Read more about cervical dysplasia
What is a LLETZ?
A LLETZ (pronounced lets) is a surgical procedure to remove a portion of the cervix. The cervix is the neck of the uterus, that connects to the upper vagina. It is from where a cervical screening test is obtained. The cervix is important in pregnancy to keep a developing baby inside the uterus.
The portion of the cervix that is removed with a LLETZ contains the is visible during a vaginal examination and includes a region of the cervix called the ‘transformation zone’. The transformation zone is highly active making it susceptible to HPV infection and development of abnormal cervical cells.
When is a LLETZ performed?
A LLETZ procedure is recommended when there is evidence of high grade cervical abnormalities. These high grade cervical abnormalities are detected by cervical smear, an examination of the cervix with a highly powered magnifying glass (called colposcopy) and a sample of tissue removed off the cervix (called a biopsy).
A LLETZ procedure may also be recommended to make a diagnosis of high grade cervical abnormalities if there is persistent HPV infection and possible high grade abnormalities present on a cervical smear, but no abnormality is visible during the examination and colposcopy.
How is a LLETZ performed?
Dr Dunn will perform your LLETZ procedure, typically with a general anaesthetic. Once the anaesthesia has taken effect, the skin surrounding the opening to the vagina (called the vulva) is inspected. A medical instrument called a speculum is used to open the vagina to inspect it and the cervix using a highly powered microscope (called colposcopy). Specialised solutions are applied to the genital tract to aide the detection of abnormalities. Local anaesthetic containing adrenaline is injected around the cervix to reduce pain and bleeding.
A surgical instrument that consists of a very fine wire loop attached to a handle is connected to medical electrical current. This instrument is hand-held and placed into the vagina through the speculum that is in place. As the electrical current runs through the wire loop it allows a portion of the cervix that is visible by vaginal examination to be excised. The electrical current simultaneously seals off the blood vessels to reduce bleeding. Additionally, the site from where the cervical excision took place is ablated with another surgical instrument to stop bleeding and reduce the risk of residual abnormal cells being left behind.
Additional products including silver nitrate and Monsel’s Gel (ferric subsulfate 20%) are applied to the cervix to assist in controlling bleeding and aide healing.
Hospital stay: You will recover from your procedure in a hospital bed with a specialist nurse by your side caring for you. You will receive pain relief to keep you comfortable and your wellbeing will be continuously checked. Once your anaesthesia has worn off and you are comfortable, you will be able to continue your recovery at home. You will need a responsible adult to take you home and be available to help you should you need until the following day. There are situations where it is necessary to remain in hospital overnight after your LLETZ procedure and this can be discussed with Dr Dunn.
Pain: Women typically describe the pain after a LLETZ as moderate cramping and aching that settles over a few days. Pain after a LLETZ is typically manageable with regular paracetamol and ibuprofen which is available without a prescription from chemists and supermarkets. If stronger pain relief is needed, this can be arranged through Dr Dunn’s clinic.
Vaginal discharge: For up to two weeks you will experience vaginal discharge that will consist of old blood (dark brown/red), light fresh blood (red), the additional products that are applied to the cervix (they are dark orange/brown in colour), as well as normal healing tissue like a scab or small blood clots. You may then experience a clear watery vaginal discharge for approximately six weeks after your procedure. This is all normal. You will likely use a sanitary item for this period of time.
Menstrual period: Your period will return and so you can expect a period according to your usual cycle. Sometimes however your period after a LLETZ will not be normal for you and may not occur in time with your usual cycle. Any change to your period is temporary.
Returning to work: Plan to have at least two days off work to recover. Your return to work however will depend on when you feel comfortable going back to work, the nature of your occupation and how physically demanding it is. Office based occupations are typically safe to resume by two to three days after your procedure. Physically intensive occupations may require up to two weeks of recovery after your procedure. Your return to work will be planned in consultation with Dr Dunn.
Driving and travel: You should not drive for the first 24 hours after your general anaesthetic. You can typically drive two days after your procedure provided you are completely pain free and fell well. Always check with your vehicle insurance provider and comply with any instructions they provide you regarding driving after a general anaesthesia and medical procedure. You typically need to wait at least 2 days after a general anaesthetic before flying. Check with your airline so you can safely time your surgery and travel.
Pregnancy: You should avoid falling pregnant for at least 3 months to allow the cervix to heal and regain strength. In some scenarios Dr Dunn recommends not falling pregnant until at least 6 months to allow for a follow up colposcopy and cervical biopsy to ensure resolution of the disease. You may still require cervical smears and colposcopy assessment in a pregnancy following a LLETZ procedure.
Intimacy, exercise and other activities: Nothing should enter the vagina (no swimming or baths, no tampons and no penetrative intercourse) for at least four to six weeks following your procedure and until any abnormal vaginal bleeding has stopped. You can resume usual physical activity and exercises 2-3 weeks after your procedure. This is to allow adequate healing and reduce the risk of infection.
What follow up do I need after my LLETZ?
Dr Dunn will speak to you within two weeks of your procedure to monitor your recovery and discuss the results from the LLETZ procedure. The portion of cervix removed at the LLETZ procedure will be sent to the pathologists for detailed assessment. The outcome of this pathology assessment will guide your follow up with Dr Dunn. Typically Dr Dunn will examine your cervix to review your healing within 6 weeks after your procedure. Dr Dunn will typically arrange a further review appointment 6 months after your LLETZ procedure to ensure the cervix has healed well, and to check the abnormal cells have been adequately removed. Dr Dunn will then recommend at least a yearly cervical smear to test for HPV and any high risk abnormal cells. This will continue yearly until there is no HPV and no abnormal cells on the cervical smear for two years in a row (this is called a Test of Cure).
