Cervical polyp

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and keywords: Polypoid cervical lesion; Cervical polypoid lesion; Polypoid cervical growth

Overview

Cervical polyps are defined as polypoid benign overgrowths of endocervical tissue. Usually, cervical polyps are growths projecting into the cervical canal. Cervical polyps are the most common cause of intermenstrual vaginal bleeding. There are no established causes for cervical polyp. Cervical polyps may be classified according to morphological features, such as: distribution, shape, size, and pedicle. The pathogenesis of cervical polyp is characterized by chronic inflammation of the endocervical canal. Typically, cervical polyps arise from the endocervical canal and tend to protrude in the external cervix. The estimated prevalence of cervical polyp is approximately 1.5–10% in general population. Common risk factors in the development of cervical polyp, include: chronic inflammation, hormonal factors, presence of endometrial hyperplasia, and previous history of pregnancy. Cervical polyp is more commonly observed among perimenopausal and postmenopausal women. Early clinical features may include abnormal vaginal bleeding, postcoital vaginal bleeding, and abnormal vaginal discharge. The diagnosis of cervical polyp is made with a cervical biopsy, findings may include: inflamed and dilated endocervical (mucus) glands and myxoid stroma. Ring forceps in conjunction with biopsy is the most common approach to the treatment of cervical polyp.

Historical Perspective

Cervical polyp was first described by Peterson and Novak in 1956 following the description of endometrial polyps.

Classification

Based on polyp location cervical polyps are of two types:

• Ectocervical polyps
  • Develop from the outer surface layer cells of the cervix.
  • More commonly seen in post-menopausal women.
• Endocervical polyps
  • Develop from cervical glands inside the cervical canal.
  • Majority of cervical polyps are endocervical polyps
  • More commonly seen in pre-menopausal women.

Pathophysiology

Anatomy

• The normal cervix is fusiform in shape, with the narrowest portions at the internal and external os and measures 3 to 5 cm in length and 2 to 3 cm in diameter.
• The portio vaginalis, is the visible portion of the cervix that protrudes into the vagina and is surrounded by a reflection of the vaginal wall on each side termed the anterior, posterior, and lateral fornix.
  • The supravaginal cervix is the intra-abdominal portion of the cervix that lies above the point of attachment of the vaginal vault
  • The peritoneum posterior to the supravaginal cervix forms the lining of the posterior cul-de-sac (pouch of Douglas).
• The external cervical os is small, round, and centrally placed in nulliparous women.
• In parous women who have labored into the third stage, it is more likely to be a patulous, transverse slit.
• The internal cervical os is normally no more than 3 mm in diameter in nonpregnant women, even if parous .
• In the sagittal axis, the cervix lies between the bladder and rectum.
• The cervix is supported by the uterosacral ligaments, which surround the cervix and vagina and extend laterally and posteriorly toward the second to fourth sacral vertebrae, and the cardinal ligaments, which are fibromuscular bands that fan out laterally from the lower uterine segment and cervix to the lateral pelvic walls.

Blood Supply

• The blood supply comes from a descending branch of the uterine artery.
• Lymphatic drainage is to the parametrial nodes, then to the obturator, internal iliac, and external iliac nodes with secondary drainage to the presacral, common iliac, and para-aortic lymph nodes.

Nerve Supply

• The nerve supply is autonomic (sympathetic and parasympathetic).
• The nerves enter the upper cervix on either side and form two lateral semicircular plexuses, called Frankenhäuser plexus, a terminal part of the presacral plexus.

Pathogenesis

• The pathogenesis of cervical polyp is characterized by chronic inflammation of the endocervical canal.
• The exact mechanism of cervical polyps origin is not clearly understood. However, polyp in cervix are believed to occur due to:
  • An abnormal response to increased levels of estrogen
  • Chronic inflammation
  • Clogged blood vessels in the cervix
• Cervical polyps arise from the endocervical canal and tend to protrude in the external cervix.
• There are no genes associated with the development of cervical polyp.
• On gross pathology, flesh-colored, single finger-like growth, 1 cm size, are characteristic findings of cervical polyp.
• On microscopic histopathological analysis, inflamed and dilated endocervical (mucus) glands and myxoid stroma are characteristic findings of cervical polyp.

Causes

There are no established causes for cervical polyp.

