A cervical polyps is a common benign polyp or tumor on the surface of the cervical canal.[1] They can cause irregular menstrual bleeding but often show no symptoms. Treatment consists of simple removal of the polyp and the prognosis is generally good. About 1% of cervical polyps will show neoplastic change which may lead to cancer. They are most common in post-menarche, pre-menopausal women who have been pregnant.
Polyps are benign lesions and may represent a reactive hyperplastic process of subepithelial myxoid stroma and misdiagnosed as malignant. Polyps are usually small, soft, spherical, and asymptomatic lesions [rx], but large polyps can present with a lot of discomfort symptoms like lower abdominal pain, abnormal vaginal discharge, intermittent bleeding and introitus mass [rx].
Cervical polyps are benign growths, usually protruding from the surface of the cervical canal. They commonly occur during the reproductive years, especially after the age of 20.
The cervical polyps may vary in size, shape, and origin. They can present as single or multiple, tear-shaped or lobular, cherry-red, or greyish-white in color, depending on the vascularity of the lesion. The size of the cervical polyp is typically less than three cm in diameter; however, as mentioned earlier, they can vary in size and can be large enough to fill the vagina or be present at the introitus. Anatomically, a cervical polyp is connected to the surface by a pedicle, which is usually long and thin but may, as well, present as short and broad-based.
Although cervical polyps are commonly benign, malignant polyps can present in 0.2 to 1.5% of the cases. Malignant polyps are more likely to be seen in postmenopausal patients.
Types of Cervical Polyps
Cervical polyps are categorized depending on their origin; ectocervical and endocervical polyps.
-
The endocervical polyps – are the most common type; they usually occur in premenopausal women. They typically arise from the cervical glands in the endocervix.
-
The ectocervical polyps – are more common in postmenopausal women and arise from the outer surface layer cells of the cervix within the ectocervix.
or
There are two types of cervical polyps
- Ectocervical polyps can develop from the outer surface layer cells of the cervix. They are more common in postmenopausal women.
- Endocervical polyps develop from cervical glands inside the cervical canal. Most cervical polyps are endocervical polyps and are more common in premenopausal
Causes of Cervical Polyps
The etiology of cervical polyps remains unknown. But many theories have been identified; one theory suggests that they may result from the congestion of cervical blood vessels, these can disrupt the blood flow, leading to polyp development.
Other theories describe that they occur due to an infection or chronic inflammation of the cervix, and in some cases, chemicals that irritate the cervix over the long term can cause abnormal changes in the cells.
Finally, others suggest an abnormal response to the increase in estrogen levels, which may result in excessive growth of the cervical tissue and may be associated with endometrial hyperplasia.
Some of the risk factors are:
- An abnormal response to increased levels of the female hormone estrogen
- Chronic inflammation
- Clogged blood vessels in the cervix
-
Premenopausal women
-
Multigravida
-
Sexually transmitted infections
-
Previous history of cervical polyps
Cervical polyps are common. They are often found in women over age 40 who have had many children. Polyps are rare in young women who have not started having their period (menstruation).
Symptoms of Cervical Polyps
Polyps do not always cause symptoms. Where there are symptoms, they include intermenstrual bleeding, abnormally heavy menstrual bleeding (menorrhagia), vaginal bleeding in postmenopausal women, bleeding after sex and thick white vaginal or yellowish discharge (leukorrhoea). 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)
- Periods that are heavier than usual
- Bleeding after sex
- Bleeding after menopause
- Bleeding between periods
- Vaginal discharge, which may stink due to infection
Diagnosis of Cervical Polyps
Histologically, cervical polyps characteristically demonstrate vascular connective tissue in addition to stromal cells, which are covered by the papillary proliferation of cells; these cells are made up of columnar, squamous, or squamocolumnar epithelium.
Cervical polyps arise from glandular epithelial hyperplasia, while the tip of the polyp is commonly squamous metaplasia.[rx]
The two types of cervical polyps, endocervical and ectocervical, cannot be distinguished by gross appearance. Microscopically, many histological patterns are found, including typical mucosa, inflammatory, vascular, fibrous, pseudo-decidual, a mixture of cervical and endometrial, and pseudosarcomatous.[rx]
Endocervical polyps, which are the most common type, microscopically show a loose, edematous stroma with variably sized vasculature, large dilated or small thick-walled. The stromal cells often present with mixed acute or chronic inflammation, erosion, as well as benign microglandular hyperplasia. These manifestations are usually visible on the surface of larger polyps protruding through the cervical os, depending on the extent of irritation.[rx]
History and Physical
Cervical polyps are usually discovered incidentally during the routine gynecological examination, colposcopy, or during the abdominal or transvaginal ultrasound.
