LEEP  is an abbreviation of Loop Elctrical Excision Procedure that was developed in the mid 1980's for minimally invasive removal of a porton of the abnormal tissue -usually the cervix. Depending on the extent of removal and other patient factors, Dr  Purdy usually recommends office based LEEP procedure. The procedure removes and seals the tissue that is severed from the body in a rather bloodless technique. LEEP is prescribed after abnormal changes in the cervix are confirmed by Pap tests and colposcopy. (Colposcopy is a non-invasive procedure to view the cervix, vagina and vulva ). LEEP removes diseased  dysplastic or early cancerous tissue.

 

Leep allows Dr. Purdy to remove the tissue under direct vision. The resection site is determined by prior colposcopic mapping or vinegar staining and colposcopy. 

The ACOG recommends the office based procedure. "LEEP is an effective and simple way to remove abnormal cells from the cervix. It can be done comfortably in your doctor’s office. Recovery time is brief in most cases".

 

Dyspalstic cells of the cervix?  The normal cervix continously grows cells from the basal region and the cells mature at the surface and are cast off. During this process, some cells may become abnormal or damaged - usaully by a virus know as Human Papilooma Virus ((HPV.)  The damaged cells grow differently and become uncontrolled. These cells are known as dysplastic cells.

• If the abnormal cell population is only 1/3 thick from the bottom of cervical cells covering the cervix, then the disease is called mild dysplasia ( low grade squamous intraepithelial lesion or LGSIL).  
• If the abnormal cell population is 2/3 thick then the disease is called moderate dysplasia .
• If  the abnormal cell population is full thickness, then the disease is called severe dysplasia or carcinoma in situ (seedling cancer). Both moderate and severe cervical dysplasia are classed as high grade squamous intraepthelial lesion  or HGSIL!

• Mild cervical dyspalsia (LGSIL)

• Moderate cervical dysplasia (HGSIL)

• Severe cervical dysplasia (HGSIL)

• Carcinoma in situ (non invasive seedling cervical cancer)

• Invasive cervical cancer (rare with modern pap smear screening)

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Alternate treatments for cervical dysplasia:

There are a number of ways your physician can remove abnormal tissue from the cervix. These methods include:

• Cold knife conization--Removal of a cone-shaped wedge of tissue from the cervix. Conization provides a larger sample of tissue for testing than LEEP.
• Laser cone excision--Heat from a high-intensity beam of light is used to cut away abnormal tissue.

The treatment that is best for you will depend on factors such as the amount and location of the abnormal tissue.

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How a LEEP is performed

The LEEP procedure will be performed in a special treatment room at Total Care for Women. The room provides complete privacy. LEEP begins much like a regular pelvic exam or colposcopic exam. The patient  will remain awake throughout the procedure, The level  or intensity of discomfort should feel like a crampy minor discomfort with the use of local injectable anesthesia. Dr. Purdy's nurse will ask the patient to lie back and place her feet in stirrups at the end of the examination table. A special coated speculum will be inserted into the vagina and opened  wider than normal to adequately visualize the cervix..

A vinegar solution will be applied to the cervix to make the abnormal cells visible. Usually Dr. Purdy then places a colposcope near the opening of the vagina. The colposcope, which remains outside of the vagina, provides a magnified view of the cervix.

The cervix is then numbed with local anesthesia. after first cleansing the vagina and cervix with an antibacterial surgical solution. The sensation of coolness will be felt as the solution is applied. Next an aerosol spray of Huricane topical anesthetic will numb the upper portion of the vagina. Finally, Dr. Purdy will circumferentially inject a local anesthetic (Lidocaine) into the cervical tissue.  A suction line will evacaute the smoke  any smell of the excisional process. The patient will hear a vacuuming sound.

Doctor Purdy will size or measure  the excision site and use the correct loop electrode wire size. This sterile preshaped loop  is made of thin wire  that is inserted through the speculum and up to the cervix on an insulated long probe.

Positioning for loop electrosurgical excision procedure:

As the loop is passed across the cervix, it cuts away a thin layer of surface tissue, seals the bleeding sites . Then a ball eleactrode is usually used to secure the excision site and further destroy any marginal diseased tissue. The sound is like a dental drill turbine sound. Finally, Dr. Purdy will place Monsell's paste onto the operative site.to prevent postoperative bleeding. The excised tissue is packaged and sent to the pathology lab  and will be later tested for cancer or abnormal cells. A report will be issued to Dr.Purdy.

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How long does the procedure take?

The procedure takes 10 to 20 minutes to perform. You will be able to go home as soon as the procedure has been completed and Dr. Purdy has discussed the details of  aftercare and an appointment time has been made for a  return.office visit.

How to prepare for the procedure?

The procedure should be planned  when the patient is not in her period (menses). She should not be pregnant. Ideally she is on oral contraception. If she has an IUD, this IUD must be removed inorder to perform the procedure..

It is unusaul to perform the procedue on a pregnant patient. A pregnant patient needing a LEEP for cancer  is the only indication for a LEEP. The procedure must be performed in a hospital outpatient or inpatient setting!