Differentiating Cervical Polyp from other Diseases

Cervical polyp must be differentiated from other diseases that cause abnormal vaginal bleeding, dyspareunia, and abnormal vaginal discharge

• Cervical intraepithelial neoplasia
• Cervicitis
• Benign endometrial polyp
• Fibroepithelial stromal polyp
• Adenosarcoma
• Cervical cancer

Abnormal Uterine bleeidng differential diagnosis
Ob-Gyn neoplasm and diseases	Clinical manifestations							Para-clinical findings					Gold standard
	Symptoms					Physical exam		Lab Findings		Imaging		Histopathology
	Abnormal vaginal bleeding	Other Genitourinary/ Gastrointestinal symptoms	Abdominal pain	Pelvic pain	B symptoms	Gynecological examinations	Abdominal mass	HPV Pap smear STI panel	Other labs	Ultrasound	Other imagings
Cervical polyp	Postcoital Intermenstrual Postmenopausal Bleeding after exam	Vaginal discharge Dyspareunia	−	−	−	Mass on exam	−	−	↓ RBC count ↓ Hemoglobin, ↓ Hct ↓ Serum Iron	Hyper/hypoechogenic masses with or without cysts Filling the endocervical or vaginal canal		Epithelial cells with no nuclear atypia/mitoses	Hysteroscopy /Biopsy
Cervical cancer	Postmenopausal Intermenstrual Postcoital Bleeding after pelvic exam	Dysuria Urinary hesitancy Dyspareunia Vaginal discharge Itching or burning of the vulva	+	+	+	Cervical mass on exam	+	± HPV Atypical cells on Pap smear STI: ± Chlamydia	↑ CA-125 Leukomoid reaction	Large cervical cancer Angiogenesis on Doppler sonography Bladder involvement Lymph node involvement	T2-weighted MRI : Ovoid, heterogeneous tumor distending the cervical canal with stromal involvement. PET/CT scan: Detect tumor size Lymph node involvement, Metastases to bladder or rectum	Cervical intraepithelial neoplasia: CIN1: mild dysplasia CIN2: moderate dysplasia CIN3: high degree of dysplasia/metastases	Colposcopy/biopsy
Cervical leiomyoma	Heavy/prolonged menstrual bleeding Intermenstrual bleeding	Urinary retention Constipation Infertility Bowel obstruction Increase in pregnancy/labor complications Vaginal discharge	+	+	−	Large,irregular pelvic mass	±	−	Erythrocytosis	Well circumscribed hyperechoic mass	T2-weighted MRI: Hypointense masses Homogeneous enhancement Red degeneration	Spindle shaped smooth muscle cells Mature adipocytes Extracellular matrix consist of collagen,fibronectin.	Clinical diagnosis/ and Ultrasound
Cervical lymphoma	Postmenopausal bleeding	Difficulty urinating Post-coital pain	+	+	+	Larrge uterine/cervix mass Irregularity	+	Pap smear: Small round blue cells High nuclear/cytoplasm ratio, Scant cytoplasm	Immunohistochemistry markers: CD19, CD20, CD79a, PAX5	Well-defined, solid, concentric, hypoechoic mass	MRI: Intramyometrial infiltrative nodules	Small tumor cells with large nuclei High mitoses and proliferation	Biopsy diffuse large B-Cell lymphoma (DLBCL) most frequent type.
Cervical sarcoma	Intermentrual Postmenopausal	Post-coital pain Fullness in pelvic Vaginal discharge	+	+	±	Cervical mass Lump protruding from vagina/vulva	+	−	Leiomyosarcoma markers: Positive for for S-100 and vimentin and are negative for desmin, myoglobin and actin.	Endometrial mass with heterogeneous echogenicity	MRI: Endometrial polypoid mass Hypointense hypervascular solid components	Poorly circumscribed bulky mass protruding from cervical canal Different subtypes: Leiomyosarcoma Endocervical sarcoma Embryonal rhabdomyosarcoma( Sarcoma botryoides)	Biopsy
Cervical erosion(Ectropion)	Light bleeding after pelvic exam Spotting	Post-coital pain Painful cramps Dyspareunia Vaginal discharge Itching of vulvovaginal area	+	+	−	Red, glandular area around os of cervix	−	−	N/A	N/A	N/A	Squamous metaplasia Vascular ectasia Lymphocytic infiltration	Colposcopy and biopsy
Cervicitis	Intermenstrual bleeding Postcoital Bleeding after pelvic exam	Pain during urination Pain during sex Painful menstruation Purulent vaginal discharge Itching of vulva	+	+	May have fever only	Red,inflammed swollen cervix Inflammation/irritation of vulva/vagina	−	STI panel: Chlamydia Gonorrhea Herpes simplex Trichomonas vaginalis	↑ WBC + NAAT for chlamydia, gonorrhea		MRI: May be detected as retention cysts in cervix.	Non-specific, lymphocytic infiltration may be seen in microscopic histology. Koilocytic changes in case of HPV as cause of chronic cervicitis.	Nucleic acid amplification tests (NAATs)
Adenemyosis	Abnormal uterine bleeding	Painful menstruation	+	+	−	Polypoid mass protruding into the endocervical canal.	Enlarged uterus may present as abdominal mass	−	↑ CA-125	Subendometrial striations Myometrial cysts Asymetrical thickness in myometrium walls Heterogenous echotexture of myometrium	MRI: Thickened junctional zone	Presence of ectopic endometrial glands into the myometrium.	Histology findings post hysterectomy
Cervical ectopic pregnancy	Amenorrhea Bleeding after pelvic exam	Pelvic pain	+	−	−	Soft and disporportionally enlarged uterus.	±	−	↑ β-HCG	Empty uterine Thickened endometrium	T2-weighted MRI: Hypointense large mass T1-weighted MRI: Partially hyperintense mass	Necrotic hemorrhagic mass with chorionic villus	Hysterectomy and biopsy
Nabothian cyst	Postcoital bleeding	Pain during sex Vaginal discharge	In very rare cases depending upon the size of cyst it can cause abdominal pain and amenorrhea	−	−	Majority of them are asymptomatic due to their small size( few milimeters) Cystic mass on exam	−	−	N/A	Anechoic well defined cystic lesions	T1-weighted Intermediate or slightly high signal intensity T2-weighted High signal intensity on T2-weighted images Benign cystic lesion	Multiple benign cystic masses, usually few milimieters in diameter.	Histopathological exam if large cystic masses

