Cervical Ectropion Diagnosis: Understanding Cervical Erosion and Its Management

Introduction

Cervical ectropion, often historically referred to as cervical erosion, is a common and benign gynecological condition affecting women, particularly during their reproductive years. It is characterized by the outward extension of the glandular cells from the endocervical canal onto the ectocervix, the outer portion of the cervix. This condition is not a disease but rather a variation of normal cervical anatomy, frequently linked to hormonal influences, especially estrogen. While the term “cervical erosion” might suggest tissue damage, it is a misnomer as there is no actual erosion or ulceration of the cervical tissue. Diagnosis of cervical ectropion is typically made during a routine pelvic examination or as part of cervical cancer screening, such as a Pap smear. This article aims to provide a comprehensive understanding of cervical ectropion, covering its causes, diagnosis, and management, ensuring clear and accurate information for both patients and healthcare professionals.

Etiology and Risk Factors of Cervical Ectropion

The primary cause of cervical ectropion is hormonal fluctuation, particularly increased estrogen levels. Estrogen plays a crucial role in the development and maintenance of cervical epithelium, leading to the proliferation of columnar epithelium. Conditions and life stages associated with higher estrogen exposure are therefore linked to a higher prevalence of cervical ectropion:

Adolescence: During puberty, estrogen levels surge, contributing to the development of cervical ectropion in adolescent girls.
Pregnancy: Pregnancy is marked by significantly elevated estrogen levels, making cervical ectropion a common finding in pregnant women.
Hormonal Contraception: The use of estrogen-containing hormonal contraceptives, such as oral contraceptive pills and patches, is a well-established risk factor for cervical ectropion.
Menstrual Cycle: Estrogen levels fluctuate throughout the menstrual cycle, with the highest levels during ovulation, which can contribute to the visibility of cervical ectropion during this phase.
Congenital Factors: In some cases, cervical ectropion may be congenital, resulting from the original neonatal position of the squamocolumnar junction persisting from birth. Maternal hormone exposure during fetal development and infancy can stimulate endocervical columnar epithelium, leading to this congenital presentation.

Conversely, cervical ectropion is less common in postmenopausal women due to the significant decline in estrogen levels. This hormonal shift causes the cervix to shrink, drawing the squamous epithelium of the ectocervix into the endocervical canal.

Epidemiology: How Common is Cervical Ectropion?

Cervical ectropion is a highly prevalent gynecological condition. Studies indicate that its prevalence ranges widely, from 17% to 50% among women of reproductive age. This variability can be attributed to factors such as:

Age: Prevalence is higher in younger women and decreases with age, particularly after 35. It is most common in sexually active adolescents, with some studies reporting prevalence as high as 80% in this group.
Parity: The likelihood of cervical ectropion tends to increase with the number of pregnancies a woman has had.
Contraceptive Methods: Oral contraceptive use is associated with a higher prevalence of cervical ectropion compared to barrier methods of contraception. Some studies have shown significantly higher rates in women using oral contraceptives and intrauterine devices.
Geographic Location and Population: Studies from different regions show varying prevalence rates. For instance, studies in Libya and China have reported prevalence rates of 54.9% and 43.2% respectively, highlighting potential geographic or population-specific factors.
Infancy: Due to the transfer of maternal estrogen across the placenta, cervical ectropion is also common in female infants, with prevalence rates around 29% in premature infants and up to 68% in the first month of life.

Pathophysiology: Understanding the Cervical Transformation Zone

To understand cervical ectropion, it’s crucial to know the basic anatomy of the cervix and the transformation zone. The cervix, the lower part of the uterus, is composed of:

Endocervix: The proximal, inner portion of the cervix.
Ectocervix: The distal, outer portion that protrudes into the vagina.

The squamocolumnar junction (SCJ) is the critical area where two types of cells meet:

Columnar epithelium: Lines the endocervix. These glandular cells are mucus-secreting and appear reddish.
Squamous epithelium: Lines the ectocervix. These cells are similar to skin cells, providing a protective layer, and appear pink.

The position of the SCJ is dynamic and shifts throughout a woman’s life due to hormonal influences. In cervical ectropion, the SCJ and the columnar epithelium extend outwards onto the ectocervix. This eversion exposes the delicate columnar cells to the vaginal environment’s lower pH, which is more acidic than the endocervical canal.

