BACKGROUND: Cryosurgery is a favored treatment method for cervical intraepithelial neoplasia (CIN) among family physicians, in part because it is inexpensive and requires the least technical training and skill. Although cervical cryosurgery has been used for more than 30 years, the natural history of the postprocedure process has never been described. The primary purpose of our study was to describe the natural history of the healing process after cervical cryosurgery. A secondary purpose was to determine the effect of mechanical debridement of the cervical eschar on the symptoms of healing.
METHODS: We conducted a prospective multicentered trial in which women who had a histologically documented CIN lesion underwent cervical cryosurgery. Forty-six women were randomized to undergo eschar debridement at 48 hours after cryosurgery, and 38 women received standard care. All women were followed up and given preweighed sanitary pads for hydrorrhea (watery discharge) collection and a diary to record the severity and number of days of odor, pain, cramping, and hydrorrhea that were experienced.
RESULTS: The average total amount of hydrorrhea or discharge was 288 g, which required using an average of 41 sanitary pads during a period of 12.4 days. The duration of odor was 8.9 days, and the pain and cramping experienced after cryosurgery lasted 4.7 days. Women who were obese had greater hydrorrhea and pad usage than nonobese women. Debridement of the cervical eschar did not significantly change the signs and symptoms of healing after cryosurgery.
CONCLUSIONS: There are significant symptoms patients experience after cryosurgery that are not ameliorated by debridement. The expectations of the cryosurgical healing process should be disclosed to women before the procedure.
Family physicians favor cryosurgery as a treatment method for cervical intraepithelial neoplasia (CIN), in part because it is inexpensive and requires the least technical training and skill. For treatment of ectocervical intraepithelial neoplasia that requires no histologic specimen, cryosurgery has been shown to produce tissue destruction between 8 and 12 mm deep, the depth needed to destroy potentially dysplastic deep gland clefts.1,2 The healing process after cryosurgery is associated with a malodorous hydrorrhea (watery discharge),3,4 in addition to pain and cramping. Obese and multigravid women are more bothered by a higher frequency of pad changes required for the hydrorrhea from cryosurgery,4 which suggests that these subpopulations may be at greater risk for increased malodorous hydrorrhea and other side effects from the procedure. Debridement of the cervical eschar after cryosurgery has been promoted as an anecdotal method for reducing the amount of malodorous hydrorrhea.5 By eliminating an exudate that breeds aerobic and anaerobic infection, a more rapid re-epithelialization may occur, and the malodor may be reduced.6 Despite these findings and although cervical cryosurgery has been used for more than 30 years, the natural history of the postprocedure process has never been quantitatively described.
The primary purpose of our study was to describe the natural history of the healing process after cervical cryosurgery. Six symptoms commonly experienced by women undergoing cryosurgery were used as markers of this process: the amount and duration of hydrorrhea, the number of pads used, the duration and intensity of the malodor associated with the hydrorrhea, and the duration of pain and cramping experienced. A second purpose was to determine the effect of mechanical debridement of the cervical eschar on these symptoms and to determine whether obesity and gravidity affected the 6 symptoms of healing. A greater understanding of the symptoms surrounding the postcryosurgery period may be beneficial during the procedure consent process, in addition to being used in cost-effectiveness analyses comparing cryosurgery with other treatment methods.
Methods
Study Population
We conducted a multicenter prospective randomized clinical trial from February 1995 through May 1996 at 4 diverse clinic sites: the gynecologic teaching clinics of Truman Medical Center-East at the University of Missouri-Kansas City and the family medicine clinics at the Medical College of Georgia, Louisiana State University, and the University of Kansas Medical Center. All women with a histologically documented CIN lesion that met the criteria for cryosurgery were recruited to participate at each clinic site. Inclusion criteria were that: (1) the woman was willing to participate; (2) the lesion extended less than 4 mm into the endocervical canal; (3) the surface extent of the cervical lesion occupied 2 quadrants or less; (4) the endocervical curettage, if necessary, was negative; (5) the colposcopic examination was satisfactory; and (6) there was no colposcopic, cytologic, or histologic evidence of cervical cancer. Exclusion criteria included any previous ablative or excisional cervical treatments, current vaginal infections as diagnosed by routine clinic procedure before cryosurgery, chronic hydrorrhea, cervical cancer, cryoglobulinemia, and pregnancy. The study protocol and consent form were approved by the local institutional review boards before the study. Pretrial work established that evaporative losses from pads were minimal.