Cervical Polyps

Etiology

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:

• Premenopausal women
• Multigravida
• Sexually transmitted infections
• Previous history of cervical polyps

Epidemiology

Cervical polyps are a common condition seen in the gynecological practice; they are the second most common polyps seen at the gynecological examination, following the endometrial polyps.

In the general population, the estimated prevalence of cervical polyps is between 2 to 5 % of women. Multigravida women have an increased risk of developing cervical polyps compared to the nulliparous. One of eight women has a recurrence of cervical polyp after removal.

Localizing polyps during the routine gynecological examination before the development of high-resolution ultrasound and hysteroscopy, in addition to the fact that the cervical polyps are asymptomatic in most cases, was very challenging. Nowadays, using the currently available technologies made it easier for the gynecologist to identify and localize cervical polyps, which correlates with improved outcomes for the patients.[1]

Histopathology

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.[6]

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.[1]

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.[2]

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.[2]

Rarely, large polyps block the cervical canal, causing infertility.

On the speculum examination, a polypoid lesion is visible within the cervix.

Evaluation

The definitive diagnosis of cervical polyps is a histological examination. Therefore an approach is needed to exclude any associated pathologies such as:

1. Triple smear or vaginal-cervical-endocervical (VCE) smear
2. Transvaginal ultrasonography evaluates associated endometrial pathologies. If indicated, the clinician should perform an endometrial sampling.[2]

Treatment / Management

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.[3]

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).[4](B2)

• Up to 25% of women with cervical polyps have a coexisting endometrial polyp.[2]
• Cervical polyps are present in 10.9% of postmenopausal women and 7.8% of premenopausal women with any endometrial pathology.[5]
(B2)

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 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 polyp 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.[6](B3)

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.[7] (B2)

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.[8](B3)

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. 

Differential Diagnosis

The differential diagnosis of cervical polyps can be extensive as symptomatic patients usually present with abnormal uterine bleeding.

Abnormal uterine bleeding may happen due to different etiologies, such as:

1. Uterine fibroid.
2. Endometrial hyperplasia and malignancy.
3. Endometriosis.
4. Adenomyosis.
5. Cervical ectropion.
6. Cervical cancer.
7. Surface lesions of the genital tract.
8. Sexually transmitted infections.
9. Pregnancy-related conditions, i.e., ectopic pregnancy
10. During the gynecological examination, an endometrial polyp projecting through the cervical canal may resemble a cervical polyp if it is in the cervix.

Prognosis

As mentioned earlier, cervical polyps are benign in most cases, although they may be malignant in 0.2 to 1.5% of the cases. The removal of cervical polyps is a simple procedure with low complications. Women who have previously had polyps are at risk of recurrence. 

Complications

The main complication of a polyp is associated with infertility when they grow big enough to block the external os of the cervix.

Moreover, the polyps can become inflamed or infected. In this case, the patient will present with yellowish vaginal discharge.

However, a polypectomy itself can be associated with a few complications, which include:

1. Infection
2. Hemorrhage
3. Uterine perforation - to reduce this risk, only polyps that are visible easily should be removed in the outpatient setting. Clinicians should not blindly attempt to remove polyps from the cervical canal or intrauterine position.