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Cervical Polyp

Polyp Cervix

Cervical polyps are pedunculated (stalked) new growths from the cervix, usually benign, which are detected incidentally during routine pelvic examination. The condition remains asymptomatic except when there is intermenstrual or postcoital bleeding. Ectocervical polyps grow on the outer surface of the cervix and are found in postmenopausal women; endocervical polyps, the more common of the two, develop from within the cervix and are found in premenopausal women.


Presentation

In general, cervical polyps are asymptomatic except when abnormal bleeding occurs in association with the following:

  • Intercourse
  • Menstrual, intermenstrual, and postmenopausal periods
  • Infections

Large polyps may obstruct the cervical opening and cause infertility.

Upon closer inspection, polyps appear as  small (1-3 cms in diameter), slippery and soft to touch, fragile (bleed easily), somewhat round, reddish purple bodies attached to the cervix with stalks. Polyps may be seen inside the cervical canal or protruding from the cervical opening (cervical os). The purplish color is from engorgement with venous blood. Reddish and inflamed appearance and odoriferous vaginal discharge, indicate an infectious process. Care must be taken when moving the polyp aside on its peduncle.

Vaginal Bleeding
  • When symptoms are present, they may include: Very heavy menstrual periods Vaginal bleeding after douching or intercourse Abnormal vaginal bleeding after menopause or between periods White or yellow mucus (leukorrhea) Your health care provider will perform[nlm.nih.gov]
  • Abnormal vaginal bleeding was of no clinical significance in excluding concomitant endometrial polyps. CONCLUSIONS: All menopausal patients with a cervical polyp could benefit from a diagnostic hysteroscopy.[ncbi.nlm.nih.gov]
  • CASE REPORT: We report the case of a giant cervical polyp of 5.5 cm occurring in a multiparous 47-year-old woman who clinically presented vaginal bleeding. The lesion was resected by electrosurgery with no recurrence 7 months after surgery.[ncbi.nlm.nih.gov]
  • Call your doctor or nurse call line now or seek immediate medical care if: You have severe vaginal bleeding. You have new or worse pain in your belly or pelvis.[myhealth.alberta.ca]
  • STUDY DESIGN: A prospective study was carried out on 467 women who were referred for treatment of symptomatic (accompanied by vaginal bleeding or discharge) or asymptomatic cervical polyps, from January 1, 1990 to December 31, 1992.[ncbi.nlm.nih.gov]
Vaginal Discharge
  • Abstract A case of adenosarcoma arising from the uterine cervix of a 55-year-old female who complained of vaginal discharge is reported.[ncbi.nlm.nih.gov]
  • Most are asymptomatic, but some cause bleeding or become infected, causing purulent vaginal discharge. Diagnose by speculum examination.[merckmanuals.com]
  • Johns Hopkins’ Alert says cervical polyps can cause heavy, watery, and bloody vaginal discharge, vaginal bleeding after a bowel movement and pelvic cramps.[empowher.com]
  • Vaginal discharge – mostly white but may be blood tinged or foul smelling. CAUSES Cervical polyps are caused by cervix inflammation from infection, erosion or ulceration.[justeves.com]
Postcoital Bleeding
  • No-one knows for sure what causes these little hangers-on, but they can lead to some unpleasant symptoms like postcoital bleeding.[baby-pedia.com]
  • The condition remains asymptomatic except when there is intermenstrual or postcoital bleeding.[symptoma.com]
  • Symptomatic cervical polyps may cause intermenstrual bleeding, postcoital bleeding, heavy menses, postmenopausal bleeding and vaginal discharge.[link.springer.com]
  • Occasionally it may cause intermittent vaginal or postcoital bleeding, a discharge or, in older women, postmenopausal bleeding. Endocervical polyps are more likely to bleed than their ectocervical counterparts.[med-ed.virginia.edu]
Metrorrhagia
  • Symptoms and Signs The most frequent symptom of women with endometrial polyps is metrorrhagia , which is reported in 50% of symptomatic cases. Post-menstrual spotting is also common.[hon.ch]

Workup

Because of the usual absence of symptoms in most women, cervical polyps are detected only incidentally during a routine pelvic examination and/or Pap smear preparation. 

Given a high index of suspicion, a biopsy is performed and the specimen is brought to a clinical laboratory for confirmation of infection and/or malignancy.

Treatment

The indication for treatment for cervical polyps derives from several factors: symptoms, age and reproductive status of the patient, risk of gynecological/obstetrical complications, type of polyp (single, pediculated), origin (ectocervical or endocervical), and benign or malignant. Histological examination is mandatory especially if malignancy is suspected [8] [9].

In asymptomatic women, polyps measuring less than 2 cm in diameter can be removed by simply twisting them off at the base, under axenic conditions in a doctor's clinic. The base of a small polyp can heal spontaneously without bleeding profusely. The base of a large polyp may require electrocautery or laser therapy. The occurrence of vagally stimulated bradycardia during operation may need atropine therapy. Hemorrhage may require cautery to halt the bleeding. For more persistent lesions, D&C (dilatation and curettage), hysteroscopic excision or electrosurgery are recommended. Healed cervix following cone biopsy may sometimes resemble a large polyp in appearance.

