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Cold coagulation (also known as thermal ablation or thermocoagulation) is a medical procedure used to treat precancerous cervial intraepitelial neoplasia (CIN), the stage before cervical cancer, and benign cervical lesions (abnormal or damaged tissue) that cause bleeding and fragile ectocervical cells.^[1]. Risk factors include pregnancy, pelvic infection and invasive cancer. Post-treatment effects are usually minor (pain, vaginal discharge, occasional infection or cervical stenosis). It is done by electrically heating a thermosound probe to 100 to 120°C, allowing for the removal of cells in the affected area. Follow-up procedures include cytology and HPV testing. The term "Cold" is so named due to the significantly lower operating temperature than other electrocautery methods^[2]. It treats cervical lesions by burning cervical tissue cells, triggering necrosis (the premature and irreversible death of cells). Procedures take 20-45 seconds per application and can ablate (remove) affected cells up to a depth of 4-7 mm. Performed almost exclusively on the cervix, the procedure remains popular in colposcopy clinics for its simplicity and favorable obstetric outcomes compared to alternative methods^[3].

There are two main medical uses for cold coagulation: Treatment of CIN lesions and the cauterization of fragile ectocervical cells.

CIN lesions are precancerous cells identified during colposcopy and confirmed by biopsy. The heat ablates abnormal tissue, allowing healthy epithelium to regenerate, preventing progression of cervical cancer.

Fragile ectocervical cells (cells covering the outer surface of the cervix) can bleed easily on contact, such as during intercourse or pelvic examinations^[4]. In these cases, the cells are not necessarily precancerous, but their removal improves quality of life by eliminating bleeding.

Thermal ablation is recommended for those who screen positive for cervical pre-cancer and meet specific anatomical criterion as assessed by colposcopy or visual inspection after application of 3-5% acetic acid^[1]. The transformation zone(TZ), which is the area where columnar cells (from the endocervix) are being replaced by squamous cells, must be fully visbile. Columnar cells are from the endocervix, the inner lining of the cervical canal, connecting the uterus to the vagina, whilst squamous cells are from the ectocervix, the outer, lower part of the cervix that protrudes into the vagina, must be fully visible. This is due to the transformation zone being where the majority of precancerous lesions and cervical cancers arise due to metaplasia (a reversible condition where one cell type is replaced by another).

Those with a type 1 CIN (transformation zone completely on the ectocervix) or type 2 CIN (transformation zone partically on the endocervix but still fully visible and within probe reach) are deemed suitable.

Type 3 CIN (extending into endocervical canal beyond reach of a probe) patients, those suspected of invasive cancer or glandular disease (adenocarcinoma or adenocarcinoma in situ) are advised against undergoing this treatment^[1][5].

In practice, the size of the lesion is also considered, where lesions beyond the probe's footprint may instead be removed via excisonal techniques like large loop excision of the transformation zone(LLETZ)^[6].

Pregnancy is a risk factor, where if a patient is pregnant, treatment is not performed and is usually deferred until 12 weeks postpartum, with colposcopic monitoring in the meantime^[7]. For those with intrauterine devices (IUD or IUS), the device can usually remain in place; should removal be necessary, it can be replaced after 4 to 6 weeks. The procedure does not appear to compromise future fertility, nor are there increased rates of miscarriage, preterm delivery or operative delivery^[7].

The presence of an untreated infection, such as pelvic inflammatory disease, causes risks to the patient.

Cold coagulation is not recommended if there is clinical suspicion of invasive cancer and glandular disease in the cervix, or a type 3 TZ.

Cold coagulation is an outpatient (treatment without need for overnight care) procedure, typically performed in a coploscopy clinic. The appointment usually lasts 15 to 20 minutes^[7]. Though is it frequently performed without the use of anaesthetics, local anaesthetics (anaesthetics used to numb a specific region of the body) and general anaesthetics (anaesthetics that numb the entire body) are sometimes used for sedation. Should it be performed with anaesthetics, the patient should not intake food or drink a few hours before the procedure^[8].

The clinician inserts a speculum (a tool to widen body orifices for inspection) to visualize the cervix and brings a colposcope (a form of specialized microscope) into position for magnification. Acetic acid or Lugol's iodine may be applied to highlight abnormal areas for better observation. A resuable metallic probe, electrically heated to approximately 100°C, is then applied directly to abnormal tissue. The probe remains in contact for 20 to 40 seconds per application. Multiple overlapping applications ensure complete coverage of the transformation zone^[9].

Cold coagulation is used as a method of ablation (the removal or destruction of unhealthy tissue). At extreme heat, this causes irreversible cell injury. Such injuries denatures structural proteins and enzymes. This prevents the injured and dead cells from being broken down and reabsorbed, resulting in necrotic debris (the accumulated remnants of dead cells and tissue). The overall structure of the tissue is preserved for several days and is then removed by tumor-infiltrating leukocytes (anti-tumor white blood cells that get into the tumor tissue from the bloodstream)^[10]

Serious complications are uncommon but can occur. Complications include pain, vaginal discharge, infection and stenosis.

