What are the treatment options for a 26-year-old nulligravid (having no previous pregnancies) woman with cervical intraepithelial neoplasia grade 3 (CIN 3), confirmed by colposcopic (using a colposcope) biopsies, who is a smoker and planning to conceive in the near future?

From the Guidelines

For a 26-year-old nulligravid woman with CIN 3 who desires future fertility, I recommend excisional treatment with loop electrosurgical excision procedure (LEEP) rather than ablative therapy. This approach is supported by the 2001 consensus guidelines for the management of women with cervical intraepithelial neoplasia, which suggest that excisional modalities, including LEEP, are often recommended for posttreatment recurrence of CIN, as they provide tissue for pathologic examination to rule out occult invasive disease 1. LEEP allows for histologic evaluation of the entire lesion while preserving fertility, and it is a preferred method for treating high-grade dysplasia in young women who desire future fertility. The procedure involves using a thin wire loop with electrical current to remove the abnormal cervical tissue, typically performed in an outpatient setting under local anesthesia.

The patient should complete her HPV vaccination series regardless of treatment, as it may protect against other HPV types. She should also be strongly encouraged to quit smoking, as tobacco use increases the risk of persistent HPV infection and cervical disease progression. Following LEEP, she will need close follow-up with co-testing (HPV and cytology) at 12 and 24 months. If both tests are negative, she can return to routine screening. This approach balances the need to treat high-grade dysplasia, which has a significant risk of progression to invasive cancer if untreated, while minimizing impact on her future fertility plans.

Some studies have reported similar success rates for different treatment modalities, including cryotherapy, laser ablation, and LEEP 1. However, the excisional approach is preferred over ablative methods because it provides tissue for pathologic examination to rule out occult invasive disease, which is particularly important in young women with high-grade lesions. The decision to use LEEP or other treatment modalities should be based on factors such as the training and experience of the clinician, the preferences of the patient, the resources available, and the expected clinical value of a given treatment modality for that patient 1.

Key considerations for this patient's treatment plan include:

• The need to preserve fertility while treating high-grade dysplasia
• The importance of completing the HPV vaccination series to protect against other HPV types
• The need for close follow-up with co-testing after treatment
• The importance of quitting smoking to reduce the risk of persistent HPV infection and cervical disease progression
• The preference for excisional treatment modalities, such as LEEP, over ablative methods to rule out occult invasive disease.

From the Research

Treatment Options for CIN 3

The patient has been diagnosed with cervical intraepithelial neoplasia grade 3 (CIN 3) and is considering treatment options. The following are some possible treatment approaches:

• Loop electrosurgical excision procedure (LEEP) is a common treatment for CIN 3, with cure rates ranging from 72.7% to 93.0% depending on the severity of the lesion 2.
• Therapeutic human papillomavirus (HPV) vaccines have shown modest efficacy in treating CIN 2/3 lesions, with an overall proportion of regression of 0.54 (95% CI 0.39 to 0.69) for vaccinated groups 3.
• Co-testing, which combines cytology and HPV testing, has been shown to be an effective follow-up protocol after treatment for CIN 2-3, with a sensitivity of 90.6% in predicting recurrent disease 4.

Risks and Benefits of Treatment Options

The patient should be aware of the potential risks and benefits of each treatment option:

• LEEP is generally a safe procedure, but may be associated with minor adverse effects such as bleeding or infection 2.
• Therapeutic HPV vaccines have been shown to be safe, with no significant unsolicited adverse events reported 3.
• Co-testing may reduce the need for frequent follow-up visits, but may also increase the risk of false positives or false negatives 4.

Considerations for Pregnancy and Fertility

The patient is planning to have children in the next few years, and should consider the potential impact of treatment on fertility:

• LEEP during pregnancy is generally considered safe, but may be associated with a small risk of complications such as bleeding or infection 5.
• Therapeutic HPV vaccines have not been specifically studied in pregnant women, and their safety and efficacy in this population are unknown 3.
• Co-testing may be a useful follow-up protocol for women who are pregnant or planning to become pregnant, as it can help identify recurrent disease early 4.