HPV, Colposcopy and LEEP in Istanbul: Cervical Assessment

What is HPV and how is it transmitted?

Human papillomavirus (HPV) is one of the most common sexually transmitted viruses. More than 200 types have been described; they can affect the genital area, anus, mouth and throat. Most sexually active people meet HPV at some time in their lives and usually notice no symptoms.

Some types (such as 6 and 11) cause genital warts; others, the “high-risk” types (such as 16 and 18), can cause pre-cancerous changes of the cervix when they persist. The virus itself is not the problem: what matters is persistence of a high-risk type and the cell changes it may cause.

What does a positive HPV result mean?

A positive HPV test means that a high-risk HPV type has been detected in the cervix; it does not mean that you have cancer. A healthy immune system can clear most infections within one to two years. The risk increases when the same high-risk type persists. HPV 16 and 18 carry more risk than other high-risk types, so genotyping matters.

The result is therefore assessed together with the smear, your age, earlier results and, when necessary, colposcopy.

How do cell changes develop in the cervix?

The outer surface of the cervix (ectocervix) is lined with squamous cells and the canal (endocervix) with glandular cells. The area where they meet is called the transformation zone and is where HPV settles most often; most pre-cancerous changes begin there. Over years, a persistent high-risk infection can cause low-grade changes (CIN 1), then high-grade changes (CIN 2–3) and, if untreated, in a minority of cases invasive cancer. Screening exists to find and treat these changes long before cancer develops.

Smear test and HPV test

Cervical screening is based on two tests. The smear (Pap test or liquid-based cytology) examines cells taken from the cervix under the microscope. The HPV DNA test looks for high-risk HPV in the same sample. Taking the sample takes a few minutes and is usually not painful. The two tests complement each other: you can be HPV-positive with a normal smear.

How often to repeat the tests depends on your age, earlier results and national or society guidelines; your doctor will set the interval for you. Sometimes a sample is “inadequate” because of few cells, blood or inflammation. This is not an abnormality and is usually repeated after a short interval.

What do abnormal smear results mean?

A smear result is a risk notification, not a diagnosis. The most common results are:

What is colposcopy?

Colposcopy is the examination of the cervix with a lighted magnifier (colposcope). It is done in the gynecological examination position; no camera or surgical instrument enters the body. Vinegar (acetic acid) and, if needed, an iodine solution are applied to the cervix so that abnormal areas become visible. A small biopsy is taken from suspicious areas; it may cause brief cramping. The biopsy is then examined by a pathologist.

To prepare, choose a day without menstrual bleeding, avoid vaginal medication, creams, douching and intercourse for two days beforehand, and bring all HPV, smear and earlier colposcopy/biopsy reports. Light bleeding or dark discharge for a few days after a biopsy is common. If the canal of the cervix cannot be seen, or if a glandular lesion is suspected, a small sample from inside the canal (endocervical curettage) may be taken; it is not done in pregnancy.

If colposcopy is “normal” for an HPV-positive result, or the biopsy is normal, it suggests the infection may be clearing; HPV and smear follow-up at set intervals (often 6–12 months) is recommended according to the type and smear result.

Biopsy results: CIN 1, CIN 2, CIN 3 and AIS

CIN (cervical intraepithelial neoplasia) describes the degree of pre-cancerous change in the cells on the surface of the cervix. CIN is not a diagnosis of cancer; however, a proportion of untreated high-grade lesions can progress to invasive cancer over years.

A pathology report says more than “CIN 2” or “CIN 3”. The surgical margins (whether the lesion reaches the edge of the removed tissue), a sample from inside the canal and markers such as p16 can all influence treatment and follow-up decisions. Bringing the full report and, if possible, the slides to the consultation is useful.

What is LEEP and when is it needed?

LEEP (loop electrosurgical excision procedure) removes the abnormal area of the cervix with a thin electrified wire loop. It is both a treatment and a way to examine the removed tissue by pathology, so the presence of a more advanced lesion can also be assessed. It is considered mainly for persistent or confirmed high-grade lesions (CIN 2–3) or lesions suspected to be high-grade on colposcopy.

Before LEEP a pregnancy test is done and infection and bleeding risk are assessed. The cervix is numbed with local anaesthetic; the transformation zone is removed with the wire loop and the bleeding area is controlled. The tissue goes to pathology. Light bleeding or brown discharge, mild cramps and a watery discharge for a few weeks are expected. Avoid intercourse, tampons and swimming for the period your doctor specifies (usually about four weeks). Seek advice promptly for heavy bleeding, fever or foul-smelling discharge.

