Loop Electrosurgical Excision Procedure in a Low-Resource Setting: Feasibility of Selective See-and-Treat Approach



To assess the correlation between cervical smear, colposcopic findings and loop electrosurgical excision procedure (LEEP) histopathology and thereby assess the feasibility of performing LEEP bypassing cervical biopsy in selected cases.


This is a retrospective study of patients who underwent LEEP at our institution from 2014 to 2018. We traditionally follow a three-step approach for detection and treatment of pre-invasive lesions of cervix—(1) pap smear, (2) colposcopy of abnormal pap smear cases and directed biopsy, and (3) treatment of abnormal biopsies with LEEP. LEEP was performed for cervical intraepithelial neoplasia (CIN) 2, CIN3, persistent CIN1 cases. Swede score ≥ 6 or major lesion on International Federation for Cervical Pathology and Colposcopy (IFCPC) scoring on colposcopy was considered to be suggestive of high-grade lesion.


Of the 123 patients who underwent LEEP, 80 patients had high-grade squamous intraepithelial lesion (HSIL) on cervical smear and swede score ≥ 6 on colposcopy. Seventy-seven (96.3%) of these patients had high-grade lesion on final histopathology. Avoiding cervical biopsy and proceeding with LEEP in these patients would reduce an additional procedure in 77 patients with overtreatment of only 3 patients (2.4%). Overtreatment rate was 3.2% when IFCPC scoring was used instead of Swede score.


LEEP may be considered in patients with high-grade lesions on both colposcopy and cervical smear, bypassing cervical biopsy, thereby reducing the number of procedures performed. This reduces the financial burden for the individual and the healthcare facilities, also decreasing the anxiety and apprehension associated with multiple hospital visits and procedures.

This is a preview of subscription content, access via your institution.


  1. 1.

    Schlecht NF, Platt RW, Duarte-franco E, Costa MC, Sobrinho JP, Prado JC, et al. Human papillomavirus infection and time to progression and regression of cervical intraepithelial neoplasia. J Natl Cancer Inst. 2003;95:1336.

    Article  Google Scholar 

  2. 2.

    Cox JT, Schiffman M, Solomon D. Prospective follow-up suggests similar risk of subsequent cervical intraepithelial neoplasia grade 2 or 3 among women with cervical intraepithelial neoplasia grade 1 or negative colposcopy and directed biopsy. Am J Obstet Gynecol. 2003;188:1406.

    Article  Google Scholar 

  3. 3.

    Rema P, Suchetha S, Thara S, Fayette JM, Wesley R, Sankaranarayanan R. Effectiveness and safety of loop electrosurgical excision procedure in a low-resource setting. Int J Gynaecol Obstet. 2008;103:105–10.

    Article  Google Scholar 

  4. 4.

    Prendiville W, Cullimore J, Norman S. Large loop excision of the transformation zone (LLETZ). A new method of management for women with cervical intraepithelial neoplasia. Br J Obstet Gynaecol. 1989;96(9):1054–60.

    CAS  Article  Google Scholar 

  5. 5.

    Bigrigg MA, Codling BW, Pearson P, Read MD, Swingler GR. Colposcopic diagnosis and treatment of cervical dysplasia at a single clinic visit. Experience of low-voltage diathermy loop in 1000 patients. Lancet. 1990;336(8709):229–31.

    CAS  Article  Google Scholar 

  6. 6.

    Sorbye SW, Arbyn M, Fismen S, Gutteberg TJ, Mortensen ES. HPV E6/E7 mRNA testing is more specific than cytology in post-colposcopy follow-up of women with negative cervical biopsy. PLoS ONE. 2011;6:e26022. https://doi.org/10.1371/journal.pone.0026022.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Eduardo AM, Dinh TV, Hannigan EV, Yandell RB, Schnadig VJ. Outpatient loop electrosurgical excision procedure for cervical intraepithelial neoplasia: Can it replace cold knife conization? J Reprod Med. 1996;41:729–32.

    CAS  PubMed  Google Scholar 

  8. 8.

    Melnikow J, Nuovo J, Willan AR, Chan BK, Howell LP. Natural history of cervical squamous intraepithelial lesions: a meta-analysis. Obstet Gynecol. 1998;92:727–35.

    CAS  PubMed  Google Scholar 

  9. 9.

    Guducu N, Sidar G, Bassullu N, Turkmen I, Dunder I. Three-step approach versus see-and-treat approach in patients with cytological abnormalities. Int J Clin Exp Med. 2013;6:372–6.

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Singla S, Mathur S, Kriplani A, Agarwal N, Garg P, Bhatla N. Single visit approach for management of cervical intraepithelial neoplasia by visual inspection & loop electrosurgical excision procedure. Indian J Med Res. 2012;135:614–20.

    PubMed  PubMed Central  Google Scholar 

  11. 11.

    Ebisch RMF, Rovers MM, Bosgraaf RP, et al. Evidence supporting see-and-treat management of cervical intraepithelial neoplasia: a systematic review and meta-analysis. BJOG. 2016;123:59–66.

    CAS  Article  Google Scholar 

  12. 12.

    Irvin WP, Andersen WA, Taylor PT, Stoler MH, Rice LW. “See-and-treat” loop electrosurgical excision. Has the time come for a reassessment? J Reprod Med. 2002;47:569–74.

    PubMed  Google Scholar 

  13. 13.

    Cho H, Kim JH. Treatment of the patients with abnormal cervical cytology: a “see-and-treat” versus three-step strategy. J Gynecol Oncol. 2009;20:164–8.

    Article  Google Scholar 

  14. 14.

    Aue-Aungkul A, Punyawatanasin S, Natprathan A, et al. “See and treat” approach is appropriate in women with high grade lesions on either cervical cytology or colposcopy. Asian Pac J Cancer Prev. 2011;12:1723–6.

    PubMed  Google Scholar 

  15. 15.

    Bosgraaf RP, Peter-Paul M, Struik-van der Zanden PHTH, Bulten J, Massuger LFAG, Bekkers RLM. Overtreatment in a see-and-treat approach to cervical intraepithelial lesions. Obstet Gynecol. 2013;121(6):1209–16. https://doi.org/10.1097/AOG.0b013e318293ab22.

    CAS  Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to P. Rema.

Ethics declarations

Conflict of interest

The authors declare that there are no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Vijayashanti, T., Rema, P., Suchetha, S. et al. Loop Electrosurgical Excision Procedure in a Low-Resource Setting: Feasibility of Selective See-and-Treat Approach. Indian J Gynecol Oncolog 19, 26 (2021). https://doi.org/10.1007/s40944-021-00497-w

Download citation


  • Loop electrosurgical excision procedure
  • CIN
  • See-and-treat procedure
  • Colposcopy