Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Treatment of cervical intraepithelial neoplasia by cryotherapy a b c d FIGURE 12.7: (a) The iceball on the cervix immediately after cryotherapy, (b) Appearance 2 weeks after cryotherapy. (c) 3 months after cryotherapy. (d) 1 year after cryotherapy surface. Normally, the wound is totally healed within 6- 8 weeks of treatment. The appearance of the cervix 3 months and 12 months after cryotherapy is shown in figures 12.7c and 12.7d. The effect of cryotherapy on the potential transmissibility of human immunodeficiency virus (HIV) infection (to or from women) during the healing phase is not known. HIV-1 shedding in the vaginal secretions after treatment of CIN in HIVpositive women has been demonstrated (Wright et al., 2001). Therefore, the authors suggest advising all women that cryotherapy may increase the transmissibility of HIV and that using condoms is an effective means of prevention. Condoms should be used for a period of at least four but preferably six weeks. Ideally, a supply of condoms should be available free of charge at colposcopy clinics in settings where HIV infection is endemic. Appointments should be made for a follow-up visit 9- 12 months after treatment. During the follow-up, cytology and/or VIA should be performed, followed by colposcopy and directed biopsy depending upon the colposcopy findings, to assess the regression or persistence of lesions. Retreatment is carried out if lesions persist. Women who are negative for neoplasia may be referred back to a screening programme (if one exists) or advised to undergo follow-up after three or five years. Management of women for whom cryotherapy fails Treatment failure is detected in about 5-10% of women 101
Chapter 12 during the follow-up in the first year. These persistent, local or multifocal lesions are more likely to occur if the original lesion was large. To rule out the presence of unsuspected invasive carcinoma, it is advisable to biopsy all persistent lesions and then re-treat with cryotherapy, LEEP, or cold-knife conization, as appropriate. Follow-up evaluation may be carried out after 9-12 months in which screening examinations such as cytology and/or VIA and colposcopy should be carried out. Those negative for neoplasia may be referred back to a screening programme (if one exists in the region) or advised to undergo follow-up after three or five years. A management approach for low resource settings is shown in Figure 11.1. Adverse effects, complications, and longterm sequelae Cryotherapy is usually a painless procedure, if women have been properly reassured, their co-operation is obtained, and the procedure is carried out properly. Some women may experience some lower abdominal pain or cramps during and after cryotherapy. Once in a while, a woman may faint due to a vasovagal reaction. In such a situation, there is no need for panic and the women may be revived easily. Bleeding is extremely rare after cryotherapy. Treated women experience a watery vaginal discharge for about 3-4 weeks after treatment. Vaginal bleeding is extremely unusual; it may be more likely to occur if freezing has been too aggressive and the ice ball has extended well past 5 mm in depth. The risk of post-operative infection is very slight and can probably be reduced further by delaying cryotherapy until any woman with a likely diagnosis of pelvic inflammatory disease (PID), sexually transmitted cervicitis (e.g., chlamydia or gonorrhea), vaginal trichomoniasis or bacterial vaginosis has been adequately treated and recovered. If a woman presents post-operatively with a malodorous discharge, pelvic pain and fever, the discharge may be cultured if possible, and empirical treatment should be prescribed with antibiotics that are effective for PID. Sexual partners should also be treated if the woman is diagnosed with PID, sexually transmitted cervicitis, or trichomoniasis. In developing countries, one may consider providing presumptive treatment with antibiotics routinely after cryotherapy (doxycycline 100 mg orally, two times a day, for seven days and metronidazole 400 mg orally, three times a day, for seven days). Cervical stenosis occurs in less than 1% of women; reduced mucus production occurs in 5-10% of women. Cryotherapy has no known adverse effect on fertility and pregnancy. Invasive cancer has rarely been reported after cryotherapy, it is usually due to missed diagnosis as a result of poor diagnostic workup before cryotherapy. 102
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Colposcopy and Treatment of Cervica
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INTERNATIONAL AGENCY FOR RESEARCH O
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Published by the International Agen
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Contents 11 Management that provide
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Acknowledgements The authors gratef
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Preface Health care providers have
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Chapter 1 An introduction to the an
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An introduction to the anatomy of t
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Chapter 2 An introduction to cervic
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An introduction to cervical intraep
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Chapter 3 An introduction to invasi
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An introduction to invasive cancer
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Chapter 4 Table 4.1: Indications fo
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Chapter 4 FIGURE 4.2: Colposcope wi
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Chapter 4 FIGURE 4.6: Endocervical
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Chapter 4 Table 4.2: Preneoplastic
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Chapter 5 between the two ocular le
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Chapter 5 Obtain specimens for labo
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Chapter 5 FIGURE 5.2: Biopsy techni
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Chapter 5 tissue tends to mimic inv
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Chapter 6 invasive carcinoma. Even
Page 59 and 60: Chapter 6 ages (Figures 1.7d, 1.7e,
Page 61 and 62: Chapter 6 FIGURE 6.7: The colour ch
Page 63 and 64: Chapter 6 Crypt openings Immature s
Page 65 and 66: Chapter 6 a FIGURE 6.17: An area of
Page 67 and 68: Chapter 7 The colposcopic diagnosis
Page 69 and 70: Chapter 7 appears as individual sma
Page 71 and 72: Chapter 7 acid stain is correlated
Page 73 and 74: Chapter 7 FIGURE 7.15: Moderately d
Page 75 and 76: Chapter 7 FIGURE 7.23: A dense acet
Page 77 and 78: Chapter 7 FIGURE 7.30: Mustard yell
Page 79 and 80: Chapter 7 We recommend that the stu
Page 81 and 82: Chapter 8 highlights this responsib
Page 83 and 84: Chapter 8 Appearance before applica
Page 85 and 86: Chapter 8 diagnosis of AIS and aden
Page 87 and 88: Chapter 8 a ↑ FIGURE 8.10: Adenoc
Page 89 and 90: Chapter 9 Inflammatory lesions of t
Page 91 and 92: Inflammatory lesions of the uterine
Page 93 and 94: Inflammatory lesions of the uterine
Page 95 and 96: Chapter 10 Table 10.1: Common sourc
Page 97 and 98: Chapter 10 Table 10.2 (cont.): A su
Page 99 and 100: Chapter 11 FIGURE 11.1: Flow chart
Page 101 and 102: Chapter 11 treatment policies for p
Page 103 and 104: Chapter 11 Vaginal delivery can be
Page 105 and 106: Chapter 12 involvement increases wi
Page 107 and 108: Chapter 12 Table 12.1: Eligibility
Page 109: Chapter 12 a b c d e f FIGURE 12.6:
Page 113 and 114: Chapter 13 (2) (1) FIGURE 13.2: Ele
Page 115 and 116: Chapter 13 (1) (2) (3) (4) (5) (8)
Page 117 and 118: Chapter 13 Once the specimen has be
Page 119 and 120: Chapter 13 in the endocervical cana
Page 121 and 122: Chapter 14 Decontamination, cleanin
Page 123 and 124: Decontamination, cleaning, high-lev
Page 125 and 126: References Herrero, R. (1997) Preva
Page 127 and 128: Further reading Suggestions on furt
Page 129 and 130: Appendix Leukoplakia Condylom
Page 131 and 132: Appendix regardless of your pregnan
Page 133 and 134: Appendix Monsel’s paste Ingredien
Page 135 and 136: Appendix 5 The modified Reid colpos
Page 137 and 138: Index Acetowhitening . . . . . . .
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Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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