Impact of Loop Electrosurgical Excision (LEEP/LLETZ) on the Quality of Sexual Life In Women of Reproductive Age – a Prospective Longitudinal Study

1. Introduction

Cervical cancer (CC) is the fourth most common cancer in women worldwide. The advent of cervical cancer screening has led to the early detection of precancerous squamous intraepithelial lesions (SIL), resulting in a decline in morbidity and mortality among patients. Various risk factors for CC have been identified, including high-risk human papillomavirus (HR HPV) infection, with HPV 16 and 18 being the predominant types contributing to SIL. It is established that persistent HR HPV infection can lead to High-Grade Squamous Intraepithelial Lesions (HSIL CIN2/3) and, consequently, the progression to invasive CC [1,2,3,4]. Cervical cancer screening encompasses HPV genotyping and cytology. In the event of an HR HPV positive result and abnormal cytology, women are referred to colposcopy in accordance with a standardized protocol [5]. If a lesion is detected during colposcopy, a guided biopsy is performed to establish a histopathological diagnosis. In cases of HSIL CIN2/3, patients are eligible for one of the following excision procedures of the pathological cervix: Loop Electrosurgical Excision Procedure (LEEP) or Large Loop Excision of Transformation Zone (LLETZ). The excisional techniques employed in such cases are office-based, making use of an electrosurgical loop for cervical conization, with excision depth of 7-25 mm. Nevertheless, patients following these procedures may experience concerns regarding their sexual functioning, as LEEP/LLETZ has the potential to result in impairment to the vascular supply and innervation of the cervix, which can subsequently lead to dyspareunia and sexual dysfunction [6]. Furthermore, the diagnosis of HSIL CIN2/3 can induce anxiety, which can in turn affect the quality of sexual intercourse. Previous studies have demonstrated that anxiety and depressive symptoms can persist for months following excision procedures [7,8,9]. The extant literature offers equivocal results with regard to the impact of LEEP/LLETZ procedures on sexual functioning [8,9,10,11,12,13,14]. Two studies demonstrated that patients post-procedure reported diminished sexual satisfaction [8,10]. Furthermore, Giovannetti et al. found that these women exhibited altered sensory perception (numbness), dyspareunia and decreased libido [11]. Conversely, three other studies found no significant difference in sexual functioning between patients after excision procedure and control group [9,13,14]. Intriguingly, one research noted an improvement in dyspareunia and postcoital bleeding after LEEP treatment [12]. A decision was taken to perform a prospective cohort study on HSIL, CIN2/3 and qualified LEEP/LLETZ, due to the paucity of studies on the subject, the inconsistency of the data available and the relevance of proper sexual functioning. The aim of the study was to investigate the impact of excision procedures on the sexual life and psychological well-being of the population concerned.

2. Materials and Methods

The present study was conducted using a prospective longitudinal approach at the 1st Department of Obstetrics and Gynaecology, Medical University of Warsaw, Poland, between October 2017 and August 2018. The inclusion criteria comprised the following: (1) age above 18 years old, (2) HR-HPV positive result, (3) cytological High-Grade Squamous Intraepithelial Lesions (HSIL) result, (4) fluency in Polish, and (5) no history of excision procedure. The exclusion criteria comprised the following: (1) pregnancy and (2) other neoplastic diseases. The study was approved by the Ethics Committee at the Medical University of Warsaw, Poland. Patients who met the inclusion criteria were given two questionnaires: the Female Sexual Function Index (FSFI) and the Brief Index of Sexual Functioning for Women (BISF-W). These were given to patients three months prior to and three months following LEEP/LLETZ.

2.1. FSFI

The Female Sexual Function Index (FSFI) is a 19-item questionnaire designed to assess female sexual function and sexual arousal disorders (FSAD). It comprises six domains of sexual function: sexual desire (questions 1 and 2), arousal (questions 3-6), lubrication (questions 7-9), orgasm (questions 10-13), satisfaction (questions 14-16), and pain (questions 17-19) (see Supplementary Materials) [15]. The FSFI provides a precise and comprehensive evaluation of each phase of female arousal and pleasure, aligned with the Masters and Johnson sexual response curve: arousal, plateau, orgasm, and resolution. Scores range from 2 to 36, with patients receiving 1–5 points for questions 1, 2, 15, and 16, and 0–5 points for items 3–14 and 17–19 [16,17]. Higher scores indicate better sexual function.

2.2. BISF-W

The Brief Index of Sexual Functioning for Women (BISF-W) questionnaire is a 22-item instrument designed to evaluate the current level of female sexual function. It is grouped into seven domains: D1 (desire), D2 (arousal), D3 (frequency of sexual activity), D4 (receptivity/initiation), D5 (pleasure/orgasm), D6 (relationship satisfaction), and D7 (problems affecting sexual satisfaction) (see Supplementary Materials). Scores on the BISF-W range from 16 to 75, with higher scores indicating better sexual function [18]. The impact of the LEEP procedure on sexual function was assessed using the FSFI as the primary scale and the BISF-W as the secondary scale. The complex correlation between medical interventions, psychological factors and sexual health in the context of HR HPV positive results and cervical dysplasia was analyzed using the questionnaires. The primary outcome was the mean difference in FSFI total score before and after excision procedure. The mean changes in domain scores in both the FSFI and BISF-W questionnaires after LEEP/LLETZ were also reported. Secondary outcomes were based on the FSFI cut-off point of 26.55, with a value below this indicating the presence of sexual functioning problems [19]. The percentage of women who exhibited a change in sexual functioning, i.e., the cessation of sexual intercourse after the excision procedure, was calculated based on the cut-off point on the FSFI scale. To the best of our knowledge, this is the first study to evaluate the impact of LEEP/LLETZ on the quality of sexual life in reproductive-aged women using validated tools, i.e., the FSFI and BISF-W questionnaires.

