Large Loop Excision of the Transformation Zone (LLETZ)

What is an LLETZ Procedure?

Large Loop Excision of the Transformation Zone (LLETZ) is a common and effective procedure used to diagnose and treat abnormal cells in the cervix. It involves using a thin wire loop heated by an electric current to remove abnormal tissue from the cervix. This procedure is often used when abnormal cells are found during a cervical screening test (Pap smear) or colposcopy.

LLETZ is both a diagnostic and therapeutic procedure because it allows for the removal and examination of tissue.

Common Names for LLETZ

LLETZ is also known by several other names, including:

Loop electrosurgical excision procedure (LEEP)
Cervical loop excision
Cervical diathermy loop excision
Diathermy loop cone biopsy
Large loop excision (LLE)

LLETZ and LEEP are the most commonly used names for this procedure.

Who is Suitable for LLETZ?

LLETZ surgery is typically recommended for women with abnormal cervical cells, also known as cervical dysplasia. Cervical dysplasia is most commonly caused by a viral infection called human papillomavirus (HPV), which can lead to precancerous changes in the cervical cells.

LLETZ surgery may be recommended for women who have:

Abnormal cervical cell changes found during a Pap smear test or cervical screening test (CST)
A cervical biopsy that shows cervical dysplasia
Cervical intraepithelial neoplasia (CIN)
Atypical squamous cells of undetermined significance (ASCUS)

Additionally, LLETZ may be recommended for women who have previously had an LLETZ and have recurrent abnormal cervical cells.

Benefits of LLETZ Surgery

The main benefit of LLETZ is that it can remove abnormal cervical tissue and effectively treat cervical dysplasia, preventing the development of cervical cancer.

Some other benefits of LLETZ include the following:

It is a relatively quick procedure that can be performed as a day surgery procedure, usually taking around 30 minutes to complete.
Recovery time is usually short; patients can resume normal activities within a few days.
LLETZ is considered a highly effective treatment for cervical dysplasia, with a high success rate of removing abnormal cervical tissue.
It is minimally invasive, resulting in less bleeding, pain, and scarring than other treatments, such as a cold knife conization.
LLETZ preserves the patient's fertility, removing only the abnormal cervical tissue and leaving the healthy cervical tissue and uterus intact.

Alternative Options to LLETZ

There are several alternative options to LLETZ for treating cervical dysplasia, which include:

Cryotherapy: This procedure involves freezing abnormal cervical tissue using a freezing probe. It is relatively quick and straightforward, but it may have a lower success rate than LLETZ.
Laser ablation: This procedure involves using a laser to remove abnormal cervical tissue. It is considered less invasive than LLETZ and may have a slightly lower risk of complications but a somewhat lower success rate.
Conization: This procedure involves using a scalpel to remove a cone-shaped piece of cervical tissue. It is considered more invasive than LLETZ and may have a slightly higher risk of complications, but it may have a higher success rate than LLETZ.
Observation: This option is usually recommended for low-grade cervical dysplasia, which means abnormal cervical cells without signs of cervical cancer. Regular cervical screening and follow-up visits are needed, as some abnormal cells may persist or progress to precancerous or cancerous cells over time.

What to Do Before a LLETZ Procedure?

Preparing for a LLETZ (Large Loop Excision of the Transformation Zone) procedure involves several important steps:

Discuss with Your Doctor: Talk to your doctor about the procedure, its benefits, risks, and what to expect.
Medical History: Ensure your doctor has your complete medical history, including any allergies and current medications.
Review Medications: Inform your doctor about all your medications and supplements. Some may need to be paused before the procedure.
Pain Relief: You may be advised to take an over-the-counter pain reliever, such as ibuprofen or acetaminophen, about 30 minutes to an hour before the procedure.
Avoid Vaginal Products: Do not use tampons, vaginal creams, or douches for at least 24 hours before the procedure.
Abstain from Intercourse: Avoid sexual intercourse for 24 to 48 hours before the procedure to reduce the risk of irritation.
Normal Eating: You can eat and drink as usual unless instructed otherwise by your doctor.
Wear Comfortable Clothing: Choose clothes that are easy to remove and comfortable.
Bring Support: Consider bringing a friend or family member for emotional support and to drive you home if needed.

LLETZ Procedure

The LLETZ procedure typically follows these steps:

Examination Table: You will lie on an examination table with your feet placed in stirrups, similar to during a Pap smear.
Visual Access: A speculum is gently inserted into your vagina to hold it open and allow access to your cervix.
Local Anaesthesia: A local anaesthetic is injected into the cervix to numb the area and minimise discomfort.
Magnification: A colposcope (a special microscope) is positioned outside the vagina to provide a magnified view of the cervix.
Loop Electrode: A thin wire loop heated by an electric current removes the abnormal tissue from the cervix.
Tissue Removal: The loop cuts away the transformation zone of the cervix where abnormal cells are located.
Control Bleeding: Any bleeding is controlled using a special paste or cauterisation (applying heat to seal blood vessels).