There is very little preparation required. The patient should avoid sexual intercourse for 24 hours prior to the planned procedure.  She should avoid intravaginal application of medications. She should not douche for 24 hours before the procedure. She may want to bring her own fresh sanitary pad for use after the procedure; Dr. Purdy's office has a suppl;y of fresh pads if needed by the patient after the procedure. There is no food or oral fluid restrictions for the procedure.

LEEP safety: this a low risk procedure!

The LEEP is very safe. \There are some risks, such as infection and bleeding. At Dr.Purdy's clinic over the years, there has been  no uncontrolled vaginal bleeding post LEEP procedure that required hospitalization. The risk of bleeding decreases after the LEEP  to almost no risk by the four weeks .Usually any bleeding encountered can be stopped by re-application of Monsell's paste. There is very little risk for infection after three weeks. Infrquent vaginal infections are usually minimal and treated by both oral antibiotic(s) and antibiotic vagianl creams. LEEP has been associated with an increased risk of future pregnancy problems. Although most women have no problems, there is a small increase in the risk of premature births due  to cervical incompetance due to resection of cervical tissue by the LEEP and having as a result a low birth weight baby. In rare cases, the cervix is narrowed after the procedure. This narrowing may cause problems with menstruation - namely increased painful periods (dysmenorrhea). If enough tissue is removed, then the cervical mucus factors needed to conduct the sperm into the lining of the uterus will be absent and there may be more difficulty in conceiving!

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After the Procedure:

• The pateint may experience mild to moderate cramping and some deep pelvic or lower abdominal pains. Dr. Purdy may inject a non steriodal anti-inflammatory agent (NSAID)- usually Toradol for immediate disconfort relief.
• Vaginal drainage or spotting is normal for 1 to 3 weeks following the procedure. The medication paste will produce a  red to brown or dark brown /black or possibly a thin  yellow discharge immediately after the procedure. A brownish-black vaginal discharge is the  normal discharge. .
• Pads may be used for discharge. The patient  should avoid placing anything in the vagina for 4 weeks, including tampons.
• Your menstrual cycle will not be disrupted by this procedure
• If oral contraception is used, the oral contraceptive should be continued to prevent postpill bleeding and los of contraception.
• Avoid excessive activity for 48 hours after the procedure.
• Refrain from exercising for at least 1 week. You can begin exercising again in 1 to 2 weeks. Stop exercising if bleeding other than normal menstruation occurs. If excessive bleeding occurs after you resume normal activities, call your physician.
• Abstain from sexual intercourse for 4 weeks. Condoms on the male are recommended until the pap smear is normal if HPV was the infecting agent for the dysplasia.
• Showers are allowed but tub baths should be avoided to reduce the remote risk  of infection from the bath water!.

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Pain relief post LEEP at home and medication(s):

During recovery, the patient may experience vaginal spotting, bleeding and mild cramping. Over the counter pain relief can be achiewed with Motrin, Aleve, Advil or Tylenol, etc. Dr. Purdy may perscribe Cataflam and or Ultram (Tramadol) for pain relief. Rarely is a narcotic required to control the post LEEP pain. A cleansing agent may be perscribed as a vaginal medication to aid in recovery and healing  of the  cervix . This medication is  Aminocerv cream and Metrogel. This combination is usually compounded as a single vaginal application for daily use for several days.

When to contact your physician

Contact your physician if you experience any of the following symptoms during your recovery:

• Heavy bleeding (more than a normal menstrual flow)
• Bleeding with clots
• Vaginal discharge that has a foul odor
• Fever over 100.4 degrees Fahrenheit
• Severe abdominal pain

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Long term follow up:

After the procedure, Dr. Purdy recommends the first visit at 3 months inorder to allow  complete healing. At that visit, Dr. Purdy will perform a colpsoscopy  and a thin prep pap smear. The highest incidence of rtecurrent cervical disease is at the first visit. A pap smear before 3 months is not advised due to incomplete healing. The healing process take about 3 months to complete. A pap during that healing phase may yield wild looking healing cells that could be misdiagnosed as spindle cells. Spindle cells would be a misdiagnose and falsely suggest the presence of imnvasive cancer!

Doctor Purdy recommends thereafter a thin prep pap smear very 3 months for one year and then every 6 months for one year. The yearly paps are recomended.

Summary of thin prep pap smear schedule:

• initial pap and colpsocopy at 3 months from LEEP
• 3 month sequential thin prep pap smears for one year after the LEEP
• 6 month sequential thin prep smears for the second year after the LEEP
• Annual thin prep pap smears after the above sequential thin prep pap smears are normal.

.Cerrvical health guidelines:

• Have regular pelvic exams and Pap tests.
• Stop smoking—smoking increases your risk of cancer of the cervix.
• Limit your number of sexual partners and please have the male partner use condoms to reduce your risk of sexually transmitted diseases
• Avoid high risk sexual behavior.