LEEP in the Family Practice Setting
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* David Lyman

*To the Editor:* Dr. Nuovo raises questions about the appropriateness of using LEEP to treat CIN 2 and CIN 3 when cryotherapy may offer a less expensive and equally efficacious treatment. There are several reasons why cryotherapy is an inferior treatment for high-grade CIN.

One, with no specimen to submit for histologic examination, both laser vaporization and cryotherapy will miss the unsuspected adenocarcinoma in situ and microinvasive squamous cell carcinoma found in 2% to 3% of specimens.1,2

Two, complications are not necessarily fewer with cryo. Mitchell and colleagues3 found no differences in rates of complications (or success) when they randomized treatment to 1 of 3 modalities—cryo, laser, or LEEP. To state that cryo has “fewer complications” is simply not true when treatment is stratified by squamous intraepithelial lesion (SIL) grade, endocervical gland involvement, and lesion size—as was done by Mitchell and colleagues.3

Three, it may be more expensive to treat CIN with cryo if we are to believe the work of Sparks and colleagues.4 Fifty-one of 83 women (61.4%) treated with cryo had an “inadequate” follow-up colposcopy versus 5 of 24 women (20.8%) treated with LEEP or cold-knife conization (CKC) [Note that the terms “inadequate” and “adequate” were not defined. I assume they are equivalent to the more familiar terms “unsatisfactory” and “satisfactory.” A “satisfactory” colposcopic examination is one in which both the entire squamocolumnar junction (SCJ) and the upper limits of the lesions are visualized.] Their conclusion was that treatment of CIN with cryotherapy increased the risk of “inadequate” follow-up colposcopy. Because the current management of an “unsatisfactory” (and I assume “inadequate”) colposcopy is to proceed to LEEP or CKC, the authors posit that an unknown number of LEEPs are done for this reason. The total cost of cryo followed by LEEP is unknown but not insignificant.

Four, Harper and colleagues5,6 in 2 papers describe the significant symptoms experienced during the healing process after cryotherapy. The authors documented a more prolonged, malodorous, and painful healing process than had been previously recognized, although they alluded to the need to reproduce this study in post-LEEP women. My experience is clearly unscientific, but when I ask women who have had both procedures their preference, they have all stated that LEEP was less painful with fewer side effects than the preceding cryosurgery.

In summary, cryotherapy is a reliable, easy-to-use, low-cost tool. However, loop electrical excision of the transformation zone or LEEP as described above is a superior treatment for CIN. The technique has a proven safety record, is easily learned by the family physician, and the equipment—which can also be used for dermatology surgery—is becoming more affordable. New recommendations on the use of LEEP are forthcoming and may resolve unanswered questions about the most appropriate treatment of epidemic CIN.

## References

1.  Wright TC Jr, Gagnon S, Richart RM, Ferenczy A. Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure. Obstet Gynecol 1992; 79: 173–8.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=1731281&link_type=MED&atom=%2Fjabfp%2F16%2F4%2F360.1.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1992HB18900004&link_type=ISI) 

2.  Ferenczy A, Choukroun D, Arseneau J. Loop electrosurgical excision procedure for squamous intraepithelial lesions of the cervix: advantages and potential pitfalls. Obstet Gynecol 1996; 87: 332–7.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/0029-7844(95)00453-X&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=8598950&link_type=MED&atom=%2Fjabfp%2F16%2F4%2F360.1.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1996TX74200003&link_type=ISI) 

3.  Mitchell MF, Tortolero-Luna G, Cook E, Whittaker L, Rhodes-Morris H, Silva E. A randomized clinical trial of cryotherapy, laser vaporization, and loop electrosurgical excision for treatment of squamous intraepithelial lesions of the cervix. Obstet Gynecol 1998; 92: 737–44.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/S0029-7844(98)00246-4&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=9794661&link_type=MED&atom=%2Fjabfp%2F16%2F4%2F360.1.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000076584000001&link_type=ISI) 

4.  Sparks RA, Scheid D, Loemker V, et al. Association of cervical cryotherapy with inadequate follow-up colposcopy. J Fam Pract 2002; 51: 526–9.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=12100775&link_type=MED&atom=%2Fjabfp%2F16%2F4%2F360.1.atom) 

5.  Harper DM, Mayeaux EJ Jr, Daaleman TP, Woodward LD, Ferris DG, Johnson CA. The natural history of cervical cryosurgical healing. The minimal effect of debridement of the cervical eschar. J Fam Pract 2000; 49: 694–700.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10947134&link_type=MED&atom=%2Fjabfp%2F16%2F4%2F360.1.atom) 

6.  Harper DM, Mayeaux EJ Jr, Daaleman TP, Johnson CA. Healing experiences after cervical cryosurgery. J Fam Pract 2000; 49: 701–6.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10947135&link_type=MED&atom=%2Fjabfp%2F16%2F4%2F360.1.atom)