What is the indication and process for Loop Electrosurgical Excision Procedure (LEEP)?

Loop Electrosurgical Excision Procedure (LEEP): Indications and Process

Primary Indications

LEEP is indicated for women with high-grade squamous intraepithelial lesions (HSIL) on cytology, either as immediate excisional treatment or following colposcopy with endocervical assessment. 1

Specific Clinical Scenarios for LEEP:

• HSIL cytology: Immediate LEEP is acceptable without prior colposcopy in non-pregnant, non-adolescent women, as 84-97% will have CIN 2 or greater on final pathology 1

• Unsatisfactory colposcopy: When the transformation zone cannot be fully visualized, LEEP is preferred over ablative methods to obtain diagnostic tissue 2

• Endocervical sampling showing dysplasia: LEEP provides both diagnosis and treatment when endocervical curettage reveals abnormal cells 2

• Persistent or recurrent LSIL: After previous ablative therapy fails or when LSIL persists beyond recommended observation periods 2

• Lesions preceded by AGC (atypical glandular cells): LEEP allows histologic evaluation to rule out adenocarcinoma 2

Important Population-Specific Considerations:

• Adolescents and young women: Observation is preferred over immediate treatment due to high regression rates; LEEP is reserved for unsatisfactory colposcopy or endocervical involvement 1

• Pregnant women: LEEP is unacceptable during pregnancy unless invasive cancer is suspected based on cytology, colposcopy, or biopsy findings 1

The LEEP Procedure

Technical Execution:

The procedure uses a thin wire loop electrode with high-frequency electrical current to excise a cone-shaped specimen of the cervical transformation zone under local anesthesia in an outpatient setting. 2, 3

• Anesthesia: Local anesthesia is typically sufficient; patients experience minimal discomfort during the procedure 3

• Specimen removal: The goal is to remove a single, non-fragmented cone-shaped specimen to allow complete pathologic assessment 2

• Margin goals: Aim for 3-mm negative margins, particularly important for fertility preservation 2

• Endocervical curettage: Should be added as clinically indicated to evaluate the endocervical canal completely 2

• Specimen orientation: Proper orientation is critical to allow pathologists to accurately assess margin status 2

Critical Technical Pitfalls to Avoid:

• Fragmented specimens: Use appropriate loop size and technique to obtain a single intact cone rather than multiple fragments, as fragmentation compromises pathologic interpretation 2

• Inadequate depth: Remove the entire transformation zone rather than selectively targeting only visible lesions to avoid missing disease 2

• Thermal artifacts: LEEP creates thermal damage at tissue margins that can compromise pathologic evaluation, particularly problematic when evaluating for microinvasive cancer 2

• Missing endocervical disease: Failure to perform endocervical sampling when indicated can miss residual disease in the canal 2

Post-Procedure Management

When CIN 2,3 is NOT Identified:

• Observation protocol: Follow with both colposcopy and cytology at 6-month intervals for up to 24 months, provided colposcopy is satisfactory and endocervical sampling is negative 1

• Persistent HSIL at 1 year: Repeat biopsy is recommended 1

• HSIL persisting 24 months without CIN 2,3: Diagnostic excisional procedure is recommended 1

• Return to routine screening: After 2 consecutive negative cytology results without high-grade colposcopic abnormality 1

Pregnancy Counseling (Critical):

Women of reproductive age must be counseled about increased risks of preterm birth before undergoing LEEP. 2, 4

• Prenatal care: Early registration is essential for women with LEEP history 4

• Cervical length monitoring: Serial transvaginal ultrasound between 16-24 weeks of gestation should be considered 4

• Progesterone supplementation: Consider for women with shortened cervix 4

• Cerclage consideration: May be indicated for women with both LEEP history and shortened cervix 4

• Multiple procedures: Women with multiple LEEPs due to positive margins have higher complication risk and warrant more intensive monitoring 4

• Persistent risk: The increased risk of complications is not limited to the first pregnancy after LEEP 4

LEEP vs. Cold Knife Conization

LEEP is preferred for routine CIN treatment due to less bleeding, shorter procedure time, and outpatient capability, while cold knife conization provides superior specimen quality when microinvasive cancer is suspected. 2

• When to choose cold knife conization: Concern for adenocarcinoma in situ (AIS) or microinvasive findings on biopsy, as LEEP's thermal artifacts may compromise pathologic evaluation 2

• LEEP advantages: Outpatient setting, local anesthesia, less bleeding, shorter recovery, and high patient acceptance 2, 5