42
Članek prispel / Received
24. 7. 2019
Članek sprejet / Accepted
1. 4. 2021
Abstract
Purpose: To evaluate the effect of a 
modified vaginal microbiota containing 
various vaginal pathogens and Chlamy-
dia trachomatis on postoperative blee-
ding following large loop excision of the 
transformation zone (LLETZ) of the 
uterine cervix. 
Methods: We performed a retrospective 
analysis of patients with cervical intraepi-
thelial neoplasia (CIN) who underwent 
LLETZ at the Clinic for Gynaecology 
and Obstetrics, UMC Maribor, between 
1993 and 2005. Cervical swabs were 
collected before the procedure to evaluate 
the presence of Chlamydia trachomatis 
and other genital pathogens. After the 
Izvleček
Namen: Z raziskavo smo želeli ugo-
toviti, ali spremenjena mikrobiota no-
žnice s simultano prisotnimi različnimi 
genitalnimi patogeni in klamidijo tra-
homatis vpliva na incidenco in jakost 
pooperativne krvavitve po široki eksci-
ziji transformacijske cone materničnega 
vratu z diatermijsko zanko (angl. large 
loop excision of the transformation zone 
- LLETZ). 
Metode: Izvedli smo retrospektivno 
analizo bolnic, pri katerih smo na Kli-
niki za ginekologijo in perinatologijo 
Univerzitetnega kliničnega centra Ma-
ribor v letih od 1993 do 2015 naredili 
LLETZ. Brisi na patogene bakterije in 
Ključne besede: 
genitalni patogeni, 
klamidija trahomatis, 
ekscizija transformacijske cone 
z zanko (LLETZ), pooperativna 
krvavitev.
Key words: 
Genital pathogens; Chlamydia 
trachomatis; Large loop excision of 
the transformation zone (LLETZ); 
Postoperative bleeding.
Vloga spremenjene mikrobiote nožnice na 
pojavnost pooperativne krvavitve po eksciziji 
transformacijske cone z električno zanko (LLETZ)
The role of modified vaginal microbiota on 
postoperative bleeding following large loop 
excision of the transformation zone (LLETZ)
Avtor / Author Darja Arko1,2, Tomaž Rojko3, Andrej Cokan1, Ivan Žebeljan4, Iztok 
Takač1,2
Ustanova / Institute 1Univerzitetni klinični center Maribor, Klinika za ginekologijo in perinatologijo, Oddelek 
za ginekološko onkologijo in onkologijo dojk, Maribor, Slovenija; 2Univerza v Mariboru, 
Medicinska fakulteta, Katedra za ginekologijo in porodništvo, Maribor, Slovenija; 3Univerzitetni 
klinični center Maribor, Oddelek za patologijo, Maribor, Slovenija;  4Zdravstveni dom Lenart, 
Dispanzer za ženske, Lenart, Slovenija.
1University Medical Centre Maribor, Clinic for Gynaecology and Obstetrics, Department for 
Gynaecological Oncology and Breast Oncology, Maribor, Slovenia; 2University of Maribor, 
Faculty of Medicine, Department for Gynaecology and Obstetrics, Maribor, Slovenia; 
3University Medical Centre Maribor, Department for Pathology, Maribor, Slovenia; 4Health 
Centre Lenart, Clinic for Women, Lenart, Slovenia;
Klinična študija / Clinical study
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2021; 14 (1): 25–37
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INTRODUCTION
Cervical intraepithelial neoplasia (CIN) is the most 
common premalignant condition of the uterine cervix. 
This condition involves atypical squamous changes 
of the transformation zone, located between the 
endocervix, covered by the glandular epithelium, and 
the ectocervix that is covered by squamous epithelium. 
The Lower Anogenital Squamous Terminology (LAST) 
Project published in 2012, divided premalignant 
conditions into low-grade (LSIL) and high-grade 
squamous intraepithelial lesions (HSILs) (1, 2). The 
major etiological agent underlying cervical precancer and 
cancer is human papillomavirus (HPV) (3, 4). Neither 
the collection of data on new cases of HPV infection, nor 
changes in the proportion of people infected with HPV, 
are incorporated in the epidemiological monitoring of 
sexually transmitted infections in Slovenia. However, 
data from 2010 showed that at least 59.2% of women 
had been infected with HPV once in their lifetime 
with at least one of the high-risk HPV genotypes (5). 