Epidemiology and Demographics

The estimated prevalence of cervical polyp is approximately 1.5–10% in general population.

Age

• Cervical polyp is more commonly observed among patients aged 40 to 55 years old.
• Cervical polyp is more commonly observed among perimenopausal and postmenopausal women.

Race

• There is no racial predilection for cervical polyp.

Risk Factors

Common risk factors in the development of cervical polyp, include:

• Chronic inflammation
• Hormonal factors
• Presence of endometrial hyperplasia
• Previous history of pregnancy

Natural History, Complications and Prognosis

• The majority of patients with cervical polyp remain asymptomatic for years.
• Early clinical features may include abnormal vaginal bleeding, postcoital vaginal bleeding, and abnormal vaginal discharge.
• If left untreated, only 0.2–1.7% of patients with cervical polyp may progress to develop malignant transformation.
• Common complications of cervical polyp include malignant transformation, bleeding, and recurrence.
• Prognosis is generally excellent, and the 5-survival rate of patients with cervical polyp is approximately 100%.

Diagnosis

Diagnostic Criteria

• The diagnosis of cervical polyp is made with a cervical biopsy, showing the following findings:

• Mixed epithelium (i.e. squamous and endocervical type (with eosinophilic mucin).
• Endocervical epithelium should have nuclei
• Inflammation
• Squamous metaplasia

Symptoms

• Cervical polyp is usually asymptomatic.
• Symptoms of cervical polyp may include the following:

• Intermenstrual bleeding (most common)
• Vaginal discharge
• Dyspareunia
• Bleeding after sex
• Dysmenorrhea
• Leukorrhea

Physical Examination

Patients with cervical polyp usually are well-appearing.

• Digital examination findings of the cervix, may include:
• Sessile or broad-based finger-like growth

Laboratory Findings

There are no specific laboratory findings associated with cervical polyp.

Imaging Findings

• Ultrasound is the imaging modality of choice for cervical polyp.
• On ultrasound, cervical polyp is characterized by the following findings:

• Sessile or pedunculated well-circumscribed masses within the endocervical canal
• May be hypoechoic or echogenic
• Identifying the stalk attaching to the cervical wall helps differentiate it from an endometrial polyp

• The image below shows a cervical polyp characterized as a well-circumscribed mass within the endocervical canal.

• 

  Image: Transverse ultrasound shows a cervical polyp characterized as a well-circumscribed mass within the endocervical canal.

Other Diagnostic Studies

• Cervical polyp may also be diagnosed with colposcopy.
• Findings on colposcopy may include:

• Protruding polypoid mass
• Smooth, red or purple, fingerlike growths on the cervix
• Cervical bleeding
• Cervical friableness

• A cervical biopsy will most often show cells that are consistent with a benign polyp.

Treatment

Medical Therapy

• There is no medical treatment for cervical polyp; the mainstay of therapy is surgical excision.
• Response to surgery can be monitored with regular ultrasound screenings every 6 or 12 months.

Surgery

• Surgery is the mainstay of therapy for cervical polyp.
• Ring forceps in conjunction with biopsy is the most common approach to the treatment of cervical polyp.
• Surgical string may also be performed for patients with cervical polyp.
• Other therapies, include: laser, or cauterisation. If the polyp is infected, an antibiotic may be prescribed.

Prevention

• Effective measures for the primary prevention of cervical polyp include periodical ultrasound and cervical screening.
• Once diagnosed and successfully treated, patients with cervical polyp are followed-up every 12 or 6 months.
• Follow-up testing includes pelvic examination, vaginal ultrasound, and colposcopy.