Pain is usually mild after treatment, it has been described to be period-like cramping, where it is typically managed with paracetamol or ibprofen. The procedure itself is generally minimal or painless if anaesthetic is used.

Vaginal discharge and bleeding are nearly universal. A watery, blood-stained or brownish discharge typically continues for up to 4 weeks as the treated area heals^[5]. While light spotting is normal and may occur, heavy bleeding is not expected^[11] and warrants medical attention.

Infection occurs in a small percentage of cases. Warning signs include offensive-smelling discharge, fever or severe lower abdominal pain^[11]. In such cases, medical advice should be sought where antibiotic treatment may be prescribed.

Cervical stenosis is the narrowing for closure of the cervical Os (the small opening at each end of the cervix) and affects fewer than 2% of patients.^[11]. Contraceptive packs are advised to not be run together without breaks, as it allows menstrual flow to occur, thereby reducing risk. Treatment often involves the dilation of the cervix^[11]

Both ablative techniques, such as cold coagulation, and excisional techniques (that surgically remove tissue) can be used to treat cervical pre-cancer. Systematic reviews and meta-analyses aimed to compare the efficacy between cold coagulation and excisional methods such as LLETZ and cryotherapy, specifically in the cure rate for CIN2 (CIN type 2) and CIN3, and efficacy over time over all types of CIN. While LLETZ achieves faster initial clearance and a higher cure rate at 6 months, both treatments are equally effective after 1 year for CIN 2-3.^[12]. For CIN3, the calculated primary success rate has been found to be significant from 1 year to 5 years. Across all types of CIN, outcomes are comparable to other ablative and excisonal methods^[3][13], such that cold coagulation are recommended as an alternative to cryotherapy and LLETZ for histologically confirmed CIN2+^[1]

When compared to cryotherapy, cold coagulation demonstrates comparable efficacy in treating cervical pre-cancerous lesions but with several practical advantages, as cold coagulation equipment is lightweight (>2kg) and portable, requiring no refrigerant gases, making it practical for countries or regions in which cryotherapy supply chains are unreliable.^[14]. Furthermore, those treated with cold coagulation showed collagenization (replacement of tissues by collagen) of the superficial stroma, which keeps deeper cervical architecture intact. In contrast, excisional treatments remove substantial cervical tissue and have been associated with increased obstetric morbidity^[3]

Patients treated with cold coagulation experience fewer complications and health problems compared to other treatment methods post-treatment, as well as shorter recovery times. They also typically experience shorter recovery times. This is likely due to coagulation leaving the deep tissue intact, removing cells to a shallower depth than excisional surgery. A follow-up screening test and HPV tests are usually performed 6 months post-treatment to confirm treatment success.^[15].

The technique traces to the 1960s and the work of German gynaecologist Kurt Semm. In 1966, Semm introduced the eponymous coagulator (also known as the Semm coagulator), which applies controlled heat at 100°C to treat benign cervical lesions^[16]. This procedure found a particularly receptive audience in the United Kingdom. By the mid-1970s colposcopists in Ireland adopted the Semm coagulator for treatment, with further journals solifidying the technique in British medical use^[1].

In 2019, the WHO issued formal guidelines endorsing cold coagulation for cervical pre-cancer. The guidelines recommend it as an alternative to cryotherapy and LLETZ for eligible women with histologically confirmed CIN over grade 2.

The guidelines also expanded on the pool of providers. Trained nurses, midwives, physicians and other healthcare workers may perform cold coagulation, a move aimed at increasing access to treatment in resource-limited settings.

Cold coagulation is often referred to as thermal ablation or thermocoagulation. Thermal ablation is more widely used in official publications to more accurately reflect the mechanisms of action, with reference to WHO's guideline development group. However, the term "cold coagulation" can be found in clinical practice, patient information leaflets and referral pathways.

Recommendations for cold coagulation apply to all women, including those with immunodeficiency such as HIV. However, post treatment follow-up is particularly critical in this population, given higher rates of persistent HPV^[3] infection and that the main cause of CIN is commonly attributed to high-risk HPV infections ^[17](HPV-16 and HPV-18).

While data specific to adolescents are limited, cold coagulation is recommended to those who meet the standard eligibility criteria compared to excisional techniques. The preservation of cervical architecture is particularly relevant for younger patients who have not yet, but wish to give birth.

For patients who have a copper coil or hormonal intrauterine device, the device may be left in place during the procedure. The threads can be tucked into the cervical canal to keep them clear of the treatment area. If removal is necessary, a new device can be fitted 4 weeks after treatment^[7].

In post-menopausal women, the transformation zone may retreat into the endocervical canal (type 3 transformation zone), making it inaccessible to the probe. In such cases, cold coagulation is not technically feasible, and excisional methods are preferred^[18].

Cold coagulation is a term used almost exclusively in human gynaecology. The principle of thermal ablation appears occasionally in veterinary medicine in domestic species such as dogs and cattle, but it is not standard procedure and literature on this application remains sparse^[19]