On the other hand, we also know that 80 - 90% of 
vaginal infections are caused by various pathogens and 
that the most commonly reported sexually transmitted 
bacterial infection in Slovenia in 2016 was Chlamydia 
trachomatis (246 cases; 11.9/100.000 inhabitants) 
(5, 6). Therefore, we suspected that a proportion 
of women with CIN will also be infected either by 
vaginal pathological microorganisms or by Chlamydia 
trachomatis. Studies have shown that local excisional 
treatment appears to alter the cervical microbiota 
towards a less diverse microbiota and also that women 
Naslov za dopisovanje /  
Correspondence
Asist. Andrej Cokan, dr. med., 
Univerzitetni klinični center Maribor, 
Klinika za ginekologijo in perinatologijo, 
Oddelek za ginekološko onkologijo in 
onkologijo dojk, Ljubljanska ulica 5, 
2000 Maribor, Slovenija
Telefon: +386 23212195
E-pošta: cokan.andrej@gmail.com
klamidijo trahomatis so bili odvzeti pred 
posegom. Po operativnem posegu so bol-
nice izpolnile vprašalnik, v katerem so 
ocenjevale trajanje in intenziteto krvavi-
tve iz nožnice.
Rezultati: V raziskavo smo vključili 
192 bolnic. Spremenjeno mikrobioto 
s simultano prisotnimi genitalnimi 
patogeni in klamidijo trahomatis je 
imelo 5,2 % bolnic. Med genitalnimi 
patogeni smo največkrat izolirali strep-
tokok skupine B in kandido. Pojavnost 
pooperativne krvavitve po LLETZ ni 
bila različna med skupinama z ali brez 
spremenjene mikrobiote s simultano pri-
sotnimi genitalnimi patogeni in klami-
dijo trahomatis (50,0 % proti 37,9 %, 
p-vrednost = 0,512).
Zaklju~ek: Spremenjena vaginalna mi-
krobiota s simultano prisotnimi različnimi 
genitalnimi patogeni in klamidijo traho-
matis je pogosta pri bolnicah s cervikalno 
intrapeiteljisko neoplazijo (CIN), vendar 
ne povzroča povečane pojavnosti poopera-
tivne vaginalne krvavitve po LLETZ.
procedure, the occurrence and severity of 
postoperative bleeding was evaluated. 
Results: A total of 192 patients were 
recruited. A modified vaginal microbiota 
containing various vaginal pathogens 
and Chlamydia trachomatis was present 
in 5.2% of patients. The most frequen-
tly isolated groups of vaginal pathogens 
were group B streptococcus and Candida 
species. The occurrence of postoperative 
bleeding after LLETZ did not differ si-
gnificantly when compared between gro-
ups with or without a modified vaginal 
microbiota containing various vaginal 
pathogens and Chlamydia trachomatis 
(50.0% vs. 37.9%, p = 0.512).
Conclusion: Patients with cervical in-
traepithelial neoplasia (CIN) commonly 
exhibit a modified vaginal microbiota 
containing various vaginal pathogens 
and Chlamydia trachomatis. However, 
this is not an important risk factor for 
postoperative bleeding after LLETZ.
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with CIN have a more diverse cervical microbiota than 
women with normal cervical cytology (7). The most 
common surgical method for treating CIN at present is 
large loop excision of the transformation zone (LLETZ). 
However, this procedure is associated with a range of 
postoperative complications, including pain, discharge, 
and bleeding. In the present study, we analyzed the 
effects of a modified vaginal microbiota containing 
various vaginal pathogens and Chlamydia trachomatis 
on the prevalence of postoperative bleeding after 
LLETZ.
MATERIALS AND METHODS 
This was a retrospective study of patients with CIN 
who underwent LLETZ between 1993 and 2015 at the 
Department for Gynaecological Oncology and Breast 
Oncology, University Medical Centre (UMC) Maribor, 
Slovenia. All patients had been histologically diagnosed 
with CIN via the analysis of specimens obtained by 
punch biopsy. 
Prior to LLETZ, all patients were asymptomatic for 
vaginal infection. To evaluate the presence of Chlamydia 
trachomatis and other genital pathogens (anaerobes, 
Streptococcus groups A–G, coliforms, Staphylococcus 
aureus, Neisseria gonorrhoeae, Trichomonas vaginalis, 
and Candida species) we took microbiological swabs 
from the vagina and uterine cervix using cotton-tipped 
swabs inserted in medium (UNI-TER AMIES CLR, 
Piove di Sacco, Italy) and rayon sterile dry swabs with 
a regular tip (162C, Copan, Brescia, Italy), respectively. 
First, the patients were given a local anesthetic (1% 
lidocaine). Then,  the LLETZ procedure was carried 
out  with an Elektrotom 400 Unit (Berchtold, Berlin, 
Germany) with loops ranging in size from 10 mm to 
20 mm. The excision was performed using a bipolar 
current with a cut frequency set to 40 W. In addition, 
the wound surface was coagulated with a coagulation 
frequency from 20 W to 40 W.
