The risks and benefits of treatment to the cervix (LLETZ) versus continued surveillance (follow up) of persistent HR HPV (Human Papilloma Virus) with an unsatisfactory colposcopy examination

The risks and benefits of treatment to the cervix (LLETZ) versus continued surveillance (follow up) of persistent HR HPV (Human Papilloma Virus) with an unsatisfactory colposcopy examination

Introduction
The purpose of this leaflet is to provide you with information about the options
available to you due to the persistence of the High-Risk Human Papilloma Virus (HR
HPV) and an unsatisfactory (inadequate) colposcopy examination.

This can be managed with either treatment to the cervix or continued surveillance in
the colposcopy clinic.

What is HPV?
HPV is a very common virus which is usually passed on through skin-to-skin contact.
On the cervix it tends to be through sexual contact, which can make some people feel
worried or embarrassed. Because HPV lives on our skin, it is easy to get and difficult
to completely protect against. At some point during our lives, 8 in 10 people will get
HPV. In most cases, your immune system will clear the HPV within two years without
it causing any problems. However, in some cases it can take longer.

The types of HR HPV detected on your cervical screening (smear) test can cause
changes in the cells in the cervix.

HR HPV infections that persist can lead to cell changes that if left untreated may get
worse over time, usually this occurs over many years and cells can develop
precancerous changes or even cancerous changes.

What do we mean by an unsatisfactory/inadequate colposcopy?
The cervix is made up of two types of cells. The tougher squamous cells on the outside
and the more delicate glandular cells that line the birth canal on the inside. It is where
these two types of cells meet that abnormal cell changes are most likely to develop.

In your case we are not able to see this junction of cells as it is tucked up inside the
birth canal.

This is not unusual as the junction of cells being visible is dependent on several factors
such as whether you have had any children, whether you have had vaginal deliveries,
if you have had previous colposcopy treatment to the cervix, if you are menopausal
or with certain types of contraception containing progesterone only.

However, as we cannot see this junction of cells, we cannot say with 100% certainty
that there are no abnormal cell changes present.

What are the Options available to me?

Continued surveillance in the colposcopy clinic

What does continued surveillance involve?
You will be seen in the colposcopy clinic at 12 monthly intervals where you will have
a colposcopic examination, a repeat cervical screening (smear) test and a cervical
biopsy if indicated.

• You will be seen every 12 months until your cervical screening test becomes HR
  HPV negative. You will then be discharged from the colposcopy clinic and your
  cervical screening tests will be performed by your GP as part of the routine NHS
  cervical screening programme. A HR HPV negative result means it is highly
  unlikely that you will have any abnormal cervical cells and it is safe to discharge
  you.
• It is not possible to predict how long this process may take. In some cases, it can
  take several years.
• If at any point your colposcopy examination or cervical screening test result
  indicates treatment is required, then removal of the cells will be offered with a
  LLETZ (Large Loop Excision of Transformation Zone) treatment.
• Your options can be discussed with you again at any point.
• If you have gone through the menopause, we may advise the use of some topical
  vaginal oestrogens to aid the colposcopy examination.
• It is very important that you attend colposcopy clinic for all your appointments. If you feel that you are not able to attend the clinic regularly then continued surveillance is not for you.

What are the benefits of continued surveillance?

• In women and people with a cervix who have not yet had any children, or may wish
  a further pregnancy, continued surveillance can avoid the slight increased risk of
  premature birth/mid trimester miscarriage (between 13 – 26 weeks’ gestation).
• Continued surveillance avoids the risks of a LLETZ treatment.

What are the risks of continued surveillance?

As we haven’t been able to see the area of your cervix at the highest risk of cell
change, there is a risk of precancerous cell changes that require treatment being
present. Precancerous cell changes are known as CIN (Cervical Intraepithelial
Neoplasia). If left untreated the higher-grade changes could develop into cancer.
This process takes many years.

What can I do?
In the UK, about 2 in 10 cervical cancers are linked to smoking tobacco. Smoking can
make your immune system weaker, which means it is less likely to protect against
disease and infection. Therefore, we know that in people who smoke it can take longer
to clear the HPV virus from your system.

What if I change my mind about continued surveillance?
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.

If I choose treatment what will this be?

Large loop excision of the transformation zone (LLETZ)

This is a common procedure used to remove abnormal cells from the neck of the
womb (cervix). It is usually performed in the colposcopy clinic with local anaesthetic.
It is a minor procedure using a thin, loop shaped tool, which is heated with an electric
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 inside the
cervix.

What are the benefits of a LLETZ?
The benefit of this treatment is that it removes any abnormal cells from the cervix and
allows normal cells to grow back in their place.

The tissue removed is looked at carefully under the microscope

What are the risks of a LLETZ?

• There is a risk of further cervical stenosis (narrowing of the neck of the womb).
  After a LLETZ procedure there is a 2-14% risk of this happening. This risk
  increases following the menopause. This could cause difficulty in obtaining a
  reliable cervical screening test (smear) in the future and continued unsatisfactory
  colposcopy examinations if required.
• As we are unable to see the junction of cells where abnormalities arise there is a
  risk that you may be over treated; no abnormal cells found on the tissue sample
  removed or we may not sample the junction of the two cell types.
• There is no treatment available for HPV. Whilst a LLETZ procedure is a very
  effective treatment for CIN it could be that when you have your follow up screening
  test 6 months after your procedure that you will remain HR HPV positive and will
  need to return to the clinic once again for further assessment.
• Heavy vaginal bleeding and vaginal infection.
• With treatment there is a slight increase in the background risk of having a
  premature birth/mid trimester miscarriage (13-26 weeks’ gestation) as removing
  the abnormal cells can weaken the cervix. The risk is usually determined by the
  amount of cervix removed during the treatment. Treatments deeper than 10mm
  may increase the risk of pre-term birth, with an unsatisfactory colposcopy
  examination, in order to sample the junction of cells a depth of at least 15mm is
  required.
• The treatment is not associated with any increased risk of infertility.
• Continued surveillance may allow you to avoid a LLETZ procedure and its
  associated risks.

What happens now?
Your colposcopist will have discussed these two options with you at your last visit.
An appointment for you to return to the clinic in 12 months’ time is attached, however
if you prefer to have treatment, please contact the colposcopy team on 01527 505762
and they will arrange this for you.

Who can I contact if I have any questions?
If you need any further information, do not hesitate to contact the colposcopy team on
01527 505762.

Useful contacts/ information
The British Society for Colposcopy and Cervical pathology www.bsccp.org.uk

If your symptoms or condition worsens, or if you are concerned about anything,
please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you
and your loved ones. If you have any questions or concerns, please do speak with a
member of staff on the ward or in the relevant department who will do their best to
answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well
and where improvements can be made. There are lots of ways you can share your
experience with us including completing our Friends and Family Test – cards are
available and can be posted on all wards, departments and clinics at our hospitals. We
value your comments and feedback and thank you for taking the time to share this with
us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the
nurse in charge or the department manager in the first instance as they are best placed
to answer any questions or resolve concerns quickly. If the relevant member of staff is
unable to help resolve your concern, you can contact the PALS Team. We offer informal
help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf,
if you feel unable to do so, to resolve your problems and where appropriate refer to
outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate
your concerns. You can make a complaint orally, electronically or in writing and we can
advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please
be aware that you may need to leave a voicemail message, but we aim to return your
call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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