Large Loop Excision of the Transformation Zone During Follicular vs. Luteal Phase of the Menstrual Cycle (LLETZ-MC) (LLETZ-MC)

April 25, 2024 updated by: Clemens Tempfer, Ruhr University of Bochum

Performance of Large Loop Excision of the Transformation Zone (LLETZ) in Women With Cervical Dysplasia in the Follicular Phase Versus the Luteal Phase of the Menstrual Cycle: a Prospective Randomized Trial

Cervical cancer is one of the most common cancers in women and one of the leading causes of death in women worldwide. Pre-cancerous lesions (dysplasias) are detected by the preventive smear test at the gynecologist and can thus contribute to a 100% chance of cure if they are clarified by a colposcopic examination as part of the dysplasia consultation and dysplastic lesions are then surgically removed if necessary (conization).

There are few data in the literature on the influence of the menstrual cycle on the bleeding pattern during and after conization. Hormonal variations during the menstrual cycle affect both the extent of blood flow to reproductive organs and hemostasis. In the follicular phase, there is a decrease in local blood flow in the uterus and pelvic organs and an increase in coagulability. Conversely, in the luteal phase there is an increase in local blood supply and a decrease in coagulability. Therefore, it seems reasonable to perform conization in the follicular phase to possibly reduce the extent and incidence of bleeding and bleeding complications. This assumption is supported by clinical observations. For example, there is evidence from other specialties that selection of the timing of surgery, taking into account the menstrual phase, may influence the risk of bleeding. Another factor of interest in menstruation-based surgical planning is psychological vulnerability, which may also vary with the menstrual cycle. Until now, consideration of the menstrual cycle in surgical planning for conization has not been standard practice and there is no recommendation in this regard in the current S3 guideline of the German Society of Gynecology and Obstetrics.

Therefore, this study now aims to answer the question under prospective randomized conditions whether LLETZ conization performed during the follicular phase results in lower blood loss and higher patient satisfaction and lower anxiety scores compared to LLETZ conization performed during the luteal phase.

Study Overview

Status

Not yet recruiting

Conditions

Intervention / Treatment

Detailed Description

HPV and dysplasia of the uterine cervix

Human papillomaviruses (HPV) are the most common sexually transmitted pathogens worldwide. The prevalence in both male and female populations is high. Epidemiological estimates suggest that 85-91% of sexually active adults acquire at least one genital HPV infection by the age of 50, with approximately 95% of HPV infections being spontaneously eliminated within 2 years in terms of HPV immunological clearance. HPV preferentially infects the epithelial cells of the anogenital area and, through incorporation of HPV DNA into the host genome of the basal cells of the squamous epithelium of the cervix and subsequent expression of viral components, causes dysplastic changes in the cervical epithelium that, if left untreated, can develop into invasive carcinoma of the cervix (cervical carcinoma). Cervical carcinoma is the fourth most common cancer as well as the fourth leading cause of cancer-related death in women worldwide, responsible for 6.6% (570,000) of all new cancer cases and 7.5% (311,000) of cancer-related deaths in women in 2018. The precursor of squamous cell carcinoma of the uterine cervix (approximately 80% of all cervical cancers) is cervical intraepithelial neoplasia (CIN), which has three grades of expression (CIN1, CIN 2, and CIN 3). Compared with invasive cervical carcinoma, the incidence of precancerous lesions of the cervix uteri is much higher. It is estimated that approximately 100,000 women in Germany develop high-grade dysplasia (CIN2/CIN3) each year.

Therapy of cervical dysplasia

Dysplasia of the cervix is typically detected during the gynecological screening examination at the gynecologist. Smears are taken from the ectocervix and endocervix and cytologically evaluated for dysplastic cells and smear quality after Papanicolaou staining. For further clarification of dysplastic changes, presentation to a specialized dysplasia consultation is recommended in the case of abnormalities with suspected presence of cervical dysplasia. Histological confirmation of abnormal areas is performed during colposcopic examination. The histopathological processing of the tissue samples and the colposcopic image of the spread of the changes in the cervix then allow individualized therapy planning.

