Management

1. The entire transformation zone should be removed. An assessment should be made as to whether a patient qualifies for ablative therapy or if she requires conization as an excisional procedure for further diagnostic work-up. In many cases conization also provides the appropriate treatment.

2. Ablative therapy. The most commonly used ablative treatment techniques are cryotherapy and laser ablation. Requirements for ablative treatment are:

a. Accurate histologic diagnosis/no discrepancy between cytology/colposcopy/histology.

b. No evidence of microinvasion/invasion.

c. No evidence of a glandular lesion (adenocarcinoma in situ or invasive adenocarcinoma).

d. Satisfactory colposcopy (the transformation zone is fully visualized).

e. The lesion is limited to the ectocervix and seen in its entirety.

f. There is no evidence of endocervical involvement as determined by colposcopy/ECC

3. Excisional therapy. Indications for excisional therapy are:

a. Suspected microinvasion b. Unsatisfactory colposcopy (the transformation zone is not fully visualized).

c. Lesion extending into the endocervical canal.

d. ECC revealing dysplasia e. Lack of correlation between the Pap smear and colposcopy/biopsies.

f. Suspected adenocarcinoma in situ.

g. Colposcopist unable to rule out invasive disease.

h. Recurrence after an ablative procedure.

4. Excisional treatment can be performed by cold-knife conization using a scalpel, laser conization, or the loop electrosurgical excision procedure (LEEP). A diagnostic excisional procedure and sampling of the endocervical canal in women in whom the complete transformation is not visualized is important to exclude cancer.

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