More women ranked the number of days experiencing pain and cramping during the cryosurgery procedure as the most important factor in their decision to undergo future treatment (42.9%). It was not significantly more important than the amount of hydrorrhea subsequent to the procedure (37.1%) or the cost of the procedure (20.0%). All 3 factors-pain and cramping, hydrorrhea, and cost-were considered equally important by 7.9% in their decision for future treatment, while 22.2% felt that only the pain and cramping and the volume of hydrorrhea were important to consider for future treatment.
Discussion
Physicians have traditionally focused on relieving the pain and cramping of the cryosurgical procedure itself1-5 and have paid less attention to the healing process. Among all aspects of the healing process, women care most about the pain and cramping but are also were bothered by the resulting hydrorrhea, odor, and necessity of wearing pads for protection. Few women were extremely bothered by the healing process; most ranked it as moderately bothersome, requiring more medications, and limiting activities more than normal menses. A small number of women found the procedure to be a positive experience. No similar study has been done for loop electrosurgery or laser surgery.
Our study documents that 16.9% of women were restricted in their daily activities by their menses. This proportion of our study population is slightly higher than Sundell’s report of 10% of 24-year-old women who were restricted in their activities because of dysmenorrhea.7 Menses causes significantly fewer days of activity restriction than the cryosurgical experience. Andersch and Milsom13 report that 38.1% of women use medications for dysmenorrhea, somewhat higher than our 26.8%. Both of these are clinically and statistically less than the almost 70% medication use for the cryosurgical healing process.
The 3 subsets of the population we examined were obese, nulligravid, and young. Obese women were stratified in the analysis because they are screened less often for cervical cancer,9,14-21 experience more dysmenorrhea cyclically,7 and take more medications for dysmenorrhea than nonobese women.8 Unpleasant experiences from cryosurgery could exacerbate the pattern of nonscreening in the future. Our study showed that obese women were more bothered by pad use than nonobese women but were not more restricted in their activities after cryosurgery. Previous work has shown that obese women produce more hydrorrhea quantitatively postprocedure than nonobese women.6 Our work shows that the obese women are not bothered by the hydrorrhea itself but by the necessity of wearing pads for protection.
Young and nulligravid subsets of the population have been found to experience more dysmenorrhea than older and multigravid women.7 These subsets of women, if sexually active, are also at high risk for human papillomavirus infection and subsequent CIN development, possibly requiring treatment. Surprisingly, in our study the youngest teens (15-18 years) were only bothered by the malodorous hy-drorrhea more than their counterparts aged 19 to 22 years and were less bothered by the hydrorrhea itself and the frequency of pad changes. Our study showed that older and multigravid woman rank the inconvenience of pad use after the cryosurgical procedure as worse than their clinical counterparts, potentially because these women had more daily responsibilities that were interrupted by the necessary pad changes.
The importance of our study is twofold. First, cryosurgery is a valuable treatment modality for all grades of CIN with lesions that meet the specific requirements. To set the patient’s expectations about the healing process following cryosurgery, patient education and informed consent should include, in addition to the description of the procedure, its necessity, and the standard Papanicolaou test follow-up, the comparison of cryosurgery with the woman’s menses, covering the points established by our study: (1) the volume of hydrorrhea will be perceived inversely to the volume of menses; (2) more activity restrictions occur; and (3) more medications are needed to alleviate cramping. Additionally, obese, older, and multigravid women experienced more aggravation from the pad use than others, and the youngest teens were more bothered by the malodorous hydrorrhea. Second, many physicians will treat CIN 1 lesions without allowing the lesion to undergo natural regression.22 By being this aggressive, the physician must weigh the quicker time that would have occurred without treatment to lesion regression caused by the cryosurgery with the risks of a bad cryosurgery experience that may affect future screening practices.
Decisions to undergo future CIN treatment were most influenced by the pain and cramping and the hydrorrhea of cryosurgery. It is unknown whether or when women will return for yearly preventive screening after experiencing cryosurgery. Winkler23 reported that women who underwent bilateral tubal ligations who later developed cervical cancer had more than a 6-year time lapse before returning for cervical cancer screening, longer than the 4 years for those women without tubal ligations. Future work will explore the influence of the cryosurgical experience on compliance with future screenings and will include formal disutility measurements due to cryosurgical treatment.