Cryotherapy and LEEP

Dwiana Ocviyanti
• Department of Obstetrics and Gynecology Faculty of
Medicine University of Indonesia
• National Clinical Training Network of Reproductive
Health/NCTN-RH
 Back Ground
• Some procedures being used to manage precancerous
lesions (dysplasia or CIN) are hysterectomy and cone
biopsy
• Available scientific evidence supports the use of
several outpatient procedures (e.g., cryotherapy and
LEEP/Loop Electrosurgical Excision Procedures) as
being highly effective
• The use of inpatient methods such as cone biopsy and
hysterectomy are more costly and potentially more
risky to women
• Cervical cancer screening in developing countries is
offered at low resource healthcare system where
outpatient treatment would be more proper if
available.
Treatment for precancerous lesions
• In order for cervical cancer prevention
programs to be truly effective and of public
health value, testing should be linked to
appropriate treatment for any precancerous
lesions detected.
 What lession need to be treated?
• High-grade (CIN II–III) lesions should be treated
because they are more likely than low-grade lesions
(CIN I) to progress to cancer
• Published studies indicate that most low-grade lesions
will regress spontaneously and thus do not require
treatment
• When close follow up or histological confirmation is
not feasible or possible, treatment of acetowhite
lesions (that could be low-grade or high-grade lesions,
or a false positive) may be advisable, particularly if the
treatment is not highly invasive or associated with
serious side effects, complications or long-term
sequellae.
 Selection criteria
• The transformation zone must be fully visible
• There should be no suspicion of microinvasive
disease or adenocarnoma in situ
• ATZ not extend into endocervical canal
• CIN biopsy proven
• Assesment by skilled colposcopist
 The advantages of cryotherapy
• effective with small- and moderate- sized
lesions (85–95% cure rate)
• inexpensive
• can be performed by non physician
• no local anesthesia required
• no electricity required
• associated with few complications/ side
effects
 The disadvantages of Cryotherapy
• variable success rate with large lesions (75–85%
cure rate)
• destructive (leaves no tissue sample for
confirmatory diagnosis)
• difficult to determine exact amount of tissue
destroyed
• associated with profuse watery discharge for up
to 6 weeks following treatment
• requires access to and resupply of coolant (CO2 or
N2O).
 Cryotherapy

• The refrigerant gas N2O (-90 C), CO2 (-60 C).

• A single-freeze ( 3 minutes)
• A double freeze ( 3 min freze, 5 min thaw and
3 min refreeze)
 The advantages of LEEP
• Effective (80–96% cure rate for all lesions),
enables tissue sampling for diagnosis and
associated with few complications/ side
effects
 The disadvantages of LEEP
• The equipment is more expensive than
cryotherapy
• primary side effect is peri- and postoperative
bleeding (about 3–8%)
• requires physician to perform it
• requires local anesthesia
• requires electricity (but could be battery
powered)
• requires resupply of loops.
 Some differences in effectiveness rates
between cryotherapy and LEEP
• Especially when lesion size is large a recent
randomized clinical trial,showed that, overall, the
differences were not statistically significant
(Mitchell et al. 1998)
• This study also demonstrated that LEEP had a
higher rate of complication (8%) than cryotherapy
(2%)
• Although these differences were not statistically
significant, the main difference in complications
among the procedures was the higher risk of
postoperative bleeding with LEEP (3%) versus
cryotherapy (0%)
 Conclusion
• Compared to other methods of treatment, it is
relatively easy to train different cadres of
healthcare providers to use cryotherapy
(Blumenthal et al.)
• This advantage, combined with its low cost
and high efficacy rate, make it appropriate for
low-resource settings where only nurses or
nurse-midwives are posted.
 Cryotherapy treatment and referral
• Women who are VIA test-positive are eligible for
cryotherapy treatment if the lesion is not suspicious for
cancer, occupies less than 75% of the cervix, does not
extend onto the vaginal wall or into the cervical canal
beyond the reach of the cryoprobe, and extends less
than 2 mm beyond the diameter of the cryotherapy
probe including the tip of the probe
• If any of the above conditions are not met, refer the
woman to an appropriate facility where additional
diagnostic and treatment methods are possible and
medical backup is available.