eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery

Gynecologic Cryosurgery: Treatment

Author: E L Kristiina Parviainen, MD, Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh
Coauthor(s): Nancy D Gaba, MD, Residency Program Director, Assistant Professor, Department of Obstetrics and Gynecology, George Washington University School of Medicine
Contributor Information and Disclosures

Updated: May 12, 2008

Treatment

Preoperative Details

No special preparation is required by the patient or physician prior to cryosurgery. The patient should be informed of the potential risks, benefits, failure rates, and alternatives to the procedure.

Prior to performing the procedure, the practitioner should confirm that the patient is not pregnant and is free of vaginal and cervical infections. The practitioner should review the Pap test, colposcopy, and ECC results to confirm that the patient is an appropriate candidate for cryosurgery. The lesion should not extend into the endocervical canal because this reduces the likelihood of success for the procedure.22,23

The equipment required to perform cervical cryosurgery is as follows:

  • Appropriately sized vaginal specula
  • Adequate light source
  • Refrigerant source - Liquid nitrous oxide
  • Cervical probes in a variety of sizes
  • Lubricant
  • Topical hemostatic agents

The following information may be provided to patients prior to their procedure.

Sample patient information sheet

Your doctor has determined that you have cervical dysplasia, which may be treated with cryosurgery. Cryosurgery is a procedure in which the abnormal cells on your cervix are destroyed by freezing. This procedure can be as much as 90% effective in eliminating the abnormal tissue. This procedure is performed in the office.

Prior to the procedure:

  • Notify your provider if you have (or will have) your period on the day of the procedure so it can be rescheduled when your period is over.
  • Notify your provider if you think that you might be pregnant. Cryosurgery usually is not performed during pregnancy because it might endanger the pregnancy.

Day of the procedure:

  • You may take a medication such as ibuprofen or acetaminophen 1-2 hours prior to your scheduled procedure.
  • No anesthetic is required for the procedure.
  • Your provider will perform the cryosurgery procedure in the office, which will require 15-20 minutes.
  • You may experience uterine cramping during and immediately after the procedure.

After the procedure:

  • You may return to work.
  • You may notice an abundant gray, white, or clear vaginal discharge for 2-4 weeks, which may have an odor. This is to be expected and is evidence of cells sloughing from the cervix.
  • Do not use tampons, douche, or have sexual intercourse for 4 weeks after treatment because this may result in infection or bleeding, which could delay the healing process.
  • You may take ibuprofen or acetaminophen for pain relief.
  • You may shower at any time after the treatment. Avoid tub baths until the vaginal discharge resolves.

Reasons to contact your provider:

  • Temperature above 38°C
  • Vaginal bleeding equal to or greater than a normal period
  • Pain not relieved by ibuprofen or acetaminophen

Intraoperative Details

Technique

In order to achieve hypothermia, liquid refrigerants are forced through a small hole at a pressure range of 750-900 pounds per square inch (psi).24 This produces a very low temperature at the surface of the probe due to the Joule-Thompson effect. The temperature at the probe tip can range from -65°C to -85°C. Cell death occurs secondary to crystallization of intracellular water at -20°C to -30°C.25,22,23 Proposed mechanisms for cell destruction include dehydration, crystallization, denaturation of membrane proteins, thermal shock, and vascular stasis.20

The refrigerant most commonly used at present is liquid nitrous oxide (N2 O). It is available commercially and is relatively inexpensive.

The external temperature of the probe depends on the conductivity of the probe material. Silver and copper are the best materials for use in probe tips because high conductivity produces both a better freezing effect and more effective local cryonecrosis.20 Adequate cryonecrosis of the tissue depends on direct contact of the probe with the lesion. This is best achieved with a water-based lubricant coating an appropriately sized probe. Boonstra and others have shown that the size and shape of the probe can dramatically affect the depth of cryonecrosis.22,23 The cryotip should cover the entire lesion and transformation zone. The 19- and 25-mm mini-cone tips are recommended by Campion.

Most authors recommend a freeze-thaw-freeze technique in which the tissue is frozen for a period of several minutes, thawed completely, and then refrozen. Creasman26 demonstrated that this method was significantly more efficacious than a single-freeze method. Some authors27 advocate the use of the double-freeze technique only in patients with CIN 3 or CIS. Generally, the freeze-thaw-freeze is divided as follows:

  • Freeze for 3 minutes
  • Thaw for 5 minutes
  • Freeze for 3 minutes

The freeze time required depends largely on the ice ball that is generated on the cervix. Campion in the 2005 edition of Practical Gynecologic Oncology recommends that the ice ball extend 7 mm laterally beyond the edge of the probe in order to achieve a 5-mm depth of destruction.25 This suggests that the operator need not watch the elapsed time, but rather monitor the width of the ice ball formed.

