Earlier this month, Cosmopolitan published an article titled “This routine gyno procedure could mean you never orgasm again,” in which writer Hannah Smothers warns that physicians are failing to counsel patients appropriately about the risks of a loop electrosurgical excision procedure (LEEP).
We are two obstetrician-gynecologists who specialize in reproductive endocrinology and infertility, and we want to reassure patients that while sexual dysfunction is common in general, permanent sexual dysfunction is not a known complication of a LEEP. In addition, the Cosmopolitan article fails to fully convey an important point: LEEPs are not elective. Rather, they are necessary to prevent cervical cancer and save lives.
A LEEP is an in-office surgical procedure in which electrocautery is used to remove a small area of the cervix suspected of containing precancerous cells. It is performed in patients at high risk for cervical cancer and is successful in eliminating the abnormal cells in more than 90 percent of cases. Cervical cancer is the second most common cause of cancer-related death worldwide, according to the National Institutes of Health. In the United States, successful screening programs have resulted in a 54 percent drop in rates of cervical cancer since 1974. Much of this decline is credited to early detection and treatment of precancerous lesions identified through Pap smears.
While a LEEP is not without risk, it is generally considered a safe and well-tolerated procedure. The reported risks include up to an 8 percent chance of post-operative bleeding and 2 percent risk of infection. In addition, there is a small increase in the risk of premature birth in subsequent pregnancies. Rarely, narrowing of the cervical opening can occur, causing problems with menstruation. As part of the informed consent process, these risks must be reviewed and balanced with the procedure’s potential benefit to the patient.
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In the Cosmopolitan piece, Smothers argues that sexual dysfunction is another potential complication from a LEEP and hypothesizes that cervical nerves are damaged by the procedure. As OB-GYNs, we take this assertion seriously. Several academic studies have addressed sexual function following LEEP. In 2010, the Journal of Sexual Medicine published an article titled, “The impact of the loop electrosurgical excisional procedure for cervical intraepithelial lesions on female sexual function.” The authors enrolled 67 sexually active women and administered a validated questionnaire on six domains of female sexuality (desire, arousal, lubrication, orgasm, satisfaction, and pain) both before the procedure and after six months. The study found a decrease in sexual interest after LEEP but no change in the total score or other domains of sexual function. The authors concluded that the “procedure could not be considered the cause of organic sexual dysfunction” and hypothesized that “psychological factors inherent in both the diagnosis and the treatment of cervical intraepithelial lesions could influence this aspect of female sexual function.”
These findings are consistent with a study from 2008, in which 100 women completed a psychosexual assessment before and after colposcopy to evaluate the cervix—generally the step following an irregular Pap smear to check for precancerous cells. In this study, there was a significant reduction in sexual function, including interest in sex, frequency of intercourse, and sexual arousal at six months. However, there was no difference in sexual functioning between those women who had a cervical biopsy and those who had a LEEP, indicating that it may be the diagnosis rather than the LEEP procedure itself that results in sexual dysfunction.
Given that a LEEP removes part of the cervix, the hypothesis of the Cosmopolitan article must be that the cervix is necessary to sexual function. This is countered by evidence that there is no difference in sexual satisfaction between patients who have a total hysterectomy (removing the cervix with the uterus) versus women who have a subtotal or supracervical hysterectomy (leaving the cervix and removing only the uterus). Based on this, it seems unlikely that removing a small portion of cervix with a LEEP would result in the significant symptoms women report in the Cosmopolitan article.
Without treatment, 30 percent of women with high-grade cervical abnormalities will progress to cervical cancer., compared to 0.7% of those who are adequately treated. Patients who present with early-stage cancer will need their reproductive organs removed surgically, including the entire cervix. Others who present with more advanced cervical cancers are treated with pelvic radiation and chemotherapy. We have strong data on the negative impact of pelvic radiation on female sexual function, due to pain, bleeding, vaginal narrowing, and lack of lubrication. These side effects may be permanent.
We certainly do not want to minimize the real symptoms reported by the women in the Cosmopolitan article. Sexual dysfunction is common, affecting 40 percent to 50 percent of women. It can have a significant impact on quality of life and relationships. Women are also often reluctant to discuss their concerns with health-care providers; this may leave symptoms untreated for years. It is hard to determine exactly why the women in the article are suffering, but the experience of being treated for precancerous cells with a LEEP procedure could absolutely be traumatic. For this reason, physicians should clearly explain what will be done and all risk factors; they should work to alleviate concerns before performing the procedure. Additionally, we acknowledge that future research may provide additional answers to why these women experienced symptoms following their procedure.
We also want women to be aware of the resources that exist. Sexuality is complex, and its dysfunction often requires a multidisciplinary treatment team, including gynecologists, physical therapists, sex therapists, and couples’ therapists. An array of treatment options are available, and a referral to a pelvic floor physical therapist or sexual medicine physician with additional training and expertise may be needed, though we recognize that patients may be limited by the level of care covered by insurance.
We encourage you to educate yourself and ask your physician questions. There are clear national guidelines regarding when a LEEP or other cervical procedure is recommended based on age and pathology results. These guidelines were designed by experts to minimize harm from both cancer and any complications, including sexual function. In the clinic, we educate and guide patients to understand their medical condition so they can make the right choice for themselves. Other physicians should do the same.
With a wide and engaged readership, Cosmopolitan has an opportunity to educate women to make informed choices regarding their health. They can also give overlooked patients a voice, as they have done in this piece. However, as physicians, we must hold its authors accountable to report accurate information rather than drive patients away from lifesaving procedures by instilling unwarranted fears.
The views expressed in this article are solely those of the authors and not of the institutions they are affiliated with.