex, swim, and had to take it easy for a month. But other than that it didn’t really affect my life.
You get to see it all on the screen as well, which is interesting. But I tried, I didn’t like to look, particularly during the procedure because it wasn’t very attractive. And I think, like I said, I didn’t feel anything but when you look at something, it’s like when you don’t feel a cut, and then you have blood and suddenly you do. So I didn’t look.
But my boyfriend, being a nurse, was very interested. So it was good having someone there. I think it’s good to take somebody with you because, at the time, there’s a lot of information being thrown at you. It’s just nice to have someone afterwards to be able to discuss things with, and if there was something you weren’t sure with they, because they’re a bit calmer because it’s not them, so yeah.
Some of the women we talked to said they felt worried and anxious on the day of treatment but the LLETZ procedure was explained to them and the staff were very caring and reassuring. They held their hand during the procedure and chatted to them throughout.
Lizzie was extremely anxious before surgery and was prescribed a sedative. The staff were very...
I was very, very, very, very nervous about the procedure because I have anxiety about pain and everything else. And I spoke to the doctor and I was sort of begging him to put me under a general anaesthetic because I just didn’t want to do it. And they said, well no, they don’t do that unless it’s for a cone biopsy.
But they assured me that it wouldn’t be too uncomfortable. But he did prescribe me some sedative to just help ease the situation, which helped me hugely I have to say because I was very, very nervous, and very anxious. And on the actual day, a couple of months elapsed and on the day of the actual biopsy, I took as many as was necessary of my sedatives and I have to say they did make a huge difference.
But the only uncomfortable bit was the local anaesthetic into my cervix. I flinched a bit at that, but it wasn’t unbearable. But it obviously was a little bit uncomfortable, but then it was all very quick, painless. They were very courteous. Very caring, and they really looked after me afterwards. They sort of sat me down with a cup of tea, and I felt a bit shaky and a bit woozy, and a bit wobbly. But they were really lovely; it was like being in a private hospital actually. And they made a very unpleasant experience a lot more bearable.
The worst thing for me was the local anaesthetic in my cervix which, you know, it wasn’t dreadful but it was just a bit sharp and uncomfortable. But even someone turning around and going, “Do you know what, you know I’ve had three children now, it can’t, it’s no worse than that,” kind of thing. You know, putting my mind at rest going, “It’s okay, you’ll be fine, you will get through it. It’s not awful.”
I know, again it’s a primal thing as a woman. You know, you’re laying yourself open, if you’ll pardon the expression. You’re in a very vulnerable position. You’re laying yourself open to quite probably a man who’s doing this to you. It invokes very primal fears, which you have to overcome.
And you need help to kind of overcome that. I mean I said to my husband it wasn’t so much the diagnosis that frightened me, it was the procedure because I was vulnerable, you know. You’re prone, you’ve got your legs in stirrups, you’re being dealt with and, you know, it can invoke all of those feelings that you don’t realise you have.
A few women found having the local anaesthetic difficult.
The local anaesthetic was a bit uncomfortable. Sandras blood pressure dropped after the...
If someone was going for their very first time, and they don’t know what to expect and they’re a friend of yours, how would you describe what happened?
I think I would just tell them it’s a bit like having a smear, but a bit more uncomfortable. But I don’t know if I’d tell them exactly how it did feel because it was, it was quite painful.
The whole thing? Or…
No, no. Just the anaesthetic I think. That was just the part, unfortunately I did, I fainted. So, it was a bit of a shock yeah.
So when they put the anaesthetic on, that’s when you…?
No, it was, it was actually, that was fine. They did the anaesthetic and I had the colposcopy done, the loop biopsy done, and that was fine. I think it was just, and after that I was still lying down, and then they obviously, they bring you up and as they brought me to sit, I just went. And they just said my blood pressure dropped. So I think it was a bit of a shock. I think that’s what it was.
Pam would have liked to have had LLETZ under a general anaesthetic because she found it very...
I had electrical diathermy. I wasn’t given the choice; I wasn’t told you could have a local or a general. So they booked it under local and I found it absolutely horrendous.