Conization as the standard of surgical treatment

If precancerous lesions with the potential to develop into an invasive cervical tumor are detected, conization (= surgical removal of a cone of tissue from the cervix) is the method of choice for removing the diseased tissue. The worldwide standard surgical procedure for conization is LLETZ conization (="Large Loop Excision of the Transformation Zone"). In addition to the risk of local persistence of precancerous lesions if cervical dysplasia is incompletely removed, LLETZ also increases the risk of preterm delivery in subsequent pregnancy. This risk increases with increasing volume of removed tissue. To reduce or avoid the aforementioned complications, conization should be performed under colposcopic vision and as little healthy cervical tissue as possible should be removed.

Influence of the menstrual cycle on the bleeding pattern during and after conization

Hormonal variations during the menstrual cycle influence both the extent of blood flow to reproductive organs and hemostasis. Concentrations of fibrinogen, von Willebrand factor antigen, and von Willebrand factor activity show significant menstrual cycle variations with maximum values during the luteal phase. In this sense, during the first cycle phase, the follicular phase, there is a decrease in local blood flow in the uterus and pelvic organs and an increase in coagulability. In contrast, in the second cycle phase, the luteal phase, there is a subsequent increase in local blood supply and a decrease in coagulability. Therefore, it seems reasonable to perform conization in the follicular phase to possibly reduce the extent and incidence of bleeding and bleeding complications. This assumption is supported by clinical observations. For example, there is evidence from other specialties that selecting the timing of surgery, taking into account the menstrual phase, may influence the risk of bleeding. In two non-controlled, retrospective studies of patients undergoing mammary reduction surgery and rhinoplasty, the magnitude of intraoperative and postoperative blood loss was lower during the follicular phase than during the luteal phase. In addition, a small randomized trial of 73 patients undergoing cervical uterine surgery (loop electrosurgical excision procedure [LEEP]) found a demonstrable advantage in terms of intraoperative and postoperative blood loss when LEEP was performed during the follicular phase. Another factor of interest in menstruation-oriented surgical planning is psychological vulnerability, which also varies with the menstrual cycle. This factor, which is important for the extent of psychological stress and processing of surgery, also seems to be relevant in the context of conization. Thus, Paraskevaidis et al. were able to show in a randomized study that women who underwent LLETZ conization in the luteal phase had significantly higher anxiety scores and evaluated the surgery more negatively than women who underwent surgery during the follicular phase. This aspect also supports the usefulness of performing conization during the follicular phase. So far, consideration of the menstrual cycle in surgical planning of conization is not standard and there is no recommendation in this regard in the current S3 guideline of the German Society of Gynecology and Obstetrics (DGGG). To date, the selection of the appropriate time for surgery depends only on the patient's time preference and the availability of the surgical site.

Study Type

Interventional

Enrollment (Estimated)

152

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Locations

  • Germany
    • North Rhine-Westphalia
      • Herne, North Rhine-Westphalia, Germany, 44625
        • Marien Hospital Herne
        • Contact:
          • Clemens B Tempfer, MD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Written consent
  • Regular menstrual cycle, defined as an interval between 21 and 35 days and a bleeding duration between 3 and 10 days during the last 3 months
  • Colposcopy performed preoperatively
  • Histologically (by previously performed colposcopy) confirmed dysplasia (CIN 1, CIN 2 or CIN 3)
  • Suspicion of low-grade or high-grade squamous intraepithelial lesion based on Papanicolaou smear with inconclusive colposcopy and need for surgical workup to exclude lesions
  • Age >18 years

Exclusion Criteria:

  • Pregnant patients
  • Patients with insufficient knowledge of the German language
  • Pre-existing oncological diseases
  • Blood coagulation disorders
  • Taking blood thinning substances
  • Use of a hormonal intrauterine device (e.g. Mirena);
  • Use of a progesterone pill or progesterone injectate;
  • Use of long cycle contraceptive (no monthly bleeding).

