What You Should Know About Your Cone Biopsy

Reasons for a Cone Biopsy, What to Expect, and Risks of the Procedure

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What do you need to know about your cone biopsy procedure?. BLDM/Cultura/Getty Images

What is a Cone Biopsy? - Definition

A cone biopsy is surgery to remove a cone-shaped piece of tissue from the cervix and cervical canal. Cone biopsy may be used to diagnose or treat a cervical condition such as cervical intraepithelial neoplasia (CIN). It is also called conization.

What is the Cervix?

The cervix is the lower, narrow end of the uterus and for this reason is sometimes referred to as the uterine cervix.

The lower portion of the cervix connects with the vagina (the birth canal.)

Why is a Cone Biopsy Performed? - Indications

There are several different reasons a cone biopsy may be recommended, and these differences may leave you feeling very anxious. For example, if you heard that someone had a cone biopsy done to determine the extent of their cervical cancer, you may be frightened if you thought the purpose of your procedure was to diagnose abnormal cells on your Pap smear. Possible reasons to do a cone biopsy (indications) include:

  • A cone biopsy may be done if a pap smear is abnormal but a colposcopy does not reveal any abnormal areas or if a colposcopy exam finds moderate to severe abnormalities in cervical cells. In this case, the biopsy is performed in order to get a better sample (a biopsy sample) of cells to evaluate under the microscope, and is done as a diagnostic test.
  • In addition, a cone biopsy can be used as a from of treatment, when it is performed to remove abnormal tissue from the cervix.
  • A third reason a cone biopsy may be done is to evaluate the extent of a cervical cancer which has already been diagnosed.

How is Cervical Tissue Removed During a Cone Biopsy?

There are three different procedures that may be used to perform a cone biopsy. These include:

  • Cryosurgery (carbon dioxide laser).
  • Loop electrosurgical excision procedure (LEEP) - In a LEEP, a thin wire loop which is attached to a generator sends a current through abnormal tissue, essentially burning the abnormal tissue.
  • Cold knife conization or CKC - In this procedure a surgical scalpel is used.

There are advantages and disadvantages to each procedure and the procedure you doctor chooses may depend on exactly what she is treating in your cervix and on her experience with the different procedures.

Will I Be Awake for the Procedure?

Your doctor will discuss what anesthesia will be best for you, but many people choose to be asleep for the procedure. Usually you will be asked to avoid eating or drinking beginning around eight hours before the procedure.

During a cone biopsy you are usually placed your back with your legs up in stirrups similar to a Pap smear. If you have any difficulty lying on your back, talk to your surgeon or anesthesiologist ahead of time.

After Your Surgery

You will usually be monitored for three to four hours after your procedure, but will be allowed to go home that night as long as someone can stay with you overnight.

After a cone biopsy, you can expect bleeding for around one week, but may have some spotting for another week or two after your bleeding stops. You will probably feels some cramping over the first day or two, and your physician will talk to you about what you can take for pain relief.

It's important to avoid the use of tampons, douches, hot tubs, and sexual intercourse for the amount of time your doctor recommends, most commonly around three to four weeks. In addition, try to avoid heavy lifting which may increase your bleeding.

Talk to your loved ones and have someone help you during days following your surgery. Your doctor will probably recommend that you have someone with you for 24 hours following the procedure, but ideally you should have someone with your for several days. A procedure like a cone biopsy is not as visible as some other procedures, and the only way your loved ones will know you need help is if you tell them. This is important not just physically but to help you cope emotionally with the uncertainty and fears that most people experience at this time.

Next Steps after Surgery

Your doctor may be able to remove all abnormal cells during your cone biopsy. If this is the case, no treatment other than follow-up testing will be needed. Ask your doctor how often she wishes to see you if no further treatments are necessary.

If a cone biopsy is unable to remove all abnormal tissue, another procedure, such as a hysterectomy may be needed. If this is the case, your doctor will talk to you. In other words, you don't have to worry that you will go to sleep and possibly wake up without a uterus unless this is carefully planned ahead of time. 

If a cancer is found which has invaded deeper into the cervix that can be reached with a cone biopsy, you may need additional treatments such as chemotherapy or radiation therapy in addition to surgery.

When Should You Call?

You should call your doctor if you have any persistent pelvic pain, a fever (most often a fever greater than 100.5). heavy bleeding (more than a normal period) or a foul smelling discharge. Also, call your doctor with any symptoms that just don't seem right to you or if you have any concerns at all. Your doctor is aware this is a frightening time for you and wants you to contact her if you are feeling uncomfortable about any aspect of your recovery.

