Cervical Polyps

Etiology

The exact etiology of cervical polyps remains unknown, although several theories have been identified. One theory suggests that they may result from congestion of the cervical blood vessels, disrupting the blood flow and leading to polyp development. Other theories propose that polyps may form due to infections or chronic inflammation of the cervix. Long-term exposure to chemicals irritating the cervix could also lead to abnormal cellular changes.[2] Finally, another hypothesis suggests that an abnormal response to elevated estrogen levels may contribute to excessive cervical tissue growth, potentially linked to endometrial hyperplasia.

Some associated risk factors include:

• Premenopausal status 
• History of prior pregnancies
• Sexually transmitted infections
• Previous history of cervical polyps

Epidemiology

Cervical polyps are a common condition encountered in gynecological practice, ranking as the second most frequent type of gynecologic polyps, after endometrial polyps. The estimated prevalence of cervical polyps in the general population ranges from 2% to 5%, and they account for 4% to 10% of all cervical lesions. Multigravida patients have a higher risk of developing cervical polyps compared to nulliparous women. Additionally, approximately 1 in 8 patients experience recurrence of a cervical polyp after removal.[3]

Before the advent of high-resolution ultrasound and hysteroscopy, detecting cervical polyps during routine gynecological exams was challenging, particularly as most polyps are asymptomatic. Today, advanced imaging technologies have significantly enhanced the ability of gynecologists to detect and localize cervical polyps, resulting in more accurate diagnoses and improved patient outcomes.[4]

Histopathology

Histologically, cervical polyps are characterized by vascular connective tissue and stromal cells, covered by papillary proliferation of cells. These cells are made up of columnar, squamous, or squamocolumnar epithelium. Cervical polyps typically arise from glandular epithelial hyperplasia, with the tip of the polyp often exhibiting squamous metaplasia. 

The 2 types of cervical polyps—endocervical and ectocervical—cannot be distinguished based on their gross appearance. Microscopically, many histological patterns may be observed, including typical mucosa, inflammatory, vascular, fibrous, pseudo-decidual, mixed cervical and endometrial components, and pseudosarcomatous features.

Endocervical polyps are the most common type of cervical polyps and typically exhibit a loose, edematous stroma with variably sized blood vessels, ranging from large and dilated to small and thick-walled. The stromal cells often present with a mixture of acute and chronic inflammation, erosion, and benign microglandular hyperplasia. These manifestations are generally visible on the surface of larger polyps that protrude through the cervical os, depending on the degree of irritation.[5] 

History and Physical

Cervical polyps are often discovered incidentally during routine pelvic gynecological exams, colposcopy, or abdominal or transvaginal ultrasound. Approximately 2 out of 3 women with cervical polyps are asymptomatic. However, symptomatic individuals may present with postcoital bleeding, abnormal uterine bleeding (such as heavy menstrual bleeding, intermenstrual bleeding, postmenopausal bleeding), and vaginal discharge.[3]

On speculum examination, a polypoid lesion is typically visible on the cervix. In rare cases, large polyps may completely obstruct the cervical canal, leading to infertility. Cervical polyps may also bleed easily upon contact or manipulation.

Evaluation

Cervical polyps can be diagnosed through various methods. When identified incidentally during a speculum examination, further evaluation may involve imaging techniques such as transvaginal ultrasound.[ISUOG Basic Training. Examining the Uterus: Cervix & Endometrium]

In grayscale imaging, polyps may appear either hyperechoic or hypoechoic. They typically appear slightly hyperechoic compared to normal mucosa and may exhibit mobility during dynamic imaging in response to transducer pressure.

On color or spectral Doppler ultrasound, a vascular stalk extending from the endocervical mucosa into the polyp may be visualized, supporting an endocervical origin. However, because these lesions are often small, the accuracy of this technique depends significantly on the skill and experience of the clinician performing the ultrasound examination.[3]

Despite the availability of various diagnostic methods, definitive diagnosis of cervical polyps requires histological examination. Therefore, a comprehensive approach is recommended to exclude associated pathologies, including:

• Triple smear or vaginal-cervical-endocervical (VCE) smear.
• Transvaginal ultrasonography, which evaluates associated endometrial pathologies. If indicated, the clinician should perform an endometrial sampling.[3]

Treatment / Management

The management of cervical polyps largely depends on their clinical characteristics. Recent studies highlight the importance of performing polypectomy for all incidentally discovered cervical polyps, as histopathological evaluation is essential for definitive diagnosis of each lesion.[6] Symptomatic, large, or atypical polyps typically require removal.(B2)

Various techniques are used to manage polyps, including:

• Polypectomy for polyps with slender pedicles, which involves grasping the base of the polyp with ring forceps and twisting it until it detaches.
• Punch biopsy forceps for smaller polyps.
• Electrosurgical excision or hysteroscopic removal for polyps with thick stalks.

