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Cervical Polyps

- The majority of cervical polyps are asymptomatic. - Some cause abnormal vaginal bleeding or discharge - Intermenstrual bleeding - Postcoital or postmenopausal bleeding - Leukorrhea

para>Rare

Pediatric Considerations

Rare

Pregnancy Considerations

Delay removal of polyps until postpartum unless bleeding or cervical dilation is found

EPIDEMIOLOGY

  • Predominant age: 40 to 60 years
  • Predominant sex: female only
  • 2-5% of females (1)

Incidence

  • Common
  • Likelihood of malignancy: 1/1,000 (2)

ETIOLOGY AND PATHOPHYSIOLOGY

Hyperplastic proliferation of cervical or endometrial cells

  • Unknown for most cases
  • Secondary reaction to cervical inflammatory or hormonal stimulation or localized vascular congestion of cervical blood vessels (1)
  • Rare incidence of dysplasia or malignancy

RISK FACTORS

None

GENERAL PREVENTION

None known

COMMONLY ASSOCIATED CONDITIONS

There is a possibility of coexisting endometrial polyps.

DIAGNOSIS

Cervical polyps are typically painless.

HISTORY

  • The majority of cervical polyps are asymptomatic.
  • Some cause abnormal vaginal bleeding or dischargeIntermenstrual bleedingPostcoital or postmenopausal bleedingLeukorrhea
  • Ask patient about diethylstilbestrol exposure, and if this is present, consider alternate diagnoses (3)[A].

PHYSICAL EXAM

  • Polyp may be an incidental finding on routine speculum exam.
  • Tear-shaped/lobular structures protruding from cervix
  • May appear-flesh colored/purple/red
  • Histologic exam: Vascular connective tissue stroma covered by epithelium may be columnar, squamous, or squamocolumnar.
  • Document a polyp's location and size.

DIFFERENTIAL DIAGNOSIS

  • Prolapsed submucous myoma or endometrial polyp
  • Other causes of intermenstrual bleeding
  • Decidualized endometrium

DIAGNOSTIC TESTS & INTERPRETATION

  • Send polyp for pathologic analysis.
  • Sonohysterography may be helpful if there is suspicion of multiple polyps or to determine if polyp is originating from the endometrium.

Diagnostic Procedures/Other

Perform Pap smear before treatment if the patient is due for screening.

Test Interpretation

  • Benign hyperplastic endocervical epithelium, often with a large number of blood vessels involved
  • Rare incidence of dysplasia or malignancy (2,4)Most atypia is found in teens and those in their 20s (2).Most cancers are found in women >48 years (2).Risk of malignancy in asymptomatic polyps with no prior evidence of abnormal cytology <1/1000 (4)
  • Case reports of metastatic disease in the polyp, lymphoma, and sarcoma botryoides (5,6)

TREATMENT

  • There is no clear indication for removal of asymptomatic cervical polyps, although it is often done (4)[B].
  • Indications for removal of polyps are abnormal vaginal bleeding, such as postcoital, postmenopausal or intermenstrual bleeding, abnormal cervical cytology (4), or a polyp with an atypical appearance (3)[B].

SURGERY/OTHER PROCEDURES

  • Smaller polyps may be removed in the office as long as hemostatic agents are available. The polyp is grasped with a ring forceps and twisted on its stalk until it detaches. Local anesthetic is not generally necessary. Silver nitrate or Monsel solution may be applied if cautery is needed. Sessile polyps may be removed using an electrosurgical loop (with local anesthetic) (5)[C].
  • Polyps with broad base are at risk for bleeding so may consider procedure under anesthesia (5)[C].
  • Larger polyps may require removal in an operating room (5)[C].
  • Hysteroscopy may be considered given its precise visualization with the option to treat endocervical polyps at the same time (5)[C].
  • For polyps managed surgically, a histologic examination should be done to exclude malignancy (1)[A].

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Uncontrolled hemorrhage

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Recheck at routine appointments or as needed.

DIET

No modifications

PATIENT EDUCATION

Given the possibility of incomplete excision, patients should be educated about symptoms. Patients should also be aware that polyps after removal have a 12% rate of recurrence (4).

PROGNOSIS

  • <0.1% risk of malignancy for asymptomatic polyps (4)
  • 12% rate of recurrence of polyps after removal (4)

COMPLICATIONS

Bleeding and mild pain with removal

REFERENCES

11 Goldshmid O, Schejter E, Kugler D, et al. Is removal of asymptomatic cervical polyps necessary?: histologic findings in asymptomatic Israeli Jewish women. J Low Genit Tract Dis. 2011;15(4):259-262.22 Schnatz PF, Ricci S, O'Sullivan DM. Cervical polyps in postmenopausal women: is there a difference in risk? Menopause. 2009;16(3):524-528.33 Casey PM, Long ME, Marnach ML. Abnormal cervical appearance: what to do, when to worry? Mayo Clin Proc. 2011;86(2):147-150.44 Nelson AL, Papa RR, Ritchie JJ. Asymptomatic cervical polyps: can we just let them be? Womens Health (Lond Engl). 2015;11(2):121-126.55 Stamatellos I, Stamatopoulos P, Bontis J. The role of hysteroscopy in the current management of the cervical polyps. Arch Gynecol Obstet. 2007;276(4):299-303.66 Ali MK, Ali AH, Abdelbadee AY, et al. Severe metrorrhagia caused by giant cervical polyp in a virgin. J Gynecol Surg. 2013;29(6):327-329.

ADDITIONAL READING

  • Dehner LP, Jarzembowski JA, Hill DA. Embryonal rhabdomyosarcoma of the uterine cervix: a report of 14 cases and a discussion of its unusual clinicopathological associations. Mod Pathol. 2012;25(4):602-614.
  • Godfrey GJ, Moore G, Alatassi H. Presentation of renal cell carcinoma as cervical polyp metastasis. J Low Genit Tract Dis. 2010;14(4):387-389.

CODES

ICD10

  • N84.1 Polyp of cervix uteri
  • O34.40 Maternal care for other abnormalities of cervix, unspecified trimester

ICD9

  • 622.7 Mucous polyp of cervix
  • 654.60 Other congenital or acquired abnormality of cervix, unspecified as to episode of care or not applicable

SNOMED

  • Polyp of cervix (disorder)
  • Endocervical polyp (disorder)
  • Polyp of cervix affecting pregnancy (disorder)

CLINICAL PEARLS

  • There is no clear indication to remove an asymptomatic polyp unless there is a suspicion of malignancy. Removal is recommended if the patient is symptomatic or if lesion is large.
  • Cervical polyps are rarely malignant.
  • Smaller polyps may be removed in the office if hemostatic agents are available. Larger polyps may be removed in the operating room.