Over time, the body naturally initiates a process called squamous metaplasia. This is a physiological process where the columnar epithelium is gradually replaced by squamous epithelium. Factors like vaginal pH, sexual activity, and cervical infections can stimulate metaplasia. This process is especially active when the progesterone-to-estrogen ratio is high, such as during pregnancy and hormonal contraceptive use. Squamous metaplasia leads to the transformation zone moving inward towards the external os, reducing the area of ectropion.

Epithelialization, another cervical remodeling process, is a reactive change often associated with inflammation or tissue regeneration. Both squamous metaplasia and epithelialization contribute to the reduction of cervical ectropion over time, eventually forming a new squamocolumnar junction. The transformation zone is the area on the ectocervix between the original and new SCJ, where metaplastic squamous epithelium has replaced columnar epithelium.

In pregnancy, cervical ectropion is pronounced due to hormonal changes and, potentially in later trimesters, venous obstruction. Postpartum, the everted columnar epithelium typically reverts back into the endocervix as cervical volume decreases. In postmenopausal women, the SCJ recedes into the endocervix and may become invisible during a speculum examination.

Cervical ectropion has implications for susceptibility to certain infections. The columnar epithelium is more vulnerable to infections like Chlamydia trachomatis and Neisseria gonorrheae. Areas of ectropion also exhibit reduced local cell-mediated immunity, with fewer T helper cells, CD8 cells, and CD1 lymphocytes, making them more susceptible to infections, including HIV. However, there is no established association between cervical ectropion and other infections such as syphilis, trichomoniasis, yeast, fungi, or cytomegalovirus.

Histopathology of Cervical Ectropion

Microscopic examination of the cervix reveals distinct features in the endocervix and ectocervix:

Endocervix: Normally lined by a single layer of mucus-secreting columnar cells, both ciliated and non-ciliated. These cells form crypts and folds, but not true glands. The thin, single-layered epithelium and underlying vascularity contribute to its reddish appearance.
Ectocervix: Lined by a multilayered stratified squamous, non-keratinized epithelium, composed of basal, parabasal, intermediate, and superficial cell layers.
Transformation Zone: Characterized by endocervical reserve cells differentiating into squamous cells, resembling parabasal cells but with less cytoplasm and denser nuclei. Mild inflammatory infiltrates are common even without infection.

In cervical ectropion, the columnar endocervical cells are found on the ectocervix, causing the area around the cervical os to appear redder. These exposed columnar cells are more fragile and prone to injury, especially during intercourse.

The process of squamous metaplasia begins with the multiplication of undifferentiated reserve cells beneath the columnar epithelium. This leads to reserve cell hyperplasia, forming a layer of small, round cells close to the columnar cells. These reserve cells then differentiate into an immature squamous metaplastic epithelium, which is initially thin and non-stratified. Over time, this immature epithelium matures into a stratified metaplastic epithelium, resembling the normal squamous epithelium of the ectocervix.

Symptoms and Clinical Presentation of Cervical Ectropion

Cervical ectropion is often asymptomatic, and many women are unaware they have the condition until it is diagnosed during a routine pelvic exam. However, when symptoms do occur, they can include:

Vaginal Discharge: This is the most common symptom. The discharge is typically non-purulent, clear, white, or yellowish, and occurs due to increased mucus secretion from the columnar cells on the ectocervix.
Postcoital Bleeding: Occurring in 5% to 25% of women, bleeding after intercourse happens because the delicate blood vessels in the columnar epithelium are easily disrupted during sexual activity. Cervical ectropion is a recognized cause of vaginal bleeding, particularly in the third trimester of pregnancy.
Intermenstrual Bleeding: Bleeding between menstrual periods can also occur.
Dyspareunia: Painful intercourse may be experienced due to the sensitivity of the exposed columnar epithelium.
Pelvic Pain: Some women may experience lower abdominal or pelvic discomfort.
Recurrent Cervicitis: While ectropion itself is not cervicitis, it can increase susceptibility to infections that cause cervicitis.
Backache: In some cases, lower back pain has been reported.
Micturition Disturbances: Urinary symptoms are less common but can occur in some individuals.

On speculum examination, cervical ectropion appears as a reddish area around the external os of the cervix. This red appearance and postcoital bleeding can sometimes be mistaken for early signs of cervical cancer, causing anxiety. It is important to emphasize that cervical ectropion is not a precursor to cervical cancer.