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Other: Follicular phase
LLETZ performed during the follicular phase of the menstrual cycle
Procedure: LLETZ
Large loop excision of the transformation zone
Other Names:
  • LEEP
  • conization
Other: Luteal phase
LLETZ performed during the luteal phase of the menstrual cycle
Procedure: LLETZ
Large loop excision of the transformation zone
Other Names:
  • LEEP
  • conization

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Intraoperative blood loss (weight)
Time Frame: During surgery
The intraoperative blood loss, measured by the net-weight (in grams) of the surgical swabs used for hemostasis
During surgery

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Intraoperative blood loss (Hb)
Time Frame: Day of surgery
The intraoperative blood loss, assessed through the difference between the Hb values measured preoperatively and 2 hours postoperatively, respectively.
Day of surgery
Intraoperative blood loss (subjective)
Time Frame: Immediately after surgery
The extent of intraoperative blood loss estimated by the surgeon (blinded to menstrual cycle phase) using a subjective categorization (mild, moderate, severe).
Immediately after surgery
Postoperative bleeding (subjective)
Time Frame: Interview 14 days after surgery
The extent of postoperative bleeding during the first 24 hours after surgery (assessed by the patient using an 11-item Numerical Rating Scale; 0 [minimal bleeding] - 10 [strong bleeding]).
Interview 14 days after surgery
Postoperative bleeding (days)
Time Frame: Interview 14 days after surgery
The number of postoperative days where bleeding occurred
Interview 14 days after surgery
Patient's anxiety
Time Frame: On the day of surgery, before surgery
The patient's anxiety level due to surgery as measured by the Spielberger State-Trait Anxiety Inventory (STAI, situational anxiety STAI-S, trait anxiety, STAI-T). Score range 20 to 80 points for each of the two parts of the test (a higher score means higher levels of anxiety).
On the day of surgery, before surgery
Rate of complications
Time Frame: During surgery up to 14 days post surgery
The occurring intra- and postoperative complications in a period within 14 days after surgery
During surgery up to 14 days post surgery
Cone mass
Time Frame: During surgery, immediately after the excision
The weight of the cone specimen (measured in grams in the unfixed state)
During surgery, immediately after the excision
Procedure duration
Time Frame: At surgery
Duration of the procedure (from start until complete hemostasis is achieved)
At surgery
Patient satisfaction
Time Frame: At discharge and 14 days after surgery
Overall patient satisfaction (11-item numerical rating scale).
At discharge and 14 days after surgery

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Ruhr University of Bochum

Investigators

  • Principal Investigator: Clemens B. Tempfer, MD, MBA, Ruhr-Universität Bochum / Marien Hospital Herne

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Helpful Links

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Estimated)

May 1, 2024

Primary Completion (Estimated)

October 1, 2025

Study Completion (Estimated)

December 1, 2025

Study Registration Dates

First Submitted

May 20, 2022

First Submitted That Met QC Criteria

May 20, 2022

First Posted (Actual)

May 25, 2022

Study Record Updates

Last Update Posted (Actual)

April 26, 2024

Last Update Submitted That Met QC Criteria

April 25, 2024

Last Verified

April 1, 2024

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • LLETZ-MC-1

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

YES

IPD Plan Description

Data will be shared upon reasonable request made to the corresponding author. This includes individual participant data underlying the results presented here, after deidentification, as well as data dictionaries and the the study protocol. Data is available after publication, without a specific end date. Requesting investigators must show that their proposed use of the data has been approved by an independent review committee identified for this purpose.

IPD Sharing Time Frame

After publication of the study results, no time limit.

IPD Sharing Access Criteria

Reasonable request, approval of the intended study by an independent review committee identified for this purpose.

IPD Sharing Supporting Information Type

  • STUDY_PROTOCOL
  • ICF
  • CSR

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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