Conization: how it differs from LEEP

Conization removes a cone-shaped piece of tissue from the cervix. LEEP and conization are separate procedures, although both can be used to treat pre-cancerous lesions such as CIN 2–3. Conization usually means removing deeper or differently shaped tissue, and can be done with a cold knife (scalpel), laser or a LEEP wire. Conization with a scalpel or laser is more often performed in the operating room, sometimes under general or regional anaesthesia.

Preserving the cervix and planning pregnancy

The amount of tissue removed from the cervix can affect the risk of cervical weakness or premature birth in later pregnancies. Therefore, especially in young patients who have not yet had children, the aim is to treat the disease completely and safely while avoiding unnecessary tissue loss and repeated procedures.

LEEP and later pregnancy

The mode of delivery after LEEP or conization is decided according to the state of the cervix and the course of pregnancy; a previous LEEP does not by itself require a caesarean section. Where a larger amount of tissue has been removed the risk of premature birth may be slightly higher, so cervical length can be monitored by ultrasound during pregnancy. Most people can conceive after LEEP.

Follow-up after treatment

After LEEP, conization or treatment for CIN, high-risk HPV may remain positive for a while. For this reason HPV and smear (and colposcopy when needed) checks are usually done during the first year, after which the screening interval is lengthened depending on the results. In people who have had a high-grade lesion, the risk remains for a long time, so long-term follow-up is recommended. The follow-up plan depends on your pathology result and HPV type; an example schedule: a healing check and discussion of pathology at 4–6 weeks, then HPV test and smear at 6–12 months.

Genital warts and the HPV vaccine

Genital warts (condylomata), mostly caused by HPV 6 and 11, are raised or cauliflower-like lesions on the skin or mucosa. They do not cause cancer but may be bothersome and are contagious. Treatments include medicated creams or solutions, freezing (cryotherapy), electrocautery, laser or excision, chosen according to the number and site.

The HPV vaccine protects against new infections but does not treat an existing infection or lesion. The greatest benefit is when it is given before exposure to the virus (usually at ages 9–14), but it can also be considered at older ages according to age and risk. Vaccination does not replace screening.

HPV, pregnancy and childbirth

HPV positivity does not prevent pregnancy. Cervical screening and, when needed, colposcopy can be performed safely in pregnancy. LEEP/conization is considered during pregnancy only in special situations such as suspected cancer; it is usually postponed until after delivery. Genital warts can grow during pregnancy and treatment options are chosen with this in mind. Colposcopy in pregnancy should be done by an experienced physician because pregnancy changes the appearance of the cervix; its purpose is to exclude invasive cancer.

HPV in men, partners and common misconceptions

Men can carry and transmit HPV; genital warts and lesions of the penis, anus, mouth and throat can occur. There is no routine HPV screening test for men; if there is a suspicious lesion an examination is needed. Whether a partner needs treatment or vaccination is decided individually. An HPV result can cause anxiety or suspicion between partners, but HPV is common, can stay silent for a long time, and the time of infection often cannot be determined.

• “If HPV is positive I have cancer.” No. Positivity is a risk notification and in most people the infection clears.
• “If my smear is normal there is no need to look at HPV.” The tests complement each other; you can be HPV-positive with a normal smear.
• “If I have been vaccinated I do not need smears.” The vaccine does not cover every type, so screening continues.

Other HPV-related changes

HPV is not limited to the cervix: it can cause lesions, and rarely cancers, of the vulva, vagina, anus, penis, mouth and throat. A sore, raised area, colour change, long-lasting itch or bleeding of the vulva or vagina that does not go away needs examination. Early cervical cancer may cause no symptoms, which is why screening saves lives; later, bleeding after intercourse, bleeding between periods or after menopause, foul-smelling discharge and groin pain can appear. These symptoms have other causes too, but they must be assessed.

My result came back like this: what is the first step?

Second opinion and preparing for the consultation

If LEEP, conization or surgery has been advised at another centre, re-examining the pathology slides and the colposcopy images can change the treatment plan. Please bring all HPV and smear reports (with the date and laboratory), earlier colposcopy and biopsy results, and the LEEP/conization pathology report. At the consultation, existing reports and previous procedures are reviewed first; if needed colposcopy is performed and a biopsy is taken, and the result is combined with pathology to plan treatment or follow-up. The aim is not to miss a high-grade lesion and to avoid an unnecessary procedure in a low-risk situation.

Sources and content principles

This guide is prepared to help patients understand the basic concepts of HPV, colposcopy and LEEP and does not replace a personal examination, diagnosis or treatment advice. Among the sources used:

• ASCCP: 2019 Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors
• World Health Organization: cervical cancer and HPV fact sheets
• ACOG and ESGO/EFC/ESP guidance on cervical screening and management of cervical pre-cancer