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An Alternative Treatment for Cervical Intraepithelial Neoplasia II, III

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This report describes a case of a woman with progressive and recurrent cervical dysplasia 4 years after cervical conization for severe dysplasia. A 20-year-old female was referred for colposcopy and biopsy following results of moderate to severe atypia of cervical cells on her Papanicolaou (Pap) test. Her colposcopy was satisfactory and her biopsy revealed cervical intraepithelial neoplasia (CIN) II, III. She refused the conventional recommendation of loop electrosurgical excision procedure (LEEP) and, as an alternative, elected to receive escharotic treatment at a frequency of 2 treatments per week for 5 weeks. In addition to the escharotic treatment she followed an oral vitamin and botanical protocol. She was followed for 5 years. The patient's 4-month and 10-month follow-up Pap smears revealed negative cervical cytology for intraepithelial lesion or malignancy. Her 10-month colposcopy was satisfactory and no lesions were noted on the colposcopic exam. Liquid based Pap results continued to remain normal for 5 years after the initiation of treatment. Escharotic treatment of high-grade cervical neoplasias with satisfactory colposcopy holds promise as an effective and low-risk alternative therapy to LEEP and other excisional procedures.
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164
laser ablation, electrofulguration, and cold coagulation)
and excisional (loop electrosurgical excision procedure
[LEEP], cold-knife conization, laser conization, and elec-
trosurgical needle conization) treatments may be imple-
mented in biopsy-confirmed CIN II, III lesions; however,
only excisional therapies are acceptable treatment options
with unsatisfactory colposcopy.2 In either case, the entire
transformation zone must be removed for the treatment
to be effective.2-5
In consideration of appropriate treatment modalities,
a satisfactory colposcopy indicates both excisional and
ablative procedures are acceptable. Previously, LEEP was
preferable to cold-knife conization because it does not
require general anesthesia and the excised tissue can be
used for diagnostic as well as therapeutic purposes. Also,
it was believed in the early 1990’s that LEEP did not have
the risks on future pregnancies that were linked to cold-
knife conization, including preterm labor, low birth-
weight infants, and cesarean section.3 Emergent research
has demonstrated an association between LEEP and
increased risk of preterm birth, premature rupture of
membranes associated with the increased depth of tissue
removed during the procedure,4 overall increased risk of
preterm delivery, and low birth weight infants.6 The
increased risk of spontaneous preterm birth has been
linked to a short cervical length independent of biological
or postprocedure nature.7 This implies a causal relation-
ship between the degree of invasiveness of a cervical
procedure and the risk of pregnancy complications. Since
The purpose of women’s annual Papanicolaou (Pap)
testing is to detect cytological abnormalities of the
cervix, which can indicate cervical disease. This
screening test has helped in early detection of cervical
dysplasia, which is associated with the sexually transmit-
ted human papillomavirus (HPV) infection. Exposure
to HPV is directly linked to the development of cervical
dysplasia and found in up to 95% of all cervical squa-
mous cell cancers.1 In 2006, the American Society for
Colposcopy and Cervical Pathology (ASCCP) issued an
updated consensus for the management and treatment of
cervical cytological abnormalities. These guidelines act as
the professional standard of care for management of
women with cervical intraepithelial neoplasia (CIN) or
adenocarcinoma in situ (AIS).2 Histological classification
of CIN is a 2-tiered system based on severity: CIN 1 indi-
cates low-grade lesions, while CIN II, III indicate high-
grade lesions.2 The severity of histological diagnosis, used
in combination with colposcopic findings, acts as the
standard for determining clinical management. While
spontaneous regression rates are high with CIN 1, ASCCP
recommends treatment to reduce incidence and mortality
from invasive cervical cancer in cases of CIN II, III.2
With a satisfactory colposcopy, both ablative (cryotherapy,
Background. This report describes a case of a woman with
progressive and recurrent cervical dysplasia 4 years after
cervical conization for severe dysplasia. Patient and methods.
