09/29/2025

“What’s in a name?” Understanding Conisation In France

Conisation and all its variants explained: LEEP, LLETZ, SWETZ, CKC, Laser

One of the things I’ve noticed as an American gynecologist practicing in Paris is that all excisional procedures of the cervix are lumped together into one word in France: Conisation!

You may have heard this word if your frottis (HPV test or pap smear) is abnormal and then you undergo a colposcopy. If the biopsies taken during a colposcopy reveal a high-grade lesion (CIN2, CIN3, AIS), your gynecologist probably recommended a conisation. At this point you’re probably alarmed, since you are dealing with a pre-cancerous lesion of the cervix. But on top of that, as an expat in Paris, you may be left wondering, what is a conisation exactly? Terminology changes across different countries, but also surgical techniques, and that matters, since not all conisations are the same! So as The Bard said, “What’s in Name?” In this case, a lot.

I know how stressful it can be to face an abnormal result a foreign healthcare system — especially when the terminology is unfamiliar. This guide will explain the differences between the various techniques (LEEP, LLETZ, CKC, or SWETZ), what each one means for your health and fertility, and how to ask the right questions so that you feel empowered in your care.

The differences, and a bit of history…

LEEP, LLETZ, SWETZ, CKC, Laser

The procedure coding system in France (CCAM), calls all of these Conisation du col de l’uterus in French, so which one should you get?!

Cold-Knife Conization (CKC): First described by Ayre in the US in 1948 (and later adopted in Europe), for the treatment of pre-cancerous and cancerous lesions of the cervix. It uses a scalpel (hence the “cold” blade) to remove a cone-shaped wedge of cervical tissue, removing portions of ECTOcervix, as well as a deeper portion of the ENDOcervix (see image below, but basically Ectocervix is the outer part of the cervix usually visible during an exam while the endocervix is the inner part in the canal and not easily seen). Because a scalpel is used, there is no heat used in the cutting, so there is less thermal damage to the tissue removed. This is an important point when margin status is important, such as suspicion of invasive cancer. CKC is sometimes also recommended for glandular lesions since they can go deeper in the endocervical canal and this procedure removes more ENDOcervix. However, CKCs remove more tissue overall, and as we’ll see below, this implies higher risks, including bleeding during the procedure and future pregnancy complications. Because of the higher risk of bleeding, it is done under general anesthesia.
Laser conization: This technique appeared in the 1970s with the advent of CO2 laser. It essentially replaces the scalpel with a laser, but the goal is still to excise a piece of the cervix in the shape of a cone, thereby removing ECTO- and ENDOcervix. The advantages at the time was that it was more precise, and had less bleeding since it uses energy to coagulate, but the downside of the cone remains: a large amount of tissue is removed.
LEEP (Loop Electrical Excisonal Procedure): First developed and popularized in the 1970s as electrosurgical techniques expanded in the US and commonly credited to Sheldon Weinstein, though no original publication describing the technique exists. It uses a thin electrified wire loop to remove the abnormal areas of the cervix. Because the loop is more circular shaped (rather than conical), it removes less tissue and is more superficial. It is a better technique to target lesions in the ECTOcervix. Thus, when lesions are suspected in the endocervix, a CKC or deeper LEEP may be recommended. There are different sized LEEP loops, so the surgeon can tailor how much tissue to remove depending on the pathology. However, most cervical lesions are treatable with loops that manage to remove less than 1 cm of the cervical stroma, minimizing the risk of bleeding and of future pregnancy complications.
LLETZ (Large Loop Excision of the Transformation Zone): This technique is essentially the same as a LEEP, but it was described in a paper in 1989 by Walter Prendiville from the UK. As is often the case, the Atlantic divide (and pride), made it such that the same procedure is now called LEEP in the US but LLETZ in the UK!
SWETZ (Straight Wire Excision of the Transformation Zone): Fewer people have probably heard of this newer technique (unless you’re Brazilian), but it is a variation of an electrosurgical excision (thus less bleeding) but instead of using a loop wire, the surgeon uses a straight wire to carve out a deeper excision that targets transformation zones that are not fully visible from the outside (called Type III transformation zones).

Which Procedure Is Right for Me? Factors to Consider

1. Pathology: Squamous, Glandular, Both?

Epithelial (squamous) lesions (CIN 2/3): In most cases, these can be safely treated with a LEEP, provided the lesion is well-visualized from the outside and confined to the ECTOcervix. If the lesion extends into the ENDOcervical canal, a deeper excision may be most beneficial to ensure complete removal of the pre-cancerous tissue.
Glandular lesions (adenocarcinoma in situ or suspected glandular disease): These often require a deeper excision (CKC or larger LEEP) because glandular cells are harder to assess and may extend into the ENDOcervix with a pattern called “skip lesions”.

2. Location of the lesion: The importance of colposcopy

A properly done colposcopy and surgeon experience is key to creating your treatment plan. Although there are guidelines that allow for expedited treatment directly from abnormal pap smear to excisional procedure, performing a colposcopy beforehand AND DURING the excisional procedure can help your surgeon determine the exact location of the cervical lesion.
If only the ectocervix is involved, a LEEP will suffice in treating the lesion.
In the endocervix is involved, based on biopsy or endocervical curettage, a deeper excision with a cone is recommended.
In either case, guidelines recommend that colposcopy is used during the excisional procedure so that residual lesions can be identified. Choosing a surgeon that follows these guidelines is important for your care.

3. Fertility and Pregnancy Considerations

If you are not considering carrying a pregnancy in the future, you can skip this section.

