Conservative Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN 2)

Introduction

The purpose of this leaflet is to provide you with information about an option for “Conservative Management” following a diagnosis of a High-Grade change also known as Cervical Intraepithelial Neoplasia (CIN 2). This leaflet is not to replace the discussion between you and the healthcare team, but can act as a starting point for discussion and allow you to have an informed choice in your care.

It is important to remember that CIN is not cancer, butindicates precancerous changes to the cells in the neck of the womb (cervix). This can be managed with either conservative management (close monitoring) or a treatment to ensure that it does not progress to cancer in the future.

Your Doctor or Specialist Nurse will discuss the options with you and help you to decide the best approach based upon your wishes and clinical results from your care to date.

What is CIN 2?

There are 3 grades of CIN and they relate to how deeply the abnormal cells have gone into the skin covering the cervix:

• CIN 1 (low grade) – up to one third of the thickness of the lining covering the cervix has abnormal cells.

• CIN 2 (high grade) – up to two thirds of the thickness of the lining covering the cervix has abnormal cells.

• CIN 3 (high grade) – the full thickness of the lining covering the cervix has abnormal cells.

CIN 2 means that these abnormal cells have a small potential risk of developing into cancer if they do not go back to normal on their own.

What are the options for the treatment of CIN 2?

Conservative Management

This option involves regular monitoring through the Colposcopy Clinic at 6 monthly intervals for a maximum of 2 years.

This will include cervical screening (a smear test) and colposcopy examinations and possible biopsies of the cervix (small piece of tissue removed) at each visit.

If at any point in your care the CIN 2 increased in size across your cervix or the cervical screening result or biopsy suggest it has progressed to a higher grade (CIN 3), a Large Loop Excision of the Transformation Zone (LLETZ) treatment will be recommended.

Your treatment options may be discussed with you again at any point in your care if the CIN 2 does not resolve. If after the 2 year monitoring period CIN 2 remains a LLETZ would be recommended.

Treatment option of Large Loop Excision of the Transformation Zone (LLETZ):

This is a common procedure to remove abnormal cells from the cervix. It is usually performed in our Colposcopy Department with Local Anesthetic. It is a small procedure that is used to remove a small area of the skin from the cervix using a thin, loop-shaped tool, which is heated with an electrical current.

This removes the abnormal cells from the cervix and seals the tissue at the same time. This should not be painful, but you may feel some pressure on your cervix.

What are the benefits of LLETZ?

It removes the abnormal cells and allows normal cells to regenerate in their place. You will have a repeat cervical screen 6 months after the LLETZ treatment to ensure that all the abnormal cells have been removed.

What are the risks of a LLETZ?

The main complications following this treatment are heavy vaginal bleeding and infection.

There is a very low risk (2% – 2 women of 100) of having a premature birth/mid-trimester miscarriage (between 13-26 weeks gestation) in women who have not yet had any children.

The risk is usually determined by the amount of the cervix removed during the treatment. Treatments deeper than 10mm may increase the risk of pre-term birth.

There is a slight risk of cervical stenosis (narrowing of the neck of the womb/cervix). This treatment does not have an effect on your ability to conceive or your fertility.

Is Conservative Management a suitable option for me?

Current guidelines on monitoring CIN 2 says it can be offered if;

• Colposcopy has shown CIN 3 or Cervical Cancer is not present.
• The CIN 2 is in less than half of the cervix.
• All cases of CIN 2 must be discussed at our Multi-disciplinary Team Meeting (MDT – consisting of Specialists from Cytology – who review any cervical screening samples, Colposcopy – Nursing/Doctor/Consultants across the Trust who have involvement in your care and Histology – who review any biopsies that may have been taken).

It is very important that you attend all of your appointments, but if you feel you are not able to attend at 6 monthly intervals, then Conservative Management is not an appropriate treatment for you and we would recommend you have LLETZ treatment.

What are the benefits of Conservative Management?

This treatment option is being offered as studies have shown that in time CIN 2 can return to normal in approximately 50% of women who have no treatment and up to 60% in women who are less than 30 years old, however it may take up to 24 months for CIN 2 to resolve.

In more recent years studies have shown that Conservative Management does not have an effect upon a woman’s reproductive health or fertility.

In women who have not yet started their family or wish a further pregnancy, Conservative Management can avoid the risks associated with LLETZ treatments of having a premature birth/mid-trimester miscarriage (between 13-26 weeks gestation).

What are the risks of Conservative Management?

The increased risk of cervical cancer in the longer term is not known, but may be higher for those who are not treated at the time of the initial CIN 2 diagnosis. Less than 1 in 200 individuals with CIN 2 will develop cervical cancer in a 2 year Conservative Management period.

The rate of progression to a higher grade of CIN is about 1 in 10 (10%) in individuals with a cervix under 30 years of age and 1 in 5 (20%) of any age. The likelihood of progression or regression depends on your personal situation, including factors such as:

• Your age.
• Whether or not you smoke.
• Whether you have a condition (or potential medication) that affects your immune system.

What if I change my mind about Conservative Management?

You can change your mind at any time. You can contact the Colposcopy Department if you are feeling worried or concerned about your treatment and speak to a member of the specialist team. It is important to understand the benefits and risks of any options for managing cell changes and that you feel comfortable with your decision.

What else can I do?

We know that in individuals who smoke, CIN 2 is less likely to resolve spontaneously. Stopping smoking will make it more likely that Conservative Management will be successful.

Using condoms, also helps increase the clearance rate of Human Papillomavirus (HPV) and CIN 2 (especially if they are used every time you have intercourse).

Further Advice:

We hope that you have found the information in this leaflet helpful. If you require any further advice regarding your care, please do not hesitate to ask the clinic staff. They are there to support you and are happy to help with any concerns or anxieties you may have.

Contact numbers:

University Hospital of North Tees

Outpatients Department:
Monday to Friday, 09.00am to 5.00pm
Telephone: 01642 624172

University Hospital of Hartlepool

Outpatients Department:
Monday to Friday, 09.00am to 5.00pm
Telephone: 01429 522865

You can also contact a Specialist Nurse Colposcopist on the following number:
Colposcopy Hub:
Monday to Friday, 8.30am to 4.30pm
Telephone 01429 522268

References:

Public Health England (2024) NHS Cervical Screening: Programme and Colposcopy Management,  https://www.gov.uk/government/publications/cervical-screening-programme-and-colposcopy-management

Lellé, R.J., Küppers, V., (2023) Colposcopy: Comprehensive Textbook and Atlas

Useful Websites:

Cancer Research UK:
www.cancerhelp.org.uk
www.cancerscreening.nhs.uk

Jo’s Cervical Cancer Trust:
www.jotrust.co.uk

The British Society for Colposcopy and Cervical Pathology:
www.bsccp.org.uk

Comments, concerns, compliments or complaints

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