A 20-year-old female was referred for colposcopy and biopsy
following results of moderate to severe atypia of cervical cells
on her Papanicolaou (Pap) test. Her colposcopy was satisfac-
tory and her biopsy revealed cervical intraepithelial neoplasia
(CIN) II, III. She refused the conventional recommendation
of loop electrosurgical excision procedure (LEEP) and, as an
alternative, elected to receive escharotic treatment at a fre-
quency of 2 treatments per week for 5 weeks. In addition to
the escharotic treatment she followed an oral vitamin and
botanical protocol. She was followed for 5 years. Results. The
patient’s 4-month and 10-month follow-up Pap smears
revealed negative cervical cytology for intraepithelial lesion
or malignancy. Her 10-month colposcopy was satisfactory
and no lesions were noted on the colposcopic exam. Liquid
based Pap results continued to remain normal for 5 years
after the initiation of treatment. Discussion. Escharotic treat-
ment of high-grade cervical neoplasias with satisfactory
colposcopy holds promise as an effective and low-risk alter-
native therapy to LEEP and other excisional procedures.
Keywords: cervical dysplasia; complementary and alterna-
tive medicine; herbs; botanical medicine; escharotic; LEEP
alternative
From the Natural Health Center, National College of Natural Medicine,
Portland, Oregon. Address correspondence to: Heather Zwickey, PhD,
Natural Health Center, National College of Natural Medicine, 2220
SW First Ave, Portland, OR 97210; e-mail: hzwickey@ncnm.edu.
Integrative Cancer Therapies
Volume 8 Number 2
June 2009 164-167
© 2009 The Author(s)
10.1177/1534735409335504
http://ict.sagepub.com
An Alternative Treatment for Cervical
Intraepithelial Neoplasia II, III
Summer Swanick, BS, Kimberly Windstar-Hamlin, MEd, ND, and Heather Zwickey, PhD
Alternative Treatment for Cervical Intraepithelial Neoplasia / Swanick et al 165
the ASCCP considers both ablative and excisional proce-
dures to have similar efficacy in eliminating CIN and
reducing the risk of progression to invasive cervical can-
cer, more research on ablative options and their potential
risks and benefits is warranted, especially for women in
their reproductive years.
Escharotic treatment is an ablative therapy that has
been used to treat cervical dysplasia in women with a
satisfactory colposcopy who have refused the recom-
mended conventional treatments. An escharotic agent is
a substance that is corrosive to flesh and burns on physi-
cal contact causing sloughing of the tissues. The resultant
scab is known as an eschar. Escharotic treatment involves
the application of a caustic paste to superficial tissues to
obliterate neoplastic growth and to allow healthy growth
to occur. When performed by a licensed and appropri-
ately trained health care professional, this procedure is
believed to have positive outcomes and is accompanied by
an oral protocol of immune-enhancing and anticarcino-
genic supplements. The criticism of such treatments in
medical literature generally addresses cases where indi-
vidual patients refused the medical standard of care treat-
ment in favor of self-prescribed, unsupervised treatment
with an escharotic concoction purchased by the patient
through the Internet.8,9
This report provides evidence for the efficacy of escha-
rotic treatment for CIN II, III in a case of recurrent, high-
grade neoplasia following conventional cervical conization.
The strength of this case emphasizes the need for clinical
research to explore the long-term effectiveness and poten-
tial risks of escharotic treatment for cervical dysplasia.
Currently, there is no information in medical literature on
long-term safety or complications that can be expected
from this ablative procedure.
Patient and Methods
A 20-year-old Caucasian female was referred to our
naturopathic clinic for colposcopy and biopsy after abnor-
mal Pap smear results from her conventional physician in
October 2002 revealed CIN II, III (moderate to severe
dysplasia), high-grade squamous intraepithelial lesions
(HSIL) with endocervical material present. She had a his-
tory of a cone biopsy for severe dysplasia dating back
4 years prior to her present visit, as well as present genital
warts and vulvar HPV lesions with pruritis. She had sev-
eral risk factors for cervical dysplasia, including early age
of first intercourse, >3 new sexual partners in the past
12 months and 15 total partners, and a 6-year history of
tobacco use. She had a history of 1 pregnancy, 1 abortion,
and 0 live births. She had a family history of breast can-
cer, lymphoma, cervical cancer, and systemic lupus ery-
thematous. Her vitals were within normal limits and
remained so throughout her treatment at our clinic. Her
colposcopy revealed a satisfactory exam with endocervical
speculum, which allowed her to be a candidate for escha-
rotic treatment. White epithelium 1-3+, fine mosaicism,
course mosaicism, and course punctuation were noted on
the colposcopic exam. The cervical biopsy revealed benign
material and mild acute inflammatory processes in the
endocervical canal (ECC), though moderate to focal
severe dysplasia (CIN II, III) was found on the cervical
biopsies with extension into the glands.