And half way through the doctor actually said to me, “Did you not know you could have it under general?” And I said, “No. But if I ever have this again, make sure it’s on my notes that I will be having a general.” Because it was quite painful.
Were you happy with the care when you were there?
Definitely. Except for the fact that I was angry that I wasn’t told about the anaesthetic. Even if I’d known that it, not obviously, not knowing how much it was going to hurt. But if I’d known I would still would have opted for the general anaesthetic because the whole thought of all that sort of thing going on while you’re awake, knowing they’re going to cut bits off you, or burn you and, you know, it’s scary.
And you’d had general anaesthetic before, so…
Yeah, I’d had loads.
…that doesn’t worry you?
No. Not at all. I would much rather and if I, if I do ever, God forbid ever have to go through this again, then I will definitely be having a general. That is one thing I would advise people. And I wouldn’t say I’ve got a low pain threshold because I’ve well, you know, I’ve had three kids and various operations and stuff.
Several women said they were treated by LLETZ under general anaesthetic instead of a local. One of these women said she felt happier having a general anaesthetic, though the other was very anxious and eventually another doctor at a different hospital treated her using local anaesthetic.
Genevieve was given a light general anaesthetic and describes what happened when she went into...
Even though it was a light general anaesthetic, I was just a bit flattened by the whole thing. And I think maybe just the whole sense of relief that I felt while I was there, that I wanted it out of my body, it was actually finally removed, so I just had a huge sense of relief.
So for someone who is looking on the internet and wants to know what will happen on the day of treatment, they know that they’re going to have a general anaesthetic and then a loop diathermy. Could, can you explain what happens on that day?
On that day?
Well I went in nil by mouth, so I had nothing to eat the night before. And I had to arrive in at 6 o’clock in the morning. So arrived in and just did the registration and, you know, they gave me the gown. And I was the first on the list so there was not too much hanging around, which was nice.
And the anaesthetist came to have a chat with me. Just asked me some general questions about my health. If I was allergic, had any allergies, and then they gave me, they took me down, wheeled me down. And I went into the sort of pre-op room and they gave me, put the needle in just to give me my pre-med. So, you know, needle, not very nice, but that’s fine. And, yeah, and then I had the pre-med which makes you feel quite wonderful actually.
And then, you know, count backwards from 100, and I think I made it to 97. And the gynaecologist surgeon had already come in before that and just said ‘welcome’ to me. And, you know, “Do you understand the procedure, this is what I’m going to do.”
And I came round in the post op and obviously just a bit groggy and very thirsty, and felt fine. And then was up, back up to the room. And had a long sleep, and had a big cup of tea with loads of sugar and a slice of toast. And that was it. My husband came, came back to pick me up and went home then.
No pain whatsoever? There was no discomfort?
No, but I was on, they’d given me just oral painkillers. So I was just having, I think paracetomol or something like that.
Bev changed to another doctor because she felt strongly about being treated under local...
Bev' I was nervous because I didn’t really know what to expect. I didn’t really know, I knew a bit about what the LLETZ treatment, that it was a laser, but I didn’t know what it actually did. So again, you know, you’re feeling really nervous, feeling a bit sick. Getting yourself worked up. And he [doctor] was just like, “Oh you know, lets see what we can, lets have a go, let’s have a try at this.”
Did you think at this point you would be having a general anaesthetic?
No, at this point I knew, because I’d fought to have it done as a local, I just thought, you know, he’d be able to do it under the local. And he started to do it, and decided that sort of five minutes into it, he couldn’t do it under the local anaesthetic because again the speculums weren’t right. The needle that they used to anaesthetise, you know for the local anaesthetic, wasn’t long enough. And he just…
Husband' Gave up.
Bev' Gave up. He didn’t even try, and at that point he said, “You know, you’ve got, you have to have it done under a general.” And I was just sort of, “Well I can’t have a general, I don’t want a general anaesthetic.” And he again just then threw a leaflet in my hand and went, “We’ll write to you when you’ve got an appointment date.”