Polypectomy in non-pregnant women is done with a polyp forceps to hold the base of the peduncle and twisting motion to detach the polyp. This is not done during pregnancy due to the risk of hemorrhage from engorged blood vessels. Diathermy is recommended in this case.

Polyp removal is likewise done by binding the base of the stalk and simply cutting off the polyp therefrom by electrosurgery in non-pregnant women, followed by prophylactic therapy with antibiotics for 5-7 days against possible infection. Excised polyps do not recur in the same place.

Polyps associated with hemorrhage or infections should be extricated. Excision is possible without anesthesia and chemical cautery can be resorted to if bleeding occurs. Cervical cytology is SOP.

In persistent hemorrhage and infection, endometrial biopsy is prescribed to rule out cancer.

Other remedial methods include:

  • Surgical ligature of the polyp at the base.
  • Electrical or laser therapy, for larger polyps.
  • Conventional surgery to completely obliterate the pathological site.
  • Dilatation and curettage.

Mandatory removal of all cervical polyps with histology is basically accepted to rule out malignancy. However, polypectomy during pregnancy is optional and permissible only if the presence of polyps causes the patient distress and apprehension.

Prognosis

The presence of cervical polyps is usually a benign condition in women. Although malignant polyps are rare, rates of 0.0 to 1.7% have been reported [2] [7]. Of 12,000 new cases of cervical polyps, only 1% of biologically reproductive women have cervical cancer. It is presumed that malignancy could have emanated from extracervical foci. Cervical polyps once extricated do not regrow in the same site.

Polypectomy or removal of polyps is optional. The procedure is recommended both as a remedial and preventive measure in symptomatic cases or those presenting with abnormal cervical cytology. This is to avoid unnecessary expenses and possible complications from polypectomy.

Etiology

Why and how cervical polyps develop is a medical enigma. So far, they are considered to be the result of infection and long-standing inflammation.

The inflamed cervix is reddish and sloughy Some known causes of this are:

  • bacterial, yeast, fungal and viral infections e.g., warts and HPV infection (also a cause of cervical cancer)
  • changes in hormonal status
  • gestation, miscarriage, abortion

Regular pelvic examinations are recommended as a primary preventive measure. A minute fleck is snipped off from the cervix for laboratory confirmation of infection or the presence of abnormal cells.

Natural estrogen and estrogen-like substances

Elevated levels of the female hormone, estrogen, normally accompany gestation, the estrus cycle and perimenopausal period, all through a woman's lifetime. Levels can increase a hundredfold during pregnancy. This may have a profound effect on the development of cervical polyps.

On the other hand, the environment can also be a source of estrogen-like substances such as xenoestrogens as found in processed meat and dairy products. In addition, chemical estrogens may contaminate food heated in plastic containers or Styrofoam, for that matter, air pollution from phthalates in air fresheners,

Clogged blood vessels and cervical polyps

Blood circulation in the cervix becomes impaired due to clogging of blood vessels during pregnancy. This appears to promote the development of polyps. In non-pregnant women, inflamed polyps have been associated with metaplasia and predisposition to cancer.

Epidemiology

Polyps are estimated to occur in approximately one out of 10,000 women, 20 years old and above, and especially those who have undergone more than one pregnancy as well as women nearing postmenopausal period.

Endocervical and cervical polyps are the most common types of polyps which have been detected in 4% of patients consulting in gynecology clinics [3]. 

Nearly all polyps are benign or roughly less than one in 200 polyps is malignant.

Sex distribution
Age distribution

Pathophysiology

An incidence of 0.1% dysplasia was attributed to the presence of endocervical polyps [4]. The report of an exhaustive study by Berzolla et al placed the malignancy rate at 0.1% with a death rate of 0.5% [5]. 

Of the 6 histological types of cervical polyps (i.e., adenomatous, vascular, fibrous, cystic, inflammatory, and fibromyomatous), adenomatous polyp is the most common, representing 80% of all polyps. Adenomatous polyps appear as a polypoid mass of benign hyperplastic glands and stroma. Overall recurrence rate is 12.6%. Postmenopausal women are more likely to manifest symptoms [6].

The comparative histology of endocervical and ectocervical polyps is as follows:

  • The epithelium covering endocervical polyps are of the endocervical, squamocolumnar or metaplastic squamous type in contrast to stratified squamous epithelium in ectocervical polyps.
  • The stroma, consisting of thick-walled blood vessels at the base and small vessels in the center, are more fibrous in ectocervical than in endocervical polyps. Moreover, endocervical glands are found in the stroma of endocervical polyps but few or none in ectocervical polyps.

