From the Guidelines
The recommended treatment for Low Grade Squamous Intraepithelial Lesion (LSIL) with a predominance of coccobacilli consistent with bacterial vaginosis involves a two-pronged approach, with the most recent and highest quality study guiding the treatment approach 1.
Treatment Approach
First, the bacterial vaginosis should be treated with either oral metronidazole 500mg twice daily for 7 days, or metronidazole gel 0.75% intravaginally once daily for 5 days, or clindamycin cream 2% intravaginally at bedtime for 7 days, as these treatments have been shown to be effective in relieving vaginal symptoms and are recommended by the Centers for Disease Control and Prevention 1.
Management of LSIL
For the LSIL, which represents mild cervical dysplasia typically caused by HPV infection, close monitoring rather than immediate treatment is usually recommended, as many LSIL cases resolve spontaneously 1.
- The patient should undergo colposcopy to confirm the diagnosis,
- followed by repeat Pap testing in 12 months,
- and if LSIL persists for 2 years or progresses, treatment options include loop electrosurgical excision procedure (LEEP), cryotherapy, or laser therapy to remove the abnormal cells. It's essential to treat the bacterial vaginosis first, as it can cause inflammation that may interfere with accurate assessment of the cervical abnormality, and the patient should be counseled about smoking cessation if applicable, as smoking can impair immune response to HPV infection 1.
From the Research
Treatment of Low Grade Squamous Intraepithelial Lesion (LSIL)
- The loop electrosurgical excision procedure (LEEP) is a rational option for patients with LSIL and high-risk HPV infection or dysplastic endocervical curettage 2.
- LEEP can be used to treat repeat LSIL with unsatisfactory colposcopy, which implies a significant risk of CIN 2-3 2, 3.
- Post-treatment follow-up of patients should include both cytology and HR-HPV testing to detect persistent or recurrent disease 2.
Association with Vaginal Flora
- Aerobic vaginitis is common in women with LSIL, but it is not an indicator of HPV infection 4.
- The presence of aerobic vaginitis in women with LSIL is associated with an increased frequency of E. coli, E. faecalis, and Staphylococcus aureus 4.
- Treatment of aerobic vaginitis may decrease the frequency of LSIL and the number of precancerous lesions 4.
Diagnosis and Management
- The diagnosis of LSIL, cannot exclude high-grade squamous intraepithelial lesion (LSIL-H), is increasingly used in gynecologic cytology 5, 6.
- The use of LSIL-H as a diagnostic category can help identify patients at increased risk of high-grade lesions 5, 6.
- Monitoring the frequency of LSIL-H and its associated outcomes can serve as a quality assurance measure in cytology laboratories 5, 6.