What to Expect After a LLETZ Procedure?

After the procedure, you can expect the following:

Immediate Aftermath:
Discomfort: Some mild cramping or discomfort, similar to menstrual cramps, is normal.
Discharge: You may experience a watery or slightly bloody discharge for up to 4 weeks, especially if a large area was treated.
Activities:
Rest: Rest for the remainder of the day. Most women can return to their normal activities within a day or two.
Avoid Strenuous Activities: Avoid heavy lifting and vigorous exercise for a few days.
Pain Management:
Over-the-counter Pain Relief: Use over-the-counter pain relievers like ibuprofen or acetaminophen as needed for any discomfort.
Avoiding Irritation:
Hygiene: Avoid using tampons, douches, or vaginal creams for about four weeks to prevent infection and allow healing.
Intercourse: Refrain from sexual intercourse for at least four weeks or as advised by your doctor.
Signs of Complications:
Infection: Watch for signs of infection, such as heavy bleeding, foul-smelling discharge, fever, or severe pain, and contact your doctor if they occur.

LLETZ Aftercare

You will have a vaginal discharge for up to three weeks
Avoid intercourse and the use of tampons for three weeks
Avoid swimming pools, spas, and baths – use the shower for three weeks
Avoid heavy exercise, running and jumping for four weeks.
Most women can resume normal daily activities within 1-2 days.

LLETZ Follow-up

You will have a follow-up appointment with Dr. Alyousif, usually four weeks after the procedure. You will generally require your next cervical screening test (+/—colposcopy) 6 to 12 months later. You will be sent a reminder for this.

Your GP will receive a copy of the results, a letter confirming that you have had the procedure, and a letter after the follow-up appointment.

LLETZ Prognosis

LLETZ is highly effective in treating cervical dysplasia, which refers to abnormal cells in the cervix that could potentially develop into cervical cancer if left untreated.

High Success Rate: The procedure removes abnormal cells in most cases, significantly reducing the risk of cervical cancer.
Recurrence: Most women who undergo LLETZ have no recurrence of abnormal cells. However, regular follow-up screenings are crucial to monitor for any potential recurrence.
Fertility and Pregnancy: LLETZ typically has minimal impact on fertility and the ability to carry a pregnancy to term. However, in some cases, especially with extensive tissue removal, there may be a slightly increased risk of preterm birth or cervical insufficiency.

LLETZ Risks

LLETZ is a relatively safe procedure, but certain risks are associated, like any surgery. Some of the risks related to LLETZ surgery include the following:

Bleeding: Some bleeding is expected after the procedure, but heavy or prolonged bleeding may require additional treatment.
Infection: LLETZ surgery carries a small risk of infection, which can commonly be treated with antibiotics.
Pain: Some patients may experience cramping or discomfort after the procedure, but this is usually mild and can be managed with pain medication.
Scarring: LLETZ surgery may cause some scarring of the cervix, but this is usually minimal.
Preterm labour and delivery: LLETZ may increase the risk of preterm labour and delivery in future pregnancies.
Recurrence of cervical dysplasia: In some cases, the abnormal cervical tissue may recur after LLETZ surgery, and additional treatment may be necessary.

What if LLETZ is Delayed?

Delaying or avoiding LLETZ can have significant implications, particularly if abnormal cervical cells are present:

Progression to Cancer: The most serious risk of delaying LLETZ is the potential progression of cervical dysplasia to cervical cancer. Early treatment of abnormal cells is crucial to prevent this.
Increased Severity: If abnormal cells are not removed, they may become more severe, requiring more extensive treatment in the future.
Symptoms: Delaying treatment can also lead to symptoms such as abnormal bleeding, pain, and discharge.

Cost of LLETZ

Public Hospitals: In the public healthcare system, Medicare often covers the cost of LLETZ. There may be minimal out-of-pocket expenses, such as hospital or specialist fees.
Private Clinics: The cost of a procedure in a private clinic can range from AUD 500 to AUD 2,000, depending on the complexity of the procedure, the location, and the doctor. Depending on your plan, private health insurance may cover part or all of the cost.
Specialist Fees: If a specialist performs the procedure, additional fees may apply, ranging from AUD 100 to AUD 500.
Medicare: Medicare often covers a significant portion of the cost, especially if the procedure is medically necessary. You should check with your doctor and insurance for specific costs and coverage details.