Having a LLETZ (Large Loop Excision of Transformation Zone) Treatment – Loop Excision

What is a loop excision treatment?

Loop excision is the most common procedure used to treat abnormal cells on the cervix (neck of the womb).

A thin wire loop heated by electric current is used to remove the area affected by abnormal cells on the cervix.

The area removed will then be sent to the laboratory for examination under a microscope.

You will be offered this if you have:

• A moderate or severely abnormal smear.
• Abnormal glandular cells on your smear.
• A biopsy that shows CIN 2 or CIN 3 (these are explained below.)
• A biopsy that shows abnormal glandular cells.
• Abnormal cells that are not visible on the outside of your cervix.

This can be offered at the first visit. The procedure will be explained, and you will be asked to sign a consent form. A colposcopy examination (looking at your cervix with a microscope) will then be carried out and a sample taken by loop excision as above.

Occasionally it may be more appropriate to have the procedure under a general anaesthetic but if this is the case, your clinician will explain everything and arrangements for a future day case admission will be made.

When a woman is first told that she has abnormal cervical cells her first reaction is often one of fear. This is a natural reaction. This leaflet has been written to provide information about the colposcopy appointment, which we hope will help you to understand what will happen during your clinic visit.

What is CIN?

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.

What will happen when I attend the clinic?

When you come to the colposcopy clinic, a colposcopist (a doctor or nurse who is trained to examine the cervix) will examine your cervix to identify the abnormal cells that may be seen across the surface of your cervix.

A fast-acting local anaesthetic will be given into your cervix. Whilst it is taking effect the rest of the equipment will be set up: a sticky pad is attached to your thigh to ensure a safe return path for the electric current being used to avoid injury and a plastic tube attached to the top of the speculum to circulate cool air.

Some of the anaesthetic can sometimes make you feel a little strange, it can make your heart beat faster and your legs feel wobbly. If this happens please do not worry, it is quite normal and will settle quite quickly. Breathe normally and try not to worry if your legs feel a bit shaky.

Once we are sure that the anaesthetic is working, a thin electrical wire loop is used to remove the abnormal area – hence the name. The area is then sealed to stop it bleeding with another type of electrical instrument. It is a very safe procedure and takes about 15 minutes.

Advice before having the treatment

If you have a period at the time of your appointment, unless it is heavy, the treatment can go ahead. If you are unsure, please contact the colposcopy office for further advice.

If you are taking any blood thinning medications, please contact our colposcopy office once you receive your appointment letter. The admin team will then inform the colposcopist who will contact you for appropriate advice.

We CANNOT carry out the treatment if there is any chance that you are pregnant. Please use reliable contraception while you are waiting for your appointment, even if you do not normally do so.

If you found out that you are pregnant before your appointment, please do attend for an assessment and review by the doctor or nurse colposcopist.

Following assessment, further follow-up will be arranged and the treatment can be delayed until you are 3-months post-delivery or at the end of your pregnancy.

What if I have a coil? (Intra-uterine contraceptive device, IUS, IUCD)

You will be offered the choice of having the coil removed or leaving it in. Both options have associated problems.

If the coil is left in the strings may get cut by the loop. This will not have any immediate effects but may cause difficulty when the coil needs to be removed.

If you have the contraceptive coil, you should use additional contraception (condoms) for seven days before your appointment, as the colposcopist may have to take the coil out before carrying out the treatment.

Taking the coil out within seven days of sexual intercourse can result in unplanned pregnancy; therefore, it is important to use an additional method of contraception or do not have sexual intercourse for seven days prior to your appointment.

You will be asked whether you have had sex in the last seven days when you attend for the treatment.

If there is any doubt or concern, the treatment will be delayed until the coil can be safely removed.

If it is taken out, it can be replaced six weeks later, at your usual contraceptive service centre (GP or Sexual Health/Contraception Clinic).

Is the treatment painful?

It is usually painless or minimally uncomfortable because of the local anaesthetic used. Some women experience period type pains for a day or two afterwards, but this will settle with standard over the counter painkillers, such as Paracetamol or Ibuprofen.

Does the treatment have any side effects?

LLETZ treatment is generally very safe but as with all surgery there can be complications:

• Up to 50% of patients will experience 10 days of bleeding and some vaginal discharge which may be moderate to heavy.
• Many experience pain for a day or two afterwards.
• Bleeding is more likely if you get an infection in the raw area on your cervix which takes about 4 weeks to heal.
• If you do get an infection there will be a smelly discharge or increased bleeding. In this case contact your GP for antibiotics.
• In very rare cases the bleeding is severe, and you may need to be admitted to hospital.
• Bleeding can occur up to 2 weeks after the procedure as a result of bacteria living in the vagina causing the blood vessels to open up.
• Some patients notice a difference in the timing and length of their periods afterwards.
• There is a small chance that as the cervix heals it scars up making the canal narrow and makes it difficult for the blood to escape when you have a period. This is called stenosis. If this occurs a simple procedure can be performed under local anaesthetic to open the canal.
• Research suggests that with a loop of less than 10mm deep there is no associated increase in the chance of pre-term labour or pre-term rupture of the membranes. There may be a small increase in miscarriage before 20 weeks, but this is very rare. Deeper and repeat treatments could increase your chance of premature delivery.
• We aim the treatment to remove all the abnormal cells but occasionally some get left behind (residual abnormality). This is why it is important to attend for your follow-up smear which will recognise if any abnormal cells and HPV virus are still present.
• Damage to other tissues is very rare.
• Loop excision does not affect how easy or otherwise it is for you to get pregnant.

To keep the risk of infection as low as possible you MUST AVOID:

• Sexual intercourse for 4 weeks.
• Using tampons for 4 weeks.
• Swimming and use of hot tubs for 4 weeks.
• Taking long soaks in the bath for 2 weeks (shower instead).
• Undertaking excessive exercise for 2 weeks.

Can I bring someone with me?

Yes of course. It is easier to have someone to take you home afterwards although you are safe to drive. You should take it easy for the rest of the day.

What about work?

You can go back to work the day after as long as it does not involve lifting or strenuous activity. If so, you may need to take a few days off.

Please note that some travel insurance companies will not provide you with health insurance following this procedure. You may wish to rearrange your colposcopy treatment appointment if you are going on holiday or flying within four weeks of the treatment date.

What happens next?

The tissue that is removed from your cervix is sent to the lab and we write to you with the results usually within 6 weeks.

Sometimes more treatment is needed so we will ask you to return to the clinic to talk through your choices.

You will be asked to have a smear 6 months post treatment to ensure that there are no abnormal cells or HPV virus left behind. This may be done in the hospital clinic or at your GP surgery.

For 95% of patients this will be all that is needed. For a few patients the problem returns, and you have to have a second treatment. For about 3 in every 10,000 treated people, cancer can still develop and that is why it is so important to have follow-up cervical screening tests.

On very rare occasions a hysterectomy may be needed, but this will all be discussed if and when necessary.

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

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