Side Effects and Short Term Risks of a Cone Biopsy

The cone biopsy procedure is usually tolerated quite well. Rarely, excessive bleeding will occur that could require a transfusion, and you should let your doctor know if your bleeding is heavier than a normal period or if you become lightheaded.

There is also a small risk of infection following the procedure. Watch for any discharge that is yellow or green in appearance, a fever, or any foul smelling discharge.

After any surgical procedure there is a small risk of blood clots in the legs. This is very uncommon with a cone biopsy, but talk to your doctor if you have any pain, redness, or swelling in one or both of your legs.

Long Term Risks of a Cone Biopsy

It's important to talk to your doctor about any long term risks related to your procedure. Possible complications may include:

Recurrence - If you have an HPV infection, there is a possibility that the infection that led to your need for a cone biopsy could cause further problems in the future. Talk to your doctor about this ahead of time, including how often you will be screened after the procedure. There is also the possibility of abnormal cells being left over that were not removed during the surgery. Overall, the risk of recurrence of abnormal cells is lowest with cold knife conization (in a 2016 study, 1.4 percent) compared with LEEP or cryotherapy (at 5.3 percent.) Since a LEEP procedure "burns" the abnormal tissue, it can be slightly more difficult for the lab to evaluate the material removed during surgery as well.

Perterm delivery - A concern for those who wish to plan a pregnancy after a cone biopsy is the risk of preterm birth and and the consequences of premature delivery for the baby. For some women, a cerclage, a procedure in which the cervical is essentially closed with suture material, may reduce the risk of preterm births. In the 2016 study cited above, the risk of preterm delivery was higher in those who had the cold knife conization technique performed than it was with either LEEP or cryotherapy. (Learn more about getting pregnant after a LEEP procedure.)

Infertility - A narrowing of the cervix called cervical stenosis could potentially lead to infertility due to in inability of sperm to travel through the tightened cervix, but this appears to be very uncommon. A 2014 study found an increased risk of second trimester miscarriages in those who had a previous cone biopsy, but no increase in infertility.

Painful periods - Cervical stenosis also carries a risk of painful periods following a cone biopsy (due to difficulty in blood flow through the cervix) but this is very uncommon.

A cone biopsy, especially a cold knife biopsy also carries the rare risk of damage to the bladder or rectum, but this is very uncommon.

Thoughts as You Plan for Your Cone Biopsy

Though scheduling a cone biopsy may seem common and routine for your health care providers, your emotions as someone facing the procedure may be all over the board.

Any time the word "C"is mentioned, even if you are assured that "carcinoma in situ" is a cancer which is not invasive, you're likely terrified. What does this mean? Will they get it all? Will it come back?

At the same time, if you plan on becoming pregnant in the future you may be just as worried about what this procedure may mean for you as far as getting pregnant and carrying a baby to term. Though the risk of premature delivery is very low (easier for a health care provider to say than for you to cope with) the thought that this is even possible is frightening.

Make sure to sit down and ask your doctor any and all questions you have. Some people find it helpful to request a second opinion. Sometimes it's helpful to talk to others who have gone through this procedure, but a word of caution is in order. As with many areas of medicine, cone biopsies are improving, and the chances that your procedure will be effective and without complications is higher than someone who may have had the procedure in the distant past.

Sources:

Kindinger, L., Kyrgiou, M., MacIntyre, D. et al. Preterm Birth Prevention Post-Conization: A Model of Cervical Length Screening with Targeted Cerclage. PLoS One. 2016. 11(11):e0163793.

Kyrgiou, M., Mitra, A., Arbyn, M. et al. Fertility and Early Pregnancy Outcomes after Treatment for Cervical Intraepithelial Neoplasia: Systematic Review and Meta-Analysis. BMJ. 2014. 349:g6192.

Santesso, N., Mustafa, R., Wiercioch, W. et al. Systematic Reviews and Meta-Analyses of Benefits and Harms of Cryotherapy, LEEP, and Cold Knife Conization to Treat Cervical Intraepithelial Neoplasia. International Journal of Gynaecology and Obstetrics. 2016. 132(3):266-71.

World Health Organization Guidelines Review Committee. WHO Guidelines for Treatment of Cervical Intraepithelial Neoplasia 2–3 and Adenocarcinoma in situ: Cryotherapy, Large Loop Excision of the Transformation Zone, and Cold Knife Conization. Geneva: World Health Organization; 2014. https://www.ncbi.nlm.nih.gov/pubmed/24901204

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