FAQ
HOW LONG DOES A LLETZ TAKE?
A LLETZ takes approximately 10-20 minutes to complete.
CAN I FALL PREGNANT AFTER A LLETZ?
Yes you can.
I recommend not falling pregnant for at least 3 months to allow the cervix to heal and regain as much strength as possible.
In some scenarios I recommend not falling pregnant for at least 6 months and until a follow up check of the cervix with repeat colposcopy and biopsy confirms there is no residual or persistent disease.
If you experience any difficulty falling pregnant after a LLETZ, I recommend following up with me to ensure there is no blockage of the cervix from scar tissue (cervical stenosis).
WHAT ARE THE BENEFITS OF A LLETZ?
Benefits of a LLETZ include:
Removes high risk cervical abnormalities that might otherwise progress to cervical cancer
Removes cervical tissue for detailed microscopic assessment to make a diagnosis
Removes cervical tissue that was causing bleeding after intercourse
WHAT ARE THE RISKS OF A LLETZ?
Recurrence of fibroids. Surgery can only remove existing fibroids. It does not prevent them recurring.
Hysterectomy is needed if bleeding occurs from the site of fibroid surgery and cannot be controlled with alternative measures. A hysterectomy means carrying a subsequent pregnancy is not possible.
Future caesarean section is typically recommended as there is disruption to the layers of the uterus, which may be sites of weakness during a subsequent labour.
Inadequate resolution of pressure, bloating and pain symptoms attributed to fibroids.
Ongoing subfertility or difficulty falling pregnant
General surgical risks include infection (of any organ from the skin to the pelvis), bleeding, injury to adjacent organs like the bladder, ureters (urine tubes that connect the kidney and bladder), bowels and nerves.
Complications from surgery can be minor with little to no impact on your quality of life, however they can also be severe – where there maybe a deterioration in your quality of life as a result. Readmission to hospital or further surgery, including complex surgery to reconstruct the affected organ may be required. Death, whole body or permanent disability is a rare complication of elective gynaecological surgery.
WHAT ARE MY OPTIONS?
You may wish to wait and see how your manage with your fibroids (conservative approach).
This might include repeat ultrasound or MRI to evaluate any change in size, characteristics or number of fibroids.
A blood test called LDH may be elevated in cancerous fibroids however it is not accurate enough to predict cancerous fibroids. LDH blood test is used together with the ultrasound or MRI, to help inform your choices around managing fibroids.
You may wish to have a hysterectomy to manage symptoms related to fibroids, when you no longer wish to conserve your uterus. This is considered definitive treatment, as fibroids and their associated symptoms cannot return after a hysterectomy.
Uterine artery embolisation is a non-surgical technique offered by interventional radiologists in some regions. This procedure is not offered by Dr Dunn but he will coordinate you having this treatment if you wish. A guide-wire and a very fine tube is inserted into a blood vessel in the groin and then using X-ray is guided into the blood vessel feeding the uterine fibroid. A fluid containing micro-particles is injected through the very fine tube and into the fibroid blood vessel. This causes the vessel to be blocked, therefore depriving the fibroid of its blood supply.
HOW LONG IS RECOVERY AFTER FIBROID SURGERY?
Recovery from fibroid surgery is typically well tolerated. Adequate pain relief will be prescribed to control pain both in hospital and at home. The 5-10mm skin incisions from ‘key-hole’ surgery will be tender for a few days. A larger incision of 5-20cm (laparotomy) will be tender for about a week.
Your uterus will have stitches in it where the fibroid/s were removed and these can cause pelvic aching and pain.
You might experience bothersome shoulder tip pain that will ease in the days after surgery. You will be able to eat and drink as usual. Your bowels might be slower than usual and can be eased with stool softeners (like Movicol® or Coloxyl®). You are unlikely to notice any difference in bladder function, but any changes are typically temporary and mild.
Hospital stay: If you have hysteroscopic fibroid surgery, you may go home the same day as your procedure if you feel well and recover at home. If you had ‘key-hole’ fibroid surgery, you will typically stay in hospital for 1-2 nights. If you have a laparotomy (larger skin incision), you will likely have 2-3 nights in hospital.
Returning to work: This depends on the type of work you are returning to. After fibroid surgery you can return to office-based work usually within 2 weeks after minimally invasive laparoscopic surgery and after 4 weeks following a laparotomy. More physically demanding work may require longer recovery of around 6 weeks. Consider if there are alternative, less-physically demanding roles you can do to ease your return to work.
Driving and travel: Typically, you can drive 2 weeks after your minimally invasive surgery. Always check with your vehicle insurance provider and comply with any instructions they provide you. You typically need to wait at least 2 days before flying. Check with your airline so you can safely time your surgery and travel.
Pregnancy: You should avoid falling pregnant for at least 4-6 months depending on your specific type of fibroid surgery. This is to allow the uterus to heal sufficiently before pregnancy.
Intimacy, exercise and other activities: You should defer penetrative intercourse for 2 weeks and until any abnormal vaginal bleeding has settled. You can resume your usual physical activity and exercises 2-3 weeks after your surgery.
Please remember your recovery is individual. Each day following surgery you can expect to have made some improvement in how you feel. Dr Dunn will happily discuss your specific recovery circumstances.
Please read more about recovery in the Patient Information pages
Recovery after a general anaesthetic:
First 24 hours: After your operation and because of the effects of the anaesthetic, it is important that you:
- Have a responsible adult stay with you for at least your first 24 hours at home.
- Rest quietly at home for 24 hours following discharge and gently easy back into normal activities.
- Do no heavy lifting, housework or cooking.
- Do not operate heavy machinery or electrical appliances.
- Do not drink alcohol or drive a car.
- Do not sign any important or legal documents.