Two out of three women with cervical polyps present asymptomatically. However, symptomatic women usually present with abnormal uterine bleeding, such as heavy menstrual bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.[rx]
Rarely, large polyps block the cervical canal, causing infertility.
On the speculum examination, a polypoid lesion is visible within the cervix.
Evaluation
- Transvaginal ultrasound – A slender, wand-like device placed in your vagina emits sound waves and creates an image of your uterus, including its interior. Your doctor may see a polyp that’s clearly present or may identify a uterine polyp as an area of thickened endometrial tissue. A related procedure, known as hysterosonography (his-tur-o-suh-NOG-ruh-fee) — also called sonohysterography (son-oh-his-tur-OG-ruh-fee) — involves having salt water (saline) injected into your uterus through a small tube threaded through your vagina and cervix. The saline expands your uterine cavity, which gives the doctor a clearer view of the inside of your uterus during the ultrasound.
- Hysteroscopy – Your doctor inserts a thin, flexible, lighted telescope (hysteroscope) through your vagina and cervix into your uterus. Hysteroscopy allows your doctor to examine the inside of your uterus.
- Endometrial biopsy – Your doctor might use a suction catheter inside the uterus to collect a specimen for lab testing. Uterine polyps may be confirmed by an endometrial biopsy, but the biopsy could also miss the polyp.
The definitive diagnosis of cervical polyps is a histological examination. Therefore an approach is needed to exclude any associated pathologies such as:
-
Triple smear or vaginal-cervical-endocervical (VCE) smear
-
Transvaginal ultrasonography evaluates associated endometrial pathologies. If indicated, the clinician should perform an endometrial sampling.[rx]
Treatment
The treatment of cervical polyps depends widely on their clinical characteristics. Asymptomatic polyps usually don’t need any intervention, but there are some exceptions. Symptomatic, large, or atypical polyps usually warrant removal. Some techniques for polyp management include polypectomy for polyps with slender pedicles, which consists in grasping the base of the polyp with a ring forceps and twisting and rotating it until it comes of off; for smaller polyps, punch biopsy forceps are used, and polyps with a thick stalk usually require electrosurgical excision or hysteroscopic removal.
After the removal of polyps, the base can be cauterized to prevent bleeding and reduce the recurrence rate. However, if the base is very wide, it can be treated using electrosurgery or laser ablation.
-
Every excised polyp should be sent for further histological examination to rule out malignancy.[rx]
In women with recurrent polyps and postmenopausal women, it is important to perform further cervical canal and uterine cavity exploration by hysteroscopy to exclude any endometrial pathologies (polyps or malignancy).[rx]
-
Up to 25% of women with cervical polyps have a coexisting endometrial polyp.[rx]
-
Cervical polyps are present in 10.9% of postmenopausal women and 7.8% of premenopausal women with any endometrial pathology.[rx]
Some of the previously mentioned approaches are blind procedures, which make them not helpful in detecting the origin and the exact number, location, or size of the polyps. As a result, this may leave residual polyp fragments in the cervical canal, which might lead to recurrence if not removed properly.
Cervical polyps are uncommon in pregnancy, and they are usually asymptomatic and small. Some cervical polyps can be misdiagnosed in the early weeks of pregnancy as abnormal vaginal bleeding and can lead to the diagnosis of an inevitable miscarriage. As a result, the recommendation is to do a color doppler ultrasound in pregnant women with recurrent unexplained bleeding to exclude endocervical polyps as well as some other causes such as vasa previa.
Bleeding in the postpartum period can be a serious complication because polyps are vascular. The other serious aspect of cervical polyps is their malignant nature; some studied showed that 5% of symptomatic women had precancerous or cancerous polyps. Therefore further histological examination is mandatory in such cases.[rx]
The guidelines are controversial in the treatment of cervical polyps in pregnancy. Some studies suggest the removal of polyps during pregnancy with cryosurgery; however, some choose conservative management to avoid heavy bleeding, preterm delivery, or abortion.[rx]
Rarely these polyps are reported in variations in size, but a huge cervical polyp with funneling and shortening of the cervical length was first reported in 2014. One of the case reports showed a pregnant woman with preterm contractions and antepartum hemorrhage secondary to a huge endocervical polyp causing funneling and shortening of the cervical length. She was managed with polypectomy at 38 weeks of gestation without any complications.[rx]
In women with infertility associated with the presence of cervical polyps, discarding any other cause of infertility, an approach with hysteroscopic polypectomy has been confirmed to increase the pregnancy rate. Untreated polyps may continue to grow, which may lead to infertility, as well as they may develop precursor lesions.
References