Obese women expelled more than half of their hydrorrhea within the first 8 days after cryosurgery when compared with the remaining time of hydrorrhea (218 g [SD=129] vs 147 g [SD=142], P=.0150). The most malodorous time of hydrorrhea was day 9 after cryosurgery, when 89.5% of obese women experienced malodor. Although both obese and nonobese women had hydrorrhea for the same total number of days, the time to expel half of the total hydrorrhea and the peak time of malodor lasted 2 to 5 days longer for obese women than for nonobese women (8 days to expel half of the hydrorrhea vs 6, peak malodor at 9 days vs 4, respectively). The average duration of pain or cramping for the obese women was 6.0 days (SD=5.6), occurring an average of 36.5% (SD=34.6%) of the days hydrorrhea was present, not statistically longer than for nonobese women.
Discussion
The natural history of the healing process after cryosurgery reveals a more prolonged, malodorous, and painful healing process than has been recognized by most clinicians. The women in our study who completed their hydrorrhea before the onset of their menses provide the clearest description of the natural history of cryosurgical healing independent of the potential confounder of the menstrual cycle. Our findings provide physicians with additional information to set appropriate expectations for cryosurgical healing and the post-treatment process at the time of consent. These findings are significant because women with an average body habitus and their treating physicians can expect the following: (1) an average of approximately 365 g (1.6 cups) of hydrorrhea postoperatively; (2) an average of 46 pads used for protection; (3) 7 days of heavy hydrorrhea out of the 2 to 4 weeks of expected hydrorrhea; (4) an average of 9 days of bad odor with the worst experienced on days 3 through 5; (5) noticeably bad odor for all women; and (6) pain and cramping following cryosurgery lasting an average of 5 days. Obese women have a more prolonged course of healing. The expectations for obese women are an average of approximately 450 g (2 cups) of hydrorrhea, an average of 65 pads used for protection, 8 days of heavy hydrorrhea, and the worst malodor on days 5 to 11 after cryosurgery.
Menses provide a useful gauge to compare the cryosurgical post-treatment and healing process. Menstrual hydrorrhea is composed of both blood and endometrial exudate,7-9 while cryosurgical hydrorrhea is purely cervical exudate. The average menstrual hydrorrhea is reported between 35 and 60 mL per cycle,10-13 while we found that the average total cryosurgical hydrorrhea may be up to 10 times that amount and can be an entire “menses-worth” in 1 day. Maximally, a woman can experience up to 30 times her menstrual volume in the month following cryosurgery. Ninety-two percent of the blood loss occurring during menses has occurred by the third day,14 while we showed that 90% of the total hydrorrhea has occurred by the 20th day. The severity of dysmenorrhea is correlated to the duration of menses.15 Women experience dysmenorrhea approximately 50% of the duration of their bleeding, 2 out of the 4 days;16 similarly, we have shown that women experience postcryosurgical pain and cramping approximately 42% of the time they have hydrorrhea.
Our study suggests that debridement after cryosurgery offers no advantages in comparison with the natural healing process. It does not decrease the amount or duration of hydrorrhea, the duration of malodorous hydrorrhea, or the duration of pain or cramping after the procedure. Debridement may reduce the overall intensity of malodor, but this small benefit must be weighed against the time and cost it takes an office to have women routinely return for debridement. In addition, only a fifth of the women who underwent debridement indicated they would return for future debridement, indicating low patient acceptance of this procedure even with its small benefit of diminishing the malodor. Nahhas and colleagues17 evaluated mechanical debridement of the cervical eschar 72 hours after cryosurgery, using the duration of hydrorrhea as a surrogate measure for the amount of hydrorrhea. Although inadequate power prevented significant conclusions about the effect of debridement on the duration of hydrorrhea in his study, he could not show any diminished hydrorrhea with debridement. Other reports of the effect of cervical debridement are anecdotal.5
Many postoperative complications and wound healing impairments are more common in obese than nonobese people.18,19 This is the first report that obese women have a greater amount of hydrorrhea after cryosurgery and use significantly more pads but produce the hydrorrhea in the same number of days as nonobese women. This corroborates the finding that obese women are more bothered by pad changes than nonobese women.4 One reason obese women do not experience any more pain or cramping after cryosurgery than nonobese women is that they self-medicate more often than nonobese women,4 a medication pattern also seen by obese women for dysmenorrhea.16