Apical ulcerations in polyps may result in extravasation of blood, manifested by intermittent bleeding and presence of stromal inflammatory cell infiltrates. 

Prevention

While most cases of cervical polyps are asymptomatic, any preventive measure at this early stage is rather impractical. However, routine pelvic examination and Pap smears are prescribed for timely detection and treatment of symptomatic and/or malignant cases.

Summary

Grossly, ectocervical and endocervical polyps are indistinguishable from each other. Both may protrude through the cervical opening and appear as single or multiple reddish-gray bodies. The histology consists of varied tissues of cervical and endometrial origins. Endocervical polyps commonly occur at age 40 to 60 and may be accompanied by the passage of yellowish-white exudate (leukorrhea) from infection or blood streaks following intercourse [1] [2].

The incidence of cervical polyps is about 4% in women of reproductive age who have had at least one child, but almost never, prior to the onset of menstruation in young women. Polyps likewise occur during pregnancy following an increase in circulation of the hormone estrogen. 

Polyps are treated by removal (polypectomy) i.e., by snipping off stalked polyps at the base with ringed forceps or with punch biopsy forceps, or by surgical excision of those with thick peduncles. 

Patient Information

Cervical polyps develop for some unknown reason at the juncture between the uterus and the vagina. These are small (a few centimeters in diameter) rounded, reddish-gray, fragile bodies with stalks (pedunculated) that grow inside (endocervical polyps) and outside (ectocervical polyps) the cervix, singly or, at most two to three in number. Cervical polyps are generally benign (innocuous), rarely associated with malignancy. If at all, only one percent of biologically reproductive women out of 12,000 new cases seen annually, has been diagnosed with cervical cancer.
Conditions linked to cervical polyps: Increased levels of estrogen during pregnancy, excessive menstruation (menorrhagia), inter-menstrual and postmenopausal periods. Infection and chronic inflammation in the genital tract. Clogged blood vessels.

Pathognomonic signs necessitating medical intervention: spotting (blood streaks) after intercourse or douching; odoriferous, whitish-yellow vaginal discharge (leukorrhea), indicating infection.

Tissue samples are taken (biopsy) and brought to the laboratory for cytological, histological, and microbiological examinations.

Cervical polyp removal (polypectomy) is a relatively simple, painless procedure that is usually done in the doctor's clinic. Analgesic is not required. The procedure involves twisting the polyp off at the base, or binding the base of the polyp and cutting it away, or using ring forceps to extricate the polyp.
The site of removal can be treated with liquid nitrogen, or surgically removed by electrocautery, or laser surgery to prevent regrowth. Expected side effects are: tolerable pain during polypectomy, mild to moderate cramps for a few hours after polypectomy and spotting from the vagina one to two days thereafter. Polyps may regrow after removal but not in the same site. Regular pelvic examination and Pap smear are prescribed as a preventive measure. Other precautionary measures: wearing of cotton underwear to minimize heat and moisture, which promote the growth of microorganisms, thus, infections. Condom use during intercourse.

References

Article

  1. Ferency A, Wright T. Anatomy and histology of the cervix. In R. Kurman (Ed.), Blaustein’s Pathology of the Female Genital Tract, 4th ed. (pp. 185-9; 191-2). New York, NY: Springer Verlag. 1994
  2. Aaro LA, Jacobson LJ, Soule EH. Endocervical polyps. Obstet Gynecol., 21, 659-65. 1963
  3. Farrar Jr HK, Nedoss BR. Benign tumors of the uterine cervix. The American Journal of Obstetrics and Gynecology, 81, 124–13. 1961
  4. Chin N, Platt AB, Nuovo GJ. Squamous intraepithelial lesion arising in benign endocervical polyps: a report of 9 cases with correlation to the Pap smears, HPV analysis, and immunoprofile. Int J Gynecol Pathol., 27, 582–90. 2008
  5. Berzolla CE, Schnatz PF, O'Sullivan DM, Bansal R, Mandavilli S, Sorosky JI. Dysplasia and malignancy in endocervical polyps. J Womens Health (Larchmt), 16, 1317–21. 2007
  6. Tirlapur SA, Adeyemo A, O'Gorman N. Clinicopathological study of cervical polyps. Arch Gynecol Obstet., 282, 535–8. 2010
  7. Caroti S, Siliotti F. Cervical polyps: a colpo-cyto-histological study. Clin Exp Obstet Gynecol., 15, 108–15. 1988
  8. Belfiore P, Costa E, de Cantis S, Vassallo R, Marino A. Effectiveness and persistence of a topical treatment for cervical ectropion with deoxyribonucleic acid. Minerva Ginecologica, 57(4), 461–466. 2005
  9. van Renterghem N, de Paepe P, van den Broecke R, Bourgain C, Serreyn R. Primary lymphoma of the cervix uteri: a diagnostic challenge, report of two cases and review of the literature. European Journal of Gynaecological Oncology, 26(1), 36–38. 2005

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Last updated: 2018-06-22 10:54