We recommended that she have a LEEP for her CIN
II, III as per ASCCP guidelines for standard of care at the
time of assessment. The patient refused the recom-
mended surgical procedure. She was unwilling to have
another surgical procedure after her experience with the
cone biopsy and signed a refusal of medical treatment
form. The patient was given information on the escha-
rotic treatment as an alternative, and opted to begin treat-
ment the following month. In addition to the escharotic
treatment, she was given the oral immune supporting and
anticarcinogenic HPV protocol (see Table 1).
The escharotic treatment protocol used in this case
study is a 4-step process, which takes a total of approxi-
mately 20 minutes per visit, 2 visits per week for 5 weeks.
(See Table 2)
Results
The patient received a total of 10 escharotic treat-
ments at a frequency of 2 treatments per week, each
treatment taking 20 minutes. Adverse symptoms reported
included cramping, burning and stinging pain, and spot-
ting. All were temporary and self-resolving symptoms that
may occur with this treatment. One month following the
completion of her escharotic treatments she returned to
clinic for a follow-up. A liquid based Pap was collected
and testing for high risk HPV was performed. Pap results
were satisfactory for interpretation and showed ASC-US.
HPV was suspected, however, she was negative for high-
risk types of HPV. Two small areas of white epithelium 1+
and fine mosaicism were noted on satisfactory colposcopic
Table 1. Oral HPV Protocol
Supplement Dosage
Folic acid10,11 10 mg per day
Vitamin C12 6 g per day
Beta carotene, natural mixed carotenoids13,14 150 000 IU per day
Green tea extract15,16 500 mg per day
Indole-3-carbinol17,18a 200 mg per day
Antiviral HPV tinctureb60 drops 3 times per day
a Based on emergent research, the current protocol replaces indole-3-carbinol
with diindolylmethane (DIM) 300mg.19
b 2 parts echinacea, 2 parts hypericum, 1 part mahonia, 1 part lomatium, 1 part
thuja, and 1 part thymus.
166 Integrative Cancer Therapies / Vol. 8, No. 2, June 2009
examination, and no biopsies were taken. The patient was
instructed to continue all of her oral supplement treat-
ments and return to the office in 3 months for a colpos-
copy for conservative evaluation of response to escharotic
treatment and a repeat Pap in 4 to 6 months.
In 3 months the patient returned for her follow-up
colposcopy. The colposcopy was satisfactory, revealing
resolution of the fine mosaicism and only 1 area of white
epithelium 1+, demonstrating a positive response to the
treatment. The patient was instructed to continue her
oral protocol supplements and return to our clinic in
2 months for a follow-up Pap.
In 4 months the patient returned for her follow-up
Pap and annual exam. She continued to take her supple-
ments. The colposcopy was satisfactory, and a single
locale of white epithelium 1+, demonstrating a progres-
sive decrease in area since the last visit, was observed on
the colposcopic visual exam. Her annual exam was
performed and a liquid Pap was collected. The results
from the liquid based Pap showed cervical cytology nega-
tive for intraepithelial lesion or malignancy. The patient
was recommended to return to our clinic for a repeat Pap
in 4 to 6 months.
In 10 months the patient returned for her follow-up
Pap. She continued to take her oral supplements and was
feeling well. Her colposcopy was satisfactory and no
lesions were noted on the colposcopic exam. The repeat
Pap test was performed and the results from the liquid-
based Pap revealed negative cervical cytology for intraepi-
thelial lesion or malignancy. The patient was to return to
the clinic in 1 year for her Pap and annual exam.
The patient returned to the clinic for her annual Pap
smear 5 years after her initial visit. Her liquid based Pap
results were normal.
Discussion
The current recommended guidelines for treatment of
CIN II, III as recommended by the ASCCP, especially
considering the risk factors present in this case, support
LEEP. However, potential long-term consequences of
LEEP are emerging in medical literature that strongly
support the need for women of childbearing age with high
grade cervical dysplasia and a satisfactory colposcopy with
negative endocervical curettage to consider ablative ther-
apies. Escharotic treatment is 1 potential alternative
available to these patients.
This case study of a 20-year-old woman with CIN II,
III who refused the LEEP therapy showed complete
remission of cervical dysplasia with escharotic trea-
tment and immune-boosting and anticarcinogenic oral
nutritional and botanical supplements. She showed
no sign of recurrence in either her follow-up Pap smears
or colposcopic examinations. Results of her treatment
were complete remission of evidence for her cervical
dysplasia. The patient remained negative for CIN on
follow-up colposcopy and Pap for 5 years after her initial
visit.
