Cone biopsy of the cervix: the procedure, recovery, bleeding and follow-up

A cone biopsy (conisation) is a procedure in which the gynaecologist removes a small cone-shaped part of the cervix. The part removed is the area where the cells have changed. This is usually the transformation zone, the border area between the outer part of the cervix and the cervical canal, because this is where cell changes most often develop.

A cone biopsy has two aims. The first is to remove the abnormal tissue. The second is to examine the whole sample under a microscope, so the doctor gets a more complete result than after a small biopsy.

The procedure can be done in several ways: with a conventional surgical scalpel (known as a cold knife), with a thin electrical or radiofrequency wire loop (loop excision or LLETZ, which many people call a “radio knife”) or with a laser. The doctor decides which method to use and how much of the cervix needs to be removed based on your results, your age and your plans for pregnancy.

Laser vaporisation is not the same as a cone biopsy. It destroys the abnormal tissue with a laser, but no sample is obtained for examination, so it is used only for selected results.

A cone biopsy usually comes after several steps. First, a Pap smear or HPV test shows an abnormality. Then colposcopy, an examination of the cervix under magnification, is carried out, with a biopsy if needed. The histopathology report from the biopsy describes the changes as CIN (cervical intraepithelial neoplasia), in three grades: - CIN 1: mild changes. They often go away on their own, so they are usually monitored with follow-up appointments. - CIN 2: moderate changes. The doctor assesses whether monitoring or a procedure is the better option, depending on your age, your results and your plans for pregnancy. - CIN 3: severe changes. Removal of the abnormal part of the cervix is usually suggested.

Some reports also use the terms LSIL and HSIL. LSIL means milder changes (usually corresponding to CIN 1), and HSIL means more significant changes (CIN 2 and CIN 3).

A cone biopsy is also used for more precise diagnosis: when the whole transformation zone cannot be seen on colposcopy, when the Pap smear and biopsy results do not match, or when changes in the glandular cells of the cervix are suspected.

CIN is not cancer. These are cell changes that, in some women, can develop into cervical cancer over several years if they are not treated. That is why they are detected and removed in good time. They are almost always linked to a long-lasting infection with high-risk types of HPV.

Before the procedure, the gynaecologist examines you and explains why a cone biopsy is being suggested and which method will be used. Basic blood tests are usually needed, and sometimes swabs. Tell the doctor which medicines you take, especially blood thinners, whether you have any allergies and whether there is any chance you could be pregnant. Do not stop taking blood thinners on your own. The doctor will tell you whether anything needs to be changed temporarily, and when. The appointment is usually booked outside your period, most often in the days after it.

A cone biopsy is done under a local anaesthetic or a short intravenous (general) anaesthetic, depending on the method and the doctor's assessment. If it is done under a general anaesthetic, you will be told how many hours before the procedure you should stop eating and drinking. The procedure itself usually takes 15 to 30 minutes. You lie in the same position as for a gynaecological examination, and the doctor removes the abnormal part of the cervix and stops the bleeding. Sometimes, during the same procedure, the doctor also takes a sample from the cervical canal (curettage), and both samples are examined together.

After the procedure you rest for a short time and the bleeding is checked. The doctor will tell you how long you will stay in hospital. After a general anaesthetic, do not drive or drink alcohol for at least 24 hours, and arrange for someone to take you home. The prices of cone biopsy, loop excision and histopathological analysis of the removed tissue are in the Maja Hospital gynaecology price list. Tissue analysis is listed as a separate item in the price list, so when booking, ask what the price of the procedure includes.

After a cone biopsy, a wound remains on the cervix that takes several weeks to heal. That is why bleeding and discharge are expected. In the first few days there is usually light bleeding and period-like pain. After that, the discharge may be brown, pink or watery. If the doctor has applied a solution to the wound to stop the bleeding, the discharge may be dark brown or granular in the first few days, which is expected. Discharge can last for several weeks, sometimes up to six weeks.

In some women, the bleeding becomes heavier again around day 7 to 14, when the scab comes away from the wound. If it is moderate and gradually eases, it is usually part of normal healing. During this time, use sanitary pads, not tampons.

Contact your doctor without delay if you have: - heavy, bright red bleeding, heavier than a heavy period, or large clots - foul-smelling discharge - a temperature of 38 °C or higher, or chills - pain in the lower abdomen that does not go away or gets worse

If you soak through a pad in less than an hour, or you feel dizzy, weak or faint, call the emergency medical service on 194 or go to the nearest emergency department. Do the same if the bleeding is heavy and you cannot reach your gynaecologist quickly, for example at night or at the weekend.

Your first period after a cone biopsy usually comes at the expected time, but it may come a few days earlier or later. It is often heavier, longer or more painful than usual. This is usually temporary, and periods mostly return to how they were before the procedure after one or two cycles.

During your first period after the procedure, also use pads, not tampons or menstrual cups, until the doctor tells you otherwise. If your period does not come, becomes very painful or is extremely heavy, contact your gynaecologist. Rarely, the cervix narrows after the procedure, making it harder for menstrual blood to flow out. The doctor can check this at an examination.

Recovery after a cone biopsy usually takes a few weeks, until the cervix has fully healed. Most women feel well after just a few days, but the wound on the cervix needs more time. The usual advice is: - no sex for about four weeks, or for as long as the doctor advises - no tampons, menstrual cups or vaginal douching - showers instead of baths; no swimming pools, swimming in the sea or saunas for about four weeks - no heavy lifting or strenuous exercise for at least the first two weeks, and often longer after a cold knife cone biopsy, as the doctor advises - walking and light housework are usually fine

Most women go back to work after a few days to two weeks. This depends on the type of work, the type of procedure and the doctor's advice. For pain, a painkiller recommended by the doctor is usually enough. Do not choose a painkiller yourself, because some painkillers can increase bleeding.

The removed part of the cervix is sent for histopathological examination, together with the sample from the cervical canal, if one was taken. The report describes the grade of the changes and, importantly, the edges of the sample (margins). If the edges are clear of changes, the abnormal tissue has most likely been removed completely. If the changes reach the edge, the doctor usually suggests more frequent follow-up, and less often a repeat procedure.

Sometimes the cone biopsy result shows a milder or more severe grade of change than the biopsy before the procedure. Rarely, it shows an early form of cervical cancer. In that case, the gynaecologist explains what the result means and what the further treatment plan is. How long you wait for the result depends on the laboratory. Ask the doctor when the result will be ready and how to collect it when you book or on the day of the procedure.

The first follow-up appointment is usually a few weeks after the procedure. At this appointment, the doctor checks how the cervix is healing and explains the result. The next check, usually a Pap smear, an HPV test and colposcopy if needed, is usually done about six months after the procedure. The schedule after that depends on the results. Regular check-ups remain important for years afterwards, because the changes can come back.

Most women can get pregnant and carry a pregnancy to term after a cone biopsy. The procedure involves only the cervix, not the ovaries or the body of the womb. When part of the cervix is removed, it becomes slightly shorter. That is why, after a cone biopsy, there is a slightly higher risk of premature birth and, less often, of late miscarriage (in the second trimester), especially after deeper or repeated procedures.

Planning a pregnancy is usually put off until the cervix has healed and the first follow-up and results are normal. The gynaecologist will advise exactly how long to wait. During pregnancy, it is important that the doctor looking after you knows about your previous cone biopsy. They can then monitor the length of the cervix with ultrasound and, if they think it necessary, suggest additional measures, such as a cervical cerclage (a stitch in the cervix).

A cone biopsy is usually not done during pregnancy. The exception is rare situations in which the doctor judges the procedure to be essential.