What is the purpose of the Loop Electrosurgical Excision Procedure (LEEP)?

Purpose of LEEP Procedure

LEEP (Loop Electrosurgical Excision Procedure) serves both diagnostic and therapeutic purposes: it removes abnormal cervical tissue for pathological examination to exclude invasive cancer while simultaneously treating cervical intraepithelial neoplasia (CIN). 1

Primary Functions

Diagnostic Purpose

• LEEP provides a tissue specimen for complete pathological evaluation to exclude microinvasive or occult invasive carcinoma, which occurs in up to 7% of CIN2/3 cases with unsatisfactory colposcopy. 2
• The procedure removes a cone-shaped, preferably non-fragmented specimen that allows pathologists to assess margin status and rule out invasion. 1
• LEEP uses a thin wire loop with electrical current to excise the transformation zone, enabling histological examination of the entire lesion. 1, 3

Therapeutic Purpose

• LEEP definitively treats high-grade squamous intraepithelial lesions (HSIL) and CIN II/III, with 84-97% of patients with HSIL cytology having CIN 2 or greater on final pathology. 1
• The procedure can be performed as immediate excisional treatment in non-pregnant, non-adolescent women with HSIL cytology without prior colposcopy. 1
• For CIN II or III lesions, LEEP is one of several acceptable treatment modalities alongside cryotherapy, cold knife conization, or laser ablation. 4

Clinical Indications

When LEEP is Recommended

• High-grade squamous intraepithelial lesions (HSIL) on cytology, either as immediate treatment or following colposcopy with endocervical assessment. 1
• Unsatisfactory colposcopy where the transformation zone cannot be fully visualized. 1
• Persistent or recurrent low-grade squamous intraepithelial lesions (LSIL) after previous ablative therapy. 1
• Lesions preceded by atypical glandular cells (AGC) cytology. 1
• When maintaining fertility is not a primary concern and definitive diagnosis is needed. 4

When LEEP is Preferred Over Ablation

• LEEP is preferred over ablative methods (cryotherapy, laser ablation) when colposcopy is unsatisfactory, endocervical sampling shows dysplasia, or there is persistent/recurrent LSIL after previous ablative therapy. 1
• Excisional procedures like LEEP are essential for CIN3 with endocervical involvement, as ablative methods cannot adequately treat disease extending into the endocervical canal and are associated with higher rates of subsequent invasive cancer diagnosis. 2

Technical Advantages

• LEEP offers practical advantages including less bleeding, shorter procedure time, and outpatient capability under local anesthesia without requiring general anesthesia. 1
• The procedure can be performed at the first visit without major complications such as fever, wound infection, massive bleeding, or cervical stenosis. 3
• Complete excision of lesions is achieved in approximately 84% of cases. 5

Important Caveats

Specimen Quality Considerations

• LEEP can create thermal artifacts at tissue margins that may compromise pathologic evaluation, particularly problematic when evaluating for microinvasive cervical cancer. 1
• When microinvasive cervical cancer is suspected, cold knife conization (CKC) is favored over LEEP due to superior specimen quality and clearer margin interpretation. 1, 2
• Fragmented specimens compromise pathologic interpretation; appropriate loop size and technique should be used to obtain a single, intact cone specimen. 1

Special Populations

• LEEP is unacceptable during pregnancy unless invasive cancer is suspected based on cytology, colposcopy, or biopsy findings. 1
• For adolescents and young women, observation rather than immediate treatment is often recommended due to high regression rates of cervical lesions. 1
• Women of reproductive age should be counseled about potential increased risks of preterm birth before undergoing LEEP. 1

Post-Procedure Follow-Up

• Follow-up depends on margin status: for negative margins, cervical cytology at 6 months or HPV DNA testing at 12 months is recommended. 4, 2
• For positive margins, options include cervical cytology at 6 months with consideration of endocervical curettage, or re-excision if invasion is suspected. 4, 2
• HPV testing, especially for HPV 16, at 6 months post-LEEP is highly sensitive for detecting recurrent CIN2+, with HPV16 positivity carrying a 37% 2-year risk of recurrence compared to 0% for HPV-negative patients. 6
• Overall recurrence rates after LEEP are low, with approximately 3.4% having persistent disease at 3 months and 1.5% developing recurrence requiring re-conization. 5