The major drawbacks of escharotic treatment include
the patient time burden of 2 treatments per week for 5
consecutive weeks and the physical discomfort of the
escharotic process during treatments such as minor and
temporary cramping, burning, stinging, and spotting that
may occur. However, the success of this case strongly
supports the need for further investigation into the effi-
cacy and potential long-term risks and side effects of
escharotic treatment for all grades of cervical dysplasia
through comparison studies to other known effective
clinical treatments.
Table 2. Escharotic Treatment Protocol
Step Justification
1. Apply bromelain powder to the cervix. Add light source to the bro-
melain application to increase the temperature and activate the
enzymatic action. Wait for 15 minutes.
Bromelain is a substance derived from the stems and fruit of pineapples
and is composed primarily of proteolytic enzymes. Bromelain has
known antiedematous, anticoagulant, and antimetastatic properties.
It has been used to facilitate soft-tissue wound healing and is being
explored for its ability to enzymatically digest burn eschar and effec-
tively clean the wound areas following second and third degree
burns.20,21,22
2. Remove bromelain powder after 15 minutes with a cotton swab
saturated with Calendula officianalis succus.
Calendula is known for its anti-inflammatory and demulcent properties.23
It is applied to sooth the tissues and decrease reactionary inflammation.
3. Apply escharotic preparation of ¼ tsp zinc chloride mixed with ¾
tsp of sanguinaria tincture to the cervix. Leave on for 1 minute,
then removed with the Calendula succus.
This is the core of the escharotic treatment. Saguinaria candensis has
antioxidant, antimicrobial, antifungal, antiangiogenic, anticancer,
irritant, and escharotic effects.24-26
4. Complete escharotic treatment by inserting 2 vag pack supposito-
ries into the vagina, against the surface of the cervix. The contents
of the suppositories include anhydrous magnesium sulfate, glycerin
complex, hydrastis tincture, thuja oil, tea tree oil, bitter orange oil,
vitamin A (as palmitate) 100 000 IU, ferric sulfate, and ferrous
sulfate in polybase.
This combination of herbs and vitamins has antimicrobial action, specifi-
cally against the human papillomavirus (HPV) and its local infection of
the cervical tissues.27,28
Alternative Treatment for Cervical Intraepithelial Neoplasia / Swanick et al 167
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... Escharotic treatment was also examined in a 2009 case study, in which a woman received treatment for CIN2/3, with long-term remission reported at the 5-year follow-up. 16 Escharotic treatment involves the topical application of an herbal escharotic agent to the lesion, which causes a burn on physical contact, thus destroying neoplastic growth. The abnormal tissue is subsequently sloughed off, and the resultant scab is known as an eschar. ...
... The abnormal tissue is subsequently sloughed off, and the resultant scab is known as an eschar. 16 Criticisms of escharotic treatments in medical literature originate from cases that were not under the care of licensed health care professionals with expertise in the areas of gynecology and alternative medicine, but rather these criticisms address cases in which individuals self-prescribed, independently purchased, and applied escharotic treatments available on the Internet. When performed by an appropriately trained medical provider, escharotic treatment accompanied by an oral anticarcinogenic protocol has been shown to have a positive outcome. ...
... When performed by an appropriately trained medical provider, escharotic treatment accompanied by an oral anticarcinogenic protocol has been shown to have a positive outcome. [14][15][16] This study was performed at the National College of Natural Medicine (NCNM) and the Helfgott Research Institute in Portland, OR. The purpose of the current case study was to explain the procedure and effect of an ablative escharotic treatment for a woman with severe and kept clear of the surrounding vaginal wall. ...