We basically went to Hospital 2. I got called in to the actual room by the nurse, and instead of just calling me into the little side room, I was actually called into the main room. The consultant number 2 was sat at the desk and obviously they had on the letters that I’d been to Hospital 1. And obviously asked me what had happened, so I explained everything to her with regards as to what had happened at Hospital 1. She went through my full medical history with myself, family history of anything like this, so I was able to tell her everything.
She explained everything to me. She explained the colposcopy, what CIN3 is, and she explained the whole lot to me. And actually asked me that if she could do the treatment there and then, would, you know, would I be happy for her to do it that day?
I was like, “Yeah please.” I got asked to sign a consent form to give my consent to having the treatment done. She went through, you know, all the possible complications, and things that you could get after having the treatment done, which nobody else had done with me.
I signed the consent form and then I was shown into another room to get changed, and came back out and admittedly, I was probably in there for a good 40, 45 minutes plus. And she did struggle to do it because my cervix apparently is a bit weird and where it’s located. But she sort of persevered with it. Every time she kept me updated with what she was doing.
A few women were particularly anxious on the day of treatment because doctors had told them that they might have cervical cancer as well as CIN3 / CGIN.
Patricia was shocked and scared that she might have cancer. She felt faint after surgery and...
It was about CIN3 and he [doctor] was concerned that it was invasive at the time, as well. That was all the initial appointment. So huge shock, a big scare about was it actually invasive cancer? And I really was absolutely scared to death. I thought I was going to die.
I had two young children at the time, so I felt an element of feeling very responsible. And what made it even worse was, you know, it was commitments, and sometimes it’s worse. Yeah, went into complete panic basically. I was at that age, I was late thirties and the consultant recommended a loop biopsy? Does that make sense? A loop excision? So I went for that. And it was cleared. I think the results were that it was cleared, and that I would have to go back to have regular smears after that.
… I mean I think it’s quite a large excision because when the consultant actually phoned my home to give me the results, which was very good of him. And he seemed pleased at the time because he’d removed everything with clear margins. So he was happy about that and I understood from his happiness that that was a good thing to have, clear margins. And he said he took a lot out, and at the time, yeah, I sort of nearly fainted. Well I had to lie down for a long time certainly because there was a lot of bleeding. And I thought it was quite a major procedure to have in a clinic to be quite honest.
The doctor suspected Rachel might have cancer, but was pleased to confirm after treatment that it...
I went for the colposcopy on 2nd January. And Mr. the consultant who’s name’s [doctor’s name], he was brilliant. He drew me a picture of what was happening. He asked me if I knew why I was there, and I said, “Well I’ve got severe pre-cancerous cells.” And he said, “No,” he said, “It’s worse than that.” He said, “We think you have cancer.”
And he said, “But,” he said, “We’re going to have a look at you, and,” he said, “We’re going to remove the bad bits.”
So I got undressed. I got onto the chair, and he gave me the local anaesthetic and put the dye on. And the whole of my cervix turned white with the abnormal cells. And he did the LLETZ procedure. Which was completely painless. Didn’t hurt at all. I just felt a bit of pulling. I actually found the colposcopy okay. [Partner’s name], my partner fainted, which was….
But I was fine yeah. The nurse was brilliant. They talked me through it. They told me what was happening at all the stages. And, to be honest, it was such an anti-climax because I thought, “Oh my gosh, this is going to be such an awful procedure.” But it was actually, it was fine, it was fine. You know, it wasn’t the most dignified I would say, but it was okay. And then they explained to me what had happened.
And I was assigned straightaway a cancer nurse, because obviously they expected it to be cancer and I was put into a room with this lady who talked to me about what would happen if I had, if the cancer was confirmed.
And then I got a phone call within a fortnight from [hospital name], and they said that, they said, “I can’t believe it, I’m so relieved to tell you that it is pre-cancer, not cancer.”
