May 4, 2004 -- It's a common condition for women: cervical dysplasia, or precancerous cells on the cervix. Women should carefully consider the treatment options, however. Some could jeopardize a pregnancy later, a new study shows.
The report appears in this week's issue of the Journal of the American Medical Association (JAMA).
In it, researchers outline risks involved with three treatments for cervical dysplasia. It's a big issue for young women, since the abnormal growths are caused by a near epidemic of human papillomavirus (HPV) infections. An estimated 80% of people in the U.S. are infected with various strains of this common virus.
Researcher Lynn Sadler, MBChB, MPH, a professor of obstetrics and gynecology at the University of Auckland in New Zealand, outlines the treatments:
- Laser conization and laser ablation involve "burning" precancerous cervical tissue with a laser.
- LEEP (loop electrosurgical excision procedure) involves cutting tissue with a low-voltage electrified wire loop.
Doctors have long debated the effects of "chipping away" at the cervix -- since the cervix supports the developing fetus in the uterus during pregnancy. Do these treatments put the fetus in jeopardy? Could membranes rupture prematurely, causing premature delivery? Also, because glands in the mother's cervix that produce protective substances can be destroyed during treatment, is the fetus at risk for infection?
One expert offered his opinion on cervical dysplasia treatments: "If it was my wife or daughter I would encourage her not to have anything done. Many studies show that 75% of these precancerous cells go away on their own," says Ira Horowitz, MD, vice chairman and director of gynecologic oncology at Emory University's Winship Cancer Institute in Atlanta.
How Babies Fare
In looking at these issues, Sadler and her colleagues studied medical records for more than 1,000 patients seen at a New Zealand cervical cancer clinic during a 12-year period. All the women were diagnosed with cervical dysplasia. Nearly half -- 425 women -- were not treated for their cervical lesions; 652 were treated with laser conization, laser ablation, or LEEP.
Sadler and colleagues found a significant risk of premature membrane rupture leading to preterm delivery with single treatment with laser conization or LEEP:
- Nearly a threefold risk of miscarriage with laser conization.
- Double the risk with LEEP.
- Laser ablation did not increase risk.
Also, the more procedures a woman had, the significantly greater her risk of spontaneous preterm delivery -- nearly threefold risk -- compared with untreated women, Sadler reports.
The problem likely occurs when the cervix shortens in midpregnancy, explains Sadler. With a smaller cervix to support the fetus, membranes can rupture. Also, less immune-boosting protection from the mother's cervical glands and greater exposure to bacteria put the fetus at risk, she writes.
Her paper makes the case for conservative treatment of young women -- unless they are at high risk for developing cervical cancer. Recurrences of these abnormal cervical cells indicate higher risk, she explains.
Also, women are too often treated for cervical dysplasia the same day as their diagnosis, says Sadler. This often leads to a more radical procedure than is necessary. This same-day service "should be abandoned," writes Sadler. Women should be informed about the risks to future pregnancies. They should also be given antibiotics and steroids if they show early signs of miscarriage, she writes.
'Wait and Watch' Often the Best Option
With the "wait-and-watch" option, Pap smears every six months are necessary, Horowitz says.
But if treatment is needed -- if the lesion has advanced all the way up the cervix -- he does laser ablation because he can limit the width and depth of tissue damage.
LEEP is the most common procedure performed, mainly because the equipment is less expensive so doctors can perform it in their offices, explains Horowitz. "But too many doctors take too much extra tissue when they do LEEP." They don't want pathology reports that leave doubts about whether all abnormal cells have been removed, he explains.
"I've had young patients come to me with hardly any cervix left because they've had so many LEEP procedures," he says. "You can do many laser ablations, too, but you're taking a lot less tissue."