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A persistent human papillomavirus (HPV) infection of a high-risk type is necessary for cervical cancer to develop. The severity of the diagnosis, together with colposcopy findings, determines the standard for treatment, and ablative or excisional options may be recommended. Escharotic treatment, together with an oral, anticarcinogenic HPV protocol and a vaginal-suppository protocol, is an alternative treatment, especially for those women of childbearing age who are concerned about the possibility of obstetrical complications associated with the use of loop electrosurgical excision (LEEP). The aim of the current case study was to observe the effect of an ablative escharotic treatment for a woman with severe dysplasia, cervical intraepithelial neoplasia grade 3 (CIN3). A 28-y-old female visited the National College of Natural Medicine clinic to obtain suggestions for alternative treatments following a satisfactory colposcopy and a biopsy revealing a high-risk HPV effect, severe dysplasia CIN3, and a positive endocervical curettage (ECC). She refused the recommended standard of care, a LEEP, because of concerns about the potential for future obstetrical complications. As an alternative, she elected to receive an escharotic treatment at a frequency of 2 treatments/wk for 5 wk. In addition to the escharotic treatment, she followed an oral protocol consisting of vitamins and botanical medicine for 1 y and she completed a 12-wk regime of vaginal suppositories following the escharotic. The authors followed her for 2 y. The woman’s Papanicolaou (Pap) test at the 6-mo follow-up revealed negative cervical cytology for intraepithelial lesion or malignancy, and her follow-up ECC was negative. Liquid-based Pap results were normal, and HPV testing was negative at her 1-y follow-up. Her Pap continued to remain normal at her 2-y follow-up. For women with high-grade cervical neoplasias and positive ECCs, with satisfactory colposcopies, escharotic treatment, accompanied by oral supplementation, holds promise as an effective alternative to LEEP and other excisional procedures.
... What is known comes from three published papers providing preliminary evidence for the efficacy of a naturopathic approach to the management of cervical atypia. 12,16,17 The first, a consecutive case study research report of the naturopathic management of cervical carcinoma in situ, describeed the incorporation of local, systemic, and constitutional therapies featuring escharotic treatments. Of the seven subjects in the study, treatment was moderately effective with three subjects and totally effective with four subjects. ...
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... Escharotic treatments as part of the cervical atypia management plan may play a role in the reduction of undue long-term consequences from invasive procedures. 17 However, more investigation is required to define the benefits, burdens and potential long term risks of escharotic treatments such as Sanguinaria canadensis, which is used in the treatment of all cervical atypia. Additionally, further research remains essential to define the significant contributions of diet and lifestyle to the progression of cervical carcinogenesis. ...
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Human papillomavirus is the most significant factor contributing to cervical cancer. Naturopathic doctors (NDs) implement an integrative approach to treat cervical atypia. This study explored practice consensus and variance among NDs. A purposefully selected panel of six NDs participated in a modified Delphi study to validate practice. Three electronic web-based surveys were completed over nine months. Local and systemic treatments were included in all ND protocols. Six protocols included cervical cancer screening guidelines, green tea suppositories, and oral folic acid. Five protocols included oral green tea, diindoylemethane (DIM), and cartenoids. Four protocols incorporated Vitamin C. Two NDs considered escharotics when managing cervical atypia. All NDs included health behavior management in their protocols. Naturopathic management of cervical atypia varies across practitioners. However, in general, elements of management include (1) cervical cancer screening guidelines, (2) local and systemic treatments, (3) health behavior/lifestyle recommendations, and (4) immune system support.
... В отношении хирургических методов лечения рандомизированные исследования показали сходную эффективность для петлевой электроконизации шейки матки, лазерной вапоризации и криотерапии в лечении CIN. Таким образом, выбор метода лечения остается на усмотрение врача [12]. ...
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Genital human papillomavirus (HPV) infection is the major causal factor of cervical intraepithelial neoplasia (CIN). The potential role of nutrition as an additional, independent risk factor for CIN has not been appropriately addressed in the context of HPV. This case-control study evaluated the etiologic role of HPV in terms of viral type and load and examined the association between CIN and plasma levels of micronutrients adjusting for HPV. Cases (n = 378) with histo-pathologically confirmed CIN and controls (n = 366) with no history of abnormal Pap smears were recruited from colposcopy and gynecology clinics, respectively. Risk of CIN was significantly increased among women who were infected with multiple HPV types (odds ratio [OR] = 21.06), a high viral load (OR = 13.08) and HPV 16 (OR = 62.49). After adjusting for HPV positivity and demographic factors, there was an inverse correlation between plasma α-tocopherol and risk of CIN (OR = 0.15). Plasma ascorbic acid was protective at a high level of ≥ 0.803 mg/ dl (OR = 0.46). CIN was not associated with plasma retinol and β-carotene levels. The effect of genital HPV infection on CIN development is highly influenced by oncogenic viral type and high viral load. Vitamins C and E may play an independent protective role in development of CIN that needs to be confirmed in prospective studies. Int. J. Cancer 78:594–599, 1998. © 1998 Wiley-Liss, Inc.
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