Following the procedure, we monitored patients for 
the occurrence and severity of postoperative bleeding. 
Patients were asked to record any bleeding on a daily 
basis for the first 90 days following the procedure. Daily 
bleeding was subjectively scored as none (0), mild (1), 
moderate (2), or severe (3). Patients were instructed 
to mark the occurrence of postoperative bleeding 
in a questionnaire that was given to them when they 
were discharged from the hospital (Figure 1). Each 
questionnaire related to a thirty-day period; thus, 
patients received three questionnaires each. Three 
months after the procedure, each patient was invited 
for a checkup during which gynecological examination 
was performed and a cervical smear was taken. 
Fisher's exact test was used to compare categorical 
data between groups of patients with modified vaginal 
microbiota containing various vaginal pathogens and 
Chlamydia trachomatis and patients without this 
modification. A statistically significant difference in the 
occurrence of postoperative bleeding between groups 
was defined as when p < 0.05. We did not perform a 
sample size calculation because this was a retrospective 
study and because parameters were provided by post-
hoc analysis.
RESULTS 
Our analysis included 192 patients. Modified vaginal 
microbiota containing various pathogens and Chlamydia 
trachomatis was present in 5.2% (10/192) and absent 
in 94.8% (182/192) of patients. In patients without 
such changes in the vaginal microbiota, 3.7% (7/182) 
of patients only showed Chlamydia trachomatis; in 
45.3% (87/182) of cases, only other genital pathogens 
were present. In 45.8% (88/182) of patients, the cervical 
swabs were negative. The most frequently isolated groups 
of genital pathogens were α-hemolytic and group B 
ß-hemolytic streptococcus and Candida species (Table 
1). The incidence of postoperative bleeding among our 
study cohort is shown in Table 2, while the severity of 
bleeding (mild, moderate or severe) is shown in Table 
3. Combined postoperative bleeding (subjectively 
scored as mild, moderate or severe) was present in 
50.0% (5/10) of the patients with a modified vaginal 
microbiota containing various pathogens and Chlamydia 
trachomatis, and in 37.9% (69/182) of patients who did 
not show these changes. The difference between these 
two groups was not statistically significant (50% vs. 
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37.9%; p = 0.512), although the absolute difference in 
the occurrence of postoperative bleeding exceeded 10%.
DISCUSSION 
In this retrospective study, patients who had modified 
vaginal microbiota containing various pathogens and 
Chlamydia trachomatis did not experience significantly 
higher levels of postoperative bleeding after LLETZ 
than patients without such changes in their vaginal 
microbiota (50% vs. 37.9%; p = 0.512). However, 
this finding should be interpreted with caution, since 
the number of patients in the first subgroup was very 
low and in the latter group, there were only 45.8% of 
patients with negative cervical swabs. Furthermore, 
the period used to record postoperative bleeding was 
Figure 1: The questionnaire used by patients for marking the occurrence of postoperative 
bleeding after LLETZ. 
 
Table 
1 . Types 
o f 
 9
Figure 1. The questionnaire used by patients for 
marking the occurrence of postoperative bleeding 
after LLETZ.
Table 1. Types of genital pathogens in patients with 
cervical intraepithelial neoplasia (n = 143)
Pathogen No. (%)
Group B ß-hemolytic Streptococcus 24 (16.8)
α-hemolytic Streptococcus 20 (14.0)
Candida 18 (12.6) 
Chlamydia trachomatis 17 (11.8) 
Gardnerella vaginalis 15 (10.5)
Enterococcus species 12 (8.4)
Diphtheroids 11 (7.7)
Coagulase-negative Staphylococcus 11 (7.7)
Escherichia coli 10 (7.0)
Atropine (mg) 10 (7.0)
Staphylococcus aureus   3 (2.1)
Haemophilus species   2 (1.4)
quite long (90 days). From this dataset, were unable 
to  ascertain whether all of the patients recorded just 
postoperative bleeding; it is possible that some patients 
also recorded menstrual bleeding, especially after the 
30 day timepoint post-LLETZ. 
The severity and distribution of bleeding was 
interesting; although 50% of patients with a modified 
vaginal microbiota containing various pathogens 
and Chlamydia trachomatis reported postoperative 
bleeding, this was minimal in all cases. However, in the 
group who did not show such changes in their vaginal 
microbiota, 12.1% and 7.1% of patients experienced 
moderate and severe postoperative bleeding, 
respectively. 
In a previous study, we investigated the role of genital 
pathogens in morbidity following LLETZ and found 
that that genital pathogens or Chlamydia trachomatis 
alone did not have a significant effect on postoperative 
morbidity, including postoperative bleeding (8-10). 