Procedure

  • The patient is carefully selected, as previously described.
  • She is premedicated with nonsteroidal anti-inflammatory drugs (NSAIDs).
  • A speculum is placed in the vagina to adequately expose the cervix and prevent contact of the probe tip with the vaginal walls and speculum.
  • Location and size of the lesion is confirmed by colposcopy or has previously been noted.
  • A water-soluble gel is applied to the tip of an appropriately sized probe, which is positioned over the lesion and transformation zone.
  • The flow of refrigerant is initiated, and the ice ball formation is observed carefully.
  • Thawing and refreezing then are carried out, if the operator prefers.

Postoperative Details

Postprocedure symptoms include the following:

  • Cramping: This can be minimized with pretreatment NSAIDs. Mucosal and paracervical block typically are not used.
  • Hydrorrhea: Most authors describe 2-4 weeks of profuse watery discharge, which may be greater in obese women. Debridement of the cervical eschar 48 hours after the cryosurgical procedure does not ameliorate this symptom.28
  • Bleeding: This symptom is rare.
  • Infection: This is a rare complication. Prophylactic antibiotics are not indicated.

Cellular repair

  • Crisp reports that 60% of patients were found to have normal histology findings on cervical biopsy at 6 weeks and 90% by 10 weeks.
  • Cervical cytology is difficult to interpret during the first 6 weeks due to the healing process, but then it returns to normal.
  • The squamocolumnar junction recedes deeper into the endocervical canal after cryosurgery.3

Follow-up

Possible strategies for follow-up post cryotherapy include repeat cytology every 6 months for 2 years and cytology and HPV testing at 6 months, with yearly screening thereafter.1 Factors that may affect screening frequency may include size and grade of the lesion and patient compliance.

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Women's Health Center. Also, see eMedicine's patient education articles Cervical Cancer and Pap Smear.

Complications

Potential impact on fertility, scarring complicating follow-up, and carcinoma developing postcryosurgery are the main concerns.

  • Fertility: Theoretical concerns about reduced fertility include the induction of cervical stenosis, a detrimental effect on cervical mucus, cervical incompetence, and tubal dysfunction secondary to ascending infection. No conclusive clinical evidence supports any of these concerns.29,30,31
  • Scarring complicating follow-up colposcopy: Of particular concern is the receding of the squamocolumnar junction into the endocervical canal.32,33 In a series of 204 patients, post-treatment colposcopy was adequate in 50% of patients after cryosurgery and 79% of patients after laser surgery.34 A more recent report of a small series of women treated with cryotherapy (n=82), LEEP (n=24), and no procedure (n=96), yielded likelihood odds ratios of 3.01 (0.78-11.58) for LEEP and 18.66 (6.99-49.81) for cryotherapy of inadequate follow-up colposcopic evaluation post procedure as compared with the no procedure group.35
  • Development of carcinoma postcryotherapy: In a series of invasive carcinoma diagnosed after cryotherapy, carcinoma was associated with the following findings: inappropriate evaluation prior to cryotherapy (57%), erroneous initial interpretation of ectocervical biopsies (20%), and erroneous initial interpretation of ECC specimens (67%).36 Appropriate preoperative evaluation is the key to minimizing the risk of postcryosurgery carcinoma.
  • Anaphylactoid reaction has been reported as a reaction to the cold exposure.37 Physicians performing cryosurgery should be aware of this potential risk and be familiar with its treatment.

More on Gynecologic Cryosurgery

Overview: Gynecologic Cryosurgery
Workup: Gynecologic Cryosurgery
Treatment: Gynecologic Cryosurgery
Follow-up: Gynecologic Cryosurgery
References
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Further Reading

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Keywords

gynecologic cryosurgery, cryotherapy, cryocautery, gynecologic surgery, gynecological surgery, gynecologic cryotherapy, cervical intraepithelial neoplasia, CIN, Papanicolaou test, Pap test, Papanicolaou smear, Pap smear

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Contributor Information and Disclosures

Author

E L Kristiina Parviainen, MD, Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh
E L Kristiina Parviainen, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Nancy D Gaba, MD, Residency Program Director, Assistant Professor, Department of Obstetrics and Gynecology, George Washington University School of Medicine
Nancy D Gaba, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, and Medical Society of the District of Columbia
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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