Claire had an uncommon experience – she had abnormal cervical screening tests (smears) but normal colposcopies. At the time of interview, she was considering having a LLETZ but was concerned about being over-treated and the impact of treatment on future pregnancies (see ‘Fertility and pregnancy’).
Claire, a doctor, was being monitored but hadnt had treatment yet. She wanted time to consider...
And he said one of the options was the LLETZ, the LLETZ treatment, but you may have to have it more than once?
Yeah, just because he couldn’t, he said that the cells were probably very high up in the cervix because he couldn’t see anything. And, because I’ve never had children, I have a very small cervix so you can’t see everything. You can just see the outside.
So he was very clear explaining. And he drew some diagrams to show what the LLETZ would take out, and how it would be, if my cells were down near the bottom then it would be fine. They would be removed. But if they were up in the top they might not be removed. And he just felt that he didn’t want to do that at this stage in case it would resolve by itself. Because he didn’t want to over treat basically.
I’m not worried if I do have to have a LLETZ. I’m not worried about the actual procedure because it’s all been explained. And the colposcopy wasn’t bad.
So you’re not worried about the procedure. Your paramount concern is preserving your cervix so that when you do have children there are fewer complications or fewer issues that…?
Yes, and also the whole, it’s more about making sure that the right area is treated. If I was going to have a LLETZ and it was going to definitely treat the right area, then I would be fine. I would have one tomorrow.
In fact I was initially pushing to have treatment, to have a LLETZ done, and initially part of me was so worried I said, “I don’t care, you know, lets, just do the LLETZ and see.” But then we discussed it further. Because that was because I was nervous and because my aunt had died of cervical cancer, your knee jerk reaction is, “Oh my goodness, I want something done about it.” So to sit back and not do anything about it has been, it’s not been an easy choice, but it’s, you know, it’s been an informative choice.
After treatment, most of the women we talked to were told about aftercare and follow-up care (see ‘Healing after LLETZ or cone biopsy’ and ‘Follow-up care’).
Two women were treated a second time by LLETZ, both at their first follow-up appointment, because there were no ‘clear margins’, i.e. the area of abnormality had not been completely removed.
Sandra was disappointed to have LLETZ again because shed been told by a nurse that her results...
They said I would hear the results of the biopsy, what they took away, and I would get a letter to tell me the results of that. And in fact what they did, they sent me another appointment to go in to speak to a nurse to get the results. And she told me that it was clear and to come back in six months for another smear.
I went back in six months for another smear, and that was still under the hospital and when the results come through for that it was abnormal again. When I went, when I was at that appointment they told me then that the first biopsy result wasn’t clear, that I was told.
It was actually borderline, but they don’t tell you that, they tell you it’s clear. So I was quite annoyed about that because I’d kind of come away from that first appointment feeling very relieved, thinking that’s it, they’ve taken it all away. So I was very upset that second time I went back to find out that I was lied to, well not, perhaps not lied to, but not quite told all the truth.
So after having the second smear abnormal, I then had to go back in for a second loop biopsy, when they said they had to go in deeper. It was, they didn’t go in deep enough. So I had the second one. That was last year, and I’ve had one clear smear since. But obviously, because of what happened before, I don’t know if it was clear or not. So I still feel very apprehensive about my next smear, which is due next month.
One woman said she wasn’t at all worried about having treatment – her only concern was recurrence.
In 85–95% of women, their cervical abnormalities (CIN or CGIN) are successfully cleared after one treatment, but between 5 and 15% of women will still be affected by CIN or CGIN after treatment*.
A few women did have a recurrence several years after their first treatment and were treated again, usually by LLETZ (see ‘Recurrence of abnormal cells’). More experiences of LLETZ can be found on our cervical screening section.
*Onuki M et al, 2016. Post treatment human papillomavirus testing for residual or recurrent high-grade cervical intraepithelial neoplasia: a pooled analysis. The Journal of Gynaecological Oncology 27(1), e3. www.ncbi.nlm.nih.gov/pmc/articles/PMC4695453/. Accessed: 11.01.2017.
Last reviewed July 2017.
Last updated July 2017.