What is LEEP?
LEEP (Loop Electrosurgical Excision Procedure) also appears in guidelines under the name LLETZ (Large Loop Excision of the Transformation Zone). It means cutting out the transformation zone of the cervix (the area where cell change begins) with a fine loop of electrosurgical wire.
LEEP is an excisional (surgical removal) method; that is, it does not burn the tissue away — it removes it. This distinction matters, because the tissue removed can be sent to pathology.
How does it differ from ablation (burning) methods?
Changes on the cervix can be treated in two ways:
- Removal (excision): LEEP/LLETZ, cold-knife conisation, laser cone biopsy.
- Burning or freezing (ablation): cryotherapy (freezing), laser ablation, thermal ablation.
In the United States, removal methods are preferred to burning methods in the treatment of high-grade cell changes. The World Health Organization also recommends LEEP rather than cryotherapy where LEEP is available.
Why is removal preferred? LEEP provides a tissue sample. That sample shows two things: whether there is a more advanced change than expected, and whether the surgical margins are clear. The state of the margins is information that guides what happens if the disease remains or recurs. With burning methods this information cannot be obtained.
The picture on the superiority of one method over another is not one-sided. In a review of randomised studies, the recurrence rate at 12 months was 26.6% after LEEP and 31.0% after cryotherapy. In another review the recurrence rate for CIN 2–3 was calculated as 5.3% after both cryotherapy and LEEP, and 1.4% after cold-knife conisation. Unwanted effects were most frequent with cold-knife conisation, then LEEP, and least with cryotherapy. A Cochrane review comparing the surgical techniques concluded that no technique is clearly superior in terms of treatment failure or side effects.
In which situations is LEEP done?
1. High-grade cell changes (HSIL — CIN 2 and CIN 3)
CIN 3 is regarded as directly precancerous. In patients who are not pregnant, treatment is recommended at every age; follow-up is not acceptable.
Treatment is recommended for CIN 2 as well. The only exception is this: if the person's concerns about the effect of treatment on future pregnancies outweigh their concerns about cancer, follow-up may be chosen. But if the upper border of the transformation zone or the whole of the lesion (tissue change) cannot be seen, or if the sample taken from the cervical canal shows CIN 2 or above, follow-up is not acceptable.
In the treatment of high-grade changes, topical medicines, therapeutic vaccines and similar non-surgical methods are not acceptable outside a clinical trial.
2. Glandular cell change in the cervical canal (AIS)
In all patients in whom adenocarcinoma in situ (AIS) is found on biopsy, a tissue removal procedure is recommended so that a hidden cancer can be ruled out. This applies even if removal of the womb is planned.
It is preferred that the piece removed be in one piece, so that the margins can be interpreted correctly. Deliberately dividing the piece — for example taking a second, "top hat" canal sample after the LEEP — is not acceptable. A length of at least 10 mm is preferred; in people who have no concerns about the effect on future pregnancies this length can be increased to 18–20 mm.
3. Direct treatment without waiting for a biopsy (expedited treatment)
In some situations, going straight to LEEP without losing time on a colposcopic biopsy comes up. The decision is made according to the person's current risk of CIN 3 or worse:
- Risk of 60% or more → direct treatment is preferred. Example: those aged 25 and over who are HPV 16 positive with an HSIL cell result; those who have never been screened or have been screened very rarely and who have an HPV-positive HSIL result.
- Risk between 25% and 59% → both direct treatment and colposcopy with biopsy are acceptable. Example: aged 25 and over, HPV-negative HSIL; HPV-positive ASC-H; HPV-positive AGC results.
The decision on expedited treatment should be taken through a shared decision-making process, particularly in people who have concerns about the effect on pregnancy outcomes.
4. Low-grade change persisting for two years (CIN 1)
In those aged 25 and over in whom CIN 1 has been found for at least two years at successive check-ups, follow-up is preferred; treatment is also an acceptable option. If treatment is chosen, the transformation zone and all the lesions must have been fully visible at colposcopy. This is not an obligation but a personal preference after shared decision making.
CIN 1 is in fact the appearance of HPV infection in the tissue; the rates of it regressing on its own are high, particularly at younger ages.
With any surgical procedure, results vary from person to person. You are advised to discuss the procedure with your doctor in detail beforehand.
Frequently Asked Questions
What is the difference between LEEP and a biopsy?
A biopsy takes a small piece in order to make a diagnosis. LEEP removes the whole transformation zone; that is, it both treats and provides pathology with a complete tissue sample. That sample makes it possible to see whether there is a more advanced change than expected and whether the surgical margins are clear.
I have CIN 2 — do I have to have an operation?
As a rule treatment is recommended for CIN 2; but follow-up can also come up — if your concerns about the effect of treatment on future pregnancies outweigh your concern about cancer. This is a matter for shared decision making. There are also situations in which follow-up is not accepted: if the upper border of the transformation zone cannot be seen, or if the sample taken from the canal shows CIN 2 or above. With CIN 3, follow-up is not accepted in those who are not pregnant.
Which is better, LEEP or freezing (cryotherapy)?
Guidelines prefer removal methods for high-grade changes — but the reason is not a definite superiority in success. A Cochrane review comparing the surgical techniques concluded that no technique is clearly superior in terms of treatment failure or side effects. What LEEP actually provides is a tissue sample to send to pathology and information about the surgical margins; with burning methods this information cannot be obtained.
Can I be treated with a cream applied to the cervix, or with a vaccine?
No. For high-grade cell changes, topical medicines, therapeutic vaccines and similar non-surgical methods are not acceptable outside the setting of a clinical trial. This is what the guidelines state plainly.
Can LEEP be done without a biopsy first?
In some situations, yes; this is called expedited treatment. The decision depends on the current risk of CIN 3 or worse: if the risk is 60% or more, direct treatment is preferred; in the 25–59% range both direct treatment and colposcopy with biopsy first are acceptable. This decision should be taken together with your doctor, particularly if you are planning a pregnancy.
Why does the size of the tissue removed matter?
In glandular cell change in the cervical canal (AIS), removing the piece in one piece is preferred so that the margins can be interpreted correctly. A length of at least 10 mm is preferred; in those who have no concerns about the effect on future pregnancies it can be increased to 18–20 mm. Deliberately dividing the piece is not acceptable.
I have CIN 1 — is treatment needed straight away?
Generally no. CIN 1 is the appearance of HPV infection in the tissue and the rate of it regressing on its own is high, particularly at younger ages. Even in those aged 25 and over in whom CIN 1 has been found for at least two years in succession, follow-up is preferred; treatment is an acceptable option only as a personal preference after shared decision making.
Sources
- ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors — Perkins RB et al., Journal of Lower Genital Tract Disease, 2020;24(2). Treatment thresholds, criteria for expedited treatment, and the management of CIN 1, CIN 2, CIN 3 and AIS.
- ASCCP Colposcopy Standards — definitions of colposcopy and excisional procedures.
- World Health Organization (WHO) recommendations on the treatment of cervical precancer — preferring LEEP to cryotherapy in settings where LEEP is available.
The information on this page is based on the national and international guidelines listed above. The page is reviewed whenever those guidelines are updated.
Practice and Contact Details
The information on this page is general. Please speak to your doctor about your own situation.
- DoctorOp. Dr. Murat Alpay — Specialist in Obstetrics and Gynaecology
- AddressOp. Dr. Murat Alpay Practice, Tekelioğlu Cd. No:51 B Kat:2, Filo Apt., 07160 Muratpaşa / Antalya
- Telephone0505 351 77 88
- HoursMonday – Saturday 09:00 – 18:00 · Closed on Sunday