2.3. Statistical Analysis

Continuous variables were described as mean ± standard deviation (SD) or medians with interquartile range (IQR). The Shapiro-Wilk test was employed to evaluate the distribution of the data.

To facilitate a comparison of FSFI and BISW-W scores before and after the excision procedure, a repeated measures analysis of variance (ANOVA) was employed. Statistically significant results were defined as p-values less than 0.05. Statistical analysis was performed by the TIBCO Statistica 13.3 (version 13.3) software.

3. Results

A total of 40 eligible women were recruited at the 1st Department of Obstetrics and Gynaecology, Medical University of Warsaw (Poland), between October 2017 and August 2018. Precisely 6/40 (15%) women had no sexual activity four weeks prior to the questionnaire before excision procedure, whereas 3/40 (7.5%) declared no sexual intercourse four weeks prior to the second questionnaire after the treatment.

3.1. Primary Outcome

Table 1 presents the FSFI domain scores before and after the excision procedure. The investigation revealed no statistically significant variation in the overall FSFI total score before and after LEEP/LLETZ (F (1,39) = 0.774; p = 0.381). Furthermore, no significant changes in mean scores in any of the FSFI domains were observed before and after the procedure.

3.2. Secondary Outcomes

The investigation revealed that 18/40 (45%) of the subjects experienced sexual dysfunction, whereas 22/40 (55%) exhibited normal sexual functioning prior to the excision procedure, as determined by the cut-off point in the FSFI. Following LEEP/LLETZ, 22/40 (55%) patients exhibited a change in status, with 14/22 (63.6%) women demonstrating an improvement in their score and 8/22 (36.3%) experiencing a deterioration (Figure 1).

In total, 32/40 (80%) cases exhibited either stability or enhancement in sexual functioning following excision procedure. In addition, the BISF-W did not reveal any significant difference in total score before and after excision procedure (F (1,39) = 2.80; p = 0.102). Furthermore, no significant changes in domain scores before and after LEEP/LLETZ were found (Table 2).

4. Discussion

Human papillomavirus (HPV) infection is one of the most prevalent sexually transmitted infections worldwide. Persistent infection has been demonstrated to heighten the risk of HSIL, CIN2/3, and excision procedures. Previous studies have indicated that LEEP/LLETZ can result in anxiety regarding postprocedural sexual functioning [20]. While numerous questionnaires have been described for the evaluation of female sexual function, only a limited number meet the requisite scientific quality standards, including the FSFI and the BISF-W [15,18]. The present study provides novel data on sexual functioning and psychological well-being in patients who underwent LEEP/LLETZ. Conversely, previous studies have yielded conflicting results, with some indicating improvement and others reporting sexual dysfunction among women post-excision procedures [8,10,11,12,21]. A limitation of previous studies was the use of a single questionnaire, which focused exclusively on patients’ sexual life [13,14]. In contrast, our study utilised two standardised tools, the FSFI and the BISF-W, and found no significant changes in overall satisfaction in sexual life after LEEP/LLETZ. This observation pertains to both the aggregate scores and the individual domains of the aforementioned questionnaires. These findings provide evidence to suggest that loop excision procedures do not have an adverse effect on sexual functioning. It has been indicated that patients with an HPV (human papillomavirus) positive result who have undergone an excision procedure have higher levels of anxiety [8,22,23,24,25,26]. However, the present study contradicts this hypothesis by demonstrating that concerns regarding sexual function subsequent to LEEP/LLETZ are unwarranted, as no substantial impairment in sexual activity was observed following the procedure. Of particular interest is the finding that the domains pertaining to desire and arousal exhibited the lowest scores. These domains may be associated with the psychological state and potential fear associated with a positive HPV result or LEEP/LLETZ procedure. As desire and arousal are directly linked to a woman’s mental health, lack of professional psychological and sexological care may have an impact on achieving arousal, anxiety, and even lead to depression in these women [27,28,29,30,31,32,33,34,35]. Consequently, healthcare professionals require comprehensive training to recognise the necessity for psychological support and appropriate education in such cases. This study demonstrates that excision procedures have no detrimental effect on sexual function. It is a pioneering effort to dispel uncertainties by utilising two sexual functioning questionnaires. Nevertheless, the study acknowledges the need for further research in the field of sexual education, particularly with regard to the dissemination of information regarding sexually transmitted diseases. The provision of comprehensive and proficient insights regarding medical conditions or proposed procedures to patients assumes paramount significance, promising a substantial reduction in psychological distress and anxiety. Furthermore, it is acknowledged that every woman’s experience with HPV infection and excision procedure may vary. Consequently, psychological and sexological care should be tailored to the distinctive requisites and inclinations of each patient, ensuring the most favorable outcomes. Nonetheless, the findings of this study indicate that eight participants had FSFI scores below the cut-off point for sexual dysfunction, and in three cases, both questionnaires indicated a deterioration in sexual functioning after loop excision procedures.

The impact of demographic and clinical variables on these outcomes cannot be discounted; however, the study’s limited sample size precludes such an analysis. Consequently, the analysis of this variable in future research would be a beneficial addition.

5. Conclusions

This study demonstrates that LEEP/LLETZ does not have a significant effect on sexual functioning. Moreover, anxiety associated with these procedures in the context of subsequent sexual activity appears to be unwarranted. However, the results of the study call for the implementation of educational initiatives aimed at enhancing public awareness regarding loop excision procedures. It is recommended that further studies be conducted with a larger cohort of women following excision procedures, with the analysis adjusted for other clinical and demographic factors, to enhance understanding of this complex problem.