If you are, you may know that one of the most feared complications from any cervical tissue excision is increased risk of preterm birth (PTB) in future pregnancies. This is because shortening the cervix (by removing portions of it), from a baseline of ~4 cm, to let’s say 2 cm, can affect the integrity of the cervical tissue and its ability to stay closed during pregnancy. While the cervix should eventually open (dilate) in order to allow for a vaginal birth, when it opens prior to 37 weeks, we call it pre-term labor, which of course can come with complications for your baby. However, the relationship between LEEPs and PTB is not so clear, and you should NOT be afraid to get a LEEP. Here’s why:

Association vs causation; confounding by indication

First off, untreated cervical dysplasia itself is associated with a higher risk of preterm birth, even without surgery. Many studies show that women with dysplasia (and underlying HPV/viral changes) already have a somewhat higher baseline risk of preterm birth, probably due to local inflammation. Thus, comparing women with LEEP to the “general obstetric population” may overestimate the risk attributable to the procedure itself. In multiple meta-analyses, when women who underwent LEEP are compared to women who had dysplasia but no excisional procedure, the risk of PTB are the same!

Larger excisions / deeper cones correlate with higher risk

Several studies show that the deeper or larger the excision (in mm or volume), the higher the risk of PTB. For example, in one study, cone depths > 15 mm (1.5 cm) were associated with a significantly greater risk of preterm birth. Not surprisingly, in many series that compare CKC vs LEEPs, CKCs tends to have a higher observed risk of PTB due to more tissue removal.

Don’t be afraid of a small LEEP

Small, single LEEPs (<1 cm depth), done correctly, have not been shown to increase preterm birth risk when compared to women with cervical dysplasia who did not undergo surgery (Kyrgiou et al., 2014, Am J Obstet Gynecol). This is an important point if you considering foregoing the LEEP, but remember that having untreated cervical dysplasia itself predisposes you for pre-term birth, as well as for cervical cancer if the lesion persists and evolves.
Age also plays a role here, since we know people under 25 have strong immune systems that can clear lesions more readily. For people 25 or younger, with CIN2, surveillance every 6 months instead of LEEP is also an option.

If you are currently pregnant

Depending on what the colposcopy showed and how concerned your gynecologist is about invasive cancer, you will have a conversation about either undergoing an excisional procedure during pregnancy or around 6 weeks postpartum. If you decide to have it during pregnancy, a CKC will be advised over a LEEP in order to avoid electrocautery in pregnancy.

4. Anatomical considerations: The importance of an experienced surgeon

For people that have already had excisional procedures in the past, the cervix may shorten, scar, or become flush with the back of the vaginal wall. These anatomic changes may pose a challenge to a surgeon trying to use electrocautery safely, since it can increase the risk of damage to nearby organs such as the bladder, vagina or rectum. In these cases, a CKC may be preferable in order to avoid damage with thermal energy.
Another consideration for people that have had one or more excisional procedures and continue to have cervical lesions is a hysterectomy. Although this is a more involved procedure since it removes the whole uterus along with the cervix, it is oftentimes safer than attempting multiple LEEPs. This is due to the fact that as mentioned above, anatomy can become distorted after multiple excisions and LEEPs can damage nearby organs.

5. Anesthesia options: Local vs. General

If based on the above considerations you and your gynecologist decide on a deeper excisional procedure such as CKC, general anesthesia is recommended (you are fully asleep), primarily because of the higher risk of bleeding which requires better visualization, possible sutures, and preparation in the operating room.
If you are a candidate for a LEEP, you can consider undergoing the procedure under local This means you will be awake during the ~20 min procedure, and the cervix will be numbed so as to avoid sharp pain, though you may still experience cramping. While not every gynecologist is equipped to offer this option since it requires performing cervical nerve blocks, having the right equipment and the prior experience, it is an option offered by some offices in Paris. Some people may choose this option if they would like to avoid or for some reason cannot undergo general anesthesia. However, it is not for everyone, especially if your prior speculum exams or colposcopies have been painful or traumatic. The decision of local vs general anesthesia requires an in-depth discussion with your surgeon.

**What’s the Follow up after conisation?**

The good news is that a single excisional procedure can cure dysplasia in up to 92% of patients! It’s amazing considering that these are pre-cancerous lesions.
Your post-operative visit is absolutely critical, since you will review the final pathology results of the specimen removed. These results include type of lesion (CIN2/3, glandular), invasion or not (cancerous or not), and whether the margins are clear (is there residual bad tissue left behind?)
These results will determine your follow up surveillance which usually involve repeat HPV testing/ Pap smears and/or colposcopy at 6–12 months, then at longer intervals if results remain normal.
HPV vaccination can also be considered as an adjuvant therapy to help clear the lesion given some newer research on this topic, but for this you should consider seeing a gynecologist specialized in HPV.

A Patient-Centered Perspective

It is normal to be anxious when facing cervical surgery, especially if you hope to have children in the future and don’t understand the terminology in French. The good news is that modern approaches emphasize tailored, conservative treatment. In the majority of cases, a LEEP removes all abnormal cells while preserving healthy cervical tissue. Asking your gynecologist about their surgical approach, excision depth, and use of colposcopy ensures that you remain in control of your health decisions. From a patient’s perspective, it’s quite reasonable to ask your surgeon:

“What technique will you use?” (loop vs cold-knife vs laser)
“How deep will you go?” (ask for expected mm of depth)
“Will colposcopy be used simultaneously to guide precise excision of abnormal areas?”
“What is the plan for follow-up and margins?”
“Am I a candidate for HPV vaccination?”

Conclusion

If you live in Paris as an expat and are told you need a conisation, remember: not all conisations are the same. For most patients, a simple LEEP is safe, effective, and fertility-preserving. Glandular lesions may require a deeper cone, but even then, careful technique helps minimize risks. Always discuss the surgical approach with your gynecologist to ensure the best balance between cure and future pregnancy outcomes.

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