Sarkar et al. also came to the same conclusion and 
found no statistically significant difference in the mean 
duration of bleeding after LLETZ in two study groups 
Figure 1: The questionnaire used by patients for marking the occurrence of postoperative 
bleeding after LLETZ. 
 
Table 
1 . Types 
o f 
 9
Figure 1: The questionnaire used by patients for markin  the occurrence of postoperative 
bleeding after LLETZ. 
 
Table 
1 . Types 
o f 
 9
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(genital pathogens present or absent), although the mean 
duration of bleeding, graded by the patient as being 
moderate to severe, did differ significantly between 
the two groups, thus. suggesting that  prophylactic 
antibiotic therapy may be useful for such cases (11). On 
the other hand, Chan et al. concluded that the use of 
routine prophylactic topical antibiotics should not be 
recommended for the general population since it is not 
possible to identify subgroups of women with positive 
vaginal or endocervical swabs prior to the procedure 
because swabs are not routinely taken (12).
Nevertheless, genital pathogens are very common 
among patients with CIN and could also represent 
an important co-factor that prevents the spontaneous 
clearance of HPV and contributes to the progression 
towards neoplasia, although their specific role in 
cervical carcinogenesis has yet to be elucidated (13-
15). In our study, 50.1% of patients tested positive for 
genital pathogens, although it is important to note that 
inflammatory changes and symptoms do not necessarily 
occur in women who are asymptomatic carriers or 
have modified vaginal microbiota. This means that 
these symptoms are not good indicators for a modified 
vaginal microbiota (16). Data from the literature 
report a relatively high incidence and prevalence of 
asymptomatic chlamydial infection (). However, there 
are also data to suggest that chlamydial infection is 
not an important risk factor for the development or 
promotion of CIN; indeed, chlamydial infection is 
not commonly detected in patients with CIN (17-20). 
In our study, chlamydial infection was present in only 
8.9% of patients with CIN.
The major limitations of this report are the retrospective 
nature of the study, the small number of patients 
included, and the subjective assesment of the occurrence 
and severity of postoperative bleeding. Furthermore, 
the number of cases with simultaneous infection was 
much smaller than those without infection; this may 
have affected the validity of our results. It is possible 
that these limitations may have restricted the statistical 
analysis. Further analyses, involving larger sample sizes 
from prospective studies, are now needed to confirm 
our findings.
Table 2. The incidence of postoperative bleeding among a 
group of patients with modified vaginal microbiota containing 
various vaginal pathogens and Chlamydia trachomatis and 
a group of patients without such changes in the vaginal 
microbiota following LLETZ (n = 192).
Postoperative 
bleeding
Various 
vaginal 
pathogens and 
Chlamydia 
trachomatis 
present
 [No. (%)]
Various 
vaginal 
pathogens and 
Chlamydia 
trachomatis 
not present 
[No. (%)]
Total [No. 
(%)]
Absent   5 (50.0) 113 (62.1) 118 (61.5)
Present   5 (50.0)   69 (37.9)   74 (38.5)
Total 10 (100.0) 182 (100.0) 192 (100.0)
Large loop excision of the transformation zone (LLETZ); p = 0.512
Table 3. The severity of postoperative bleeding in a group of 
patients with modified vaginal microbiota containing various 
vaginal pathogens and Chlamydia trachomatis and a group 
of patients without such changes in the vaginal microbiota 
following LLETZ (n = 192). 
Severity
Vaginal 
pathogens and 
Chlamydia 
trachomatis 
present [No. 
(%)]
Vaginal 
pathogens and 
Chlamydia 
trachomatis not 
present [No. 
(%)]
Total [No. 
(%)]
Absent   5 (50.0) 113 (62.1) 118 (61.5)
Minimal   5 (50.0) 34 (18.7) 39 (20.3)
Moderate 0 (0.0) 22 (12.1) 22 (11.5)
Severe 0 (0.0) 13 (7.1) 13 (6.8)
Total 10 (100.0) 182 (100.0) 192 (100.0)
Large loop excision of the transformation zone (LLETZ)
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CONCLUSIONS 
A modified vaginal microbiota containing genital 
pathogens and Chlamydia trachomatis does not play a 
specific role in the postoperative bleeding experienced 
after LLETZ and it is not an important risk factor for 
such bleeding. Our results suggest that routine testing 
with microbiological cervical swabs prior to LLETZ, or the 
routine use of prophylactic topical antibiotics, should not 
be  recommended for the general population.
FUNDING 
This research received no specific grant from any funding 
agency in the public, commercial and not-for-profit sectors.
DECLARATION OF CONFLICTING 
INTERESTS 
None of the authors have any conflicts of interest to 
declare. 
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