After polyp removal, the base may be cauterized or treated with silver nitrate to prevent bleeding and reduce the risk of recurrence. Electrosurgery or laser ablation may be used for treatment if the base is very wide. All excised polyps should be submitted for histological examination to exclude malignancy.[7]

In individuals with recurrent polyps or postmenopausal women, it is essential to perform further exploration of the cervical canal and uterine cavity via hysteroscopy to rule out any endometrial pathologies, such as polyps or malignancy.[8] Up to 25% of patients with cervical polyps have coexisting endometrial polyps.[3] Cervical polyps are present in 10.9% of postmenopausal women and 7.8% of premenopausal women with any endometrial pathology.[9] Some of the previously mentioned approaches are blind procedures, limiting their ability to accurately detect the origin, number, location, or size of the polyps. As a result, residual polyp fragments may remain in the cervical canal, potentially leading to recurrence if not properly removed.(B2)

Cervical polyps are uncommon during pregnancy and are typically small and asymptomatic. In some cases, cervical polyps can be misdiagnosed in the early weeks of pregnancy as abnormal vaginal bleeding, potentially leading to a diagnosis of an inevitable miscarriage. Ultrasound can help localize the source of the symptoms and aid in the differential diagnosis. Therefore, it is recommended to perform color Doppler ultrasound in pregnant patients with recurrent unexplained bleeding to exclude endocervical polyps and other potential causes, such as vasa previa.

Bleeding in the postpartum period can be a significant complication due to the vascular nature of cervical polyps. Another critical concern is their potential for malignancy; some studies have reported that up to 5% of symptomatic patients have precancerous or cancerous polyps. Therefore, histological examination is essential in such cases to confirm the diagnosis and guide appropriate management.[10](B3)

Suggested management of cervical polyps during pregnancy depends on the patient’s symptoms, the size of the polyp, and gestational age. However, definitive guidelines for these patients remain lacking and controversial.[11] Some studies suggest the removal of polyps during pregnancy with cryosurgery, whereas others advocate for conservative management to minimize the risk of heavy bleeding, preterm delivery, or abortion.[12][13][14](B2)

Significant variations in the size of cervical polyps are rare; however, giant cervical polyps were first reported in 2014. A case report described a pregnant patient who presented with preterm contractions and antepartum hemorrhage secondary to a giant endocervical polyp, which caused funneling and shortening of the cervical length. The patient underwent polypectomy at 38 weeks of gestation without complications.[12](B3)

In females with infertility associated with cervical polyps, after excluding other potential causes of infertility, hysteroscopic polypectomy has been shown to improve pregnancy rates. Untreated polyps may continue to grow, complicating infertility treatment and potentially developing into precursor lesions.

Differential Diagnosis

The differential diagnosis of cervical polyps can be broad, as symptomatic patients typically present with abnormal uterine bleeding. Abnormal uterine bleeding may result from various etiologies, including:

• Uterine fibroids
• Endometrial hyperplasia and malignancy
• Endometriosis
• Adenomyosis
• Cervical ectropion
• Nabothian cysts
• Cervical cancer
• Surface lesions of the genital tract
• Sexually transmitted infections
• Pregnancy-related conditions, such as ectopic pregnancy
• Endometrial polyps

Prognosis

Cervical polyps are predominantly benign but may be malignant in 0.2% to 1.5% of cases. Removal of cervical polyps is a straightforward procedure with a low complication rate. Women who have previously had polyps are at risk of recurrence. The recurrence rate is relatively low, reported at 6.2%, although this figure may not fully represent the true rate due to limited patient follow-up.[1][15]

Complications

The main complication of cervical polyps is infertility, particularly when they grow large enough to block the external os of the cervix. Additionally, polyps can become inflamed or infected, leading to the patient presenting with yellowish vaginal discharge.

Polypectomy itself can be associated with complications, including:

• Infection
• Hemorrhage
• Uterine perforation: Only easily visible polyps should be removed in the outpatient setting to reduce this risk. Clinicians should avoid blindly attempting to remove polyps from the cervical canal or intrauterine cavity.