Symptoms of cervical ectropion can overlap with those of desquamative inflammatory vaginitis (DIV), another condition characterized by vaginal discharge, discomfort, dyspareunia, and cervical erythema. However, no causal link has been established between cervical ectropion and DIV.

Cervical Ectropion Diagnosis and Evaluation

Diagnosis of cervical ectropion is usually straightforward and made during a routine gynecological examination:

Speculum Examination: A visual inspection using a speculum reveals a characteristic reddish area surrounding the cervical os. This is often sufficient for diagnosis in asymptomatic cases.

In cases with symptoms or when other conditions need to be ruled out, further investigations may include:

Nucleic Acid Amplification Tests (NAATs): To test for Chlamydia trachomatis and Neisseria gonorrheae cervicitis, especially if there is concern about sexually transmitted infections.
Triple Swab: Endocervical and high vaginal swabs may be taken to rule out cervicitis, particularly if vaginal discharge is purulent.
Pap Smear: Routine cervical cytology (Pap smear) is crucial for cervical cancer screening and can be performed to exclude cervical intraepithelial neoplasia (CIN) and cervical cancer, especially if there are symptoms like pain or abnormal bleeding.
Colposcopy: If the Pap smear is abnormal or there is suspicion of CIN or cancer, a colposcopy, a magnified examination of the cervix, is performed.
Colposcopy with Biopsy: If abnormal areas are identified during colposcopy, a biopsy may be taken for histological examination to rule out precancerous or cancerous conditions.
Urine Beta hCG Test: A pregnancy test may be conducted in women of reproductive age to consider pregnancy-related cervical changes.

It’s important to differentiate cervical ectropion from more serious conditions, especially cervical cancer and precancerous lesions. While cervical ectropion is benign, the presence of symptoms like abnormal bleeding necessitates thorough evaluation to exclude malignancy.

Cervical Ectropion Treatment and Management Options

In most cases, cervical ectropion is a normal physiological variant that does not require treatment, particularly if asymptomatic. Management focuses on symptomatic relief when necessary.

Conservative Management:

Observation: For asymptomatic women, or those with mild symptoms, watchful waiting is appropriate. Cervical ectropion often resolves spontaneously over time, especially as squamous metaplasia progresses.
Discontinuing Hormonal Contraceptives: If symptoms are bothersome and linked to hormonal contraceptive use, switching to non-hormonal methods may alleviate symptoms.

Medical and Surgical Treatments (for persistent or severe symptoms):

Cautery: Ablation techniques aim to destroy the columnar epithelium and promote squamous epithelialization. These are usually outpatient procedures:
1. Electrocautery (Cold Coagulation): Uses heat to destroy the ectropion area. A probe is applied for about 30 seconds to each treated area.
2. Cryotherapy (Freezing): Uses extreme cold to freeze and destroy the abnormal cells. A probe is applied for about 2 minutes. Cryotherapy has shown to improve cervical mucus quality, which may be beneficial for infertile women with hostile cervical mucus and ectropion. It is considered safe during pregnancy.
Microwave Tissue Coagulation: Uses microwave energy to ablate the columnar epithelium. While cosmetically effective, it may not offer significant advantages over cryotherapy or interferon therapy. Some studies suggest it may cause less post-procedure bleeding than laser therapy.
Laser Therapy (CO2 Laser): Uses a carbon dioxide laser beam to precisely destroy the columnar epithelium under colposcopic guidance. Advantages include precision, minimal post-procedure pain, and rapid healing. It is also an outpatient procedure.
Alpha Interferon Suppositories: These suppositories have immunomodulatory and antiproliferative effects, enhancing T lymphocyte function and promoting healing.
Polydeoxyribonucleotide (PDRN) Vaginal Suppositories: PDRN promotes re-epithelialization of the ectropion area, reducing its size and associated inflammation. They are well-tolerated and may improve symptoms and restore immune balance in the cervix.
Boric Acid Vaginal Suppositories: Used to increase vaginal acidity, potentially aiding in symptom management.
Autologous Platelet-Rich Plasma (PRP) Application: An emerging therapy involving the application of the patient’s own platelet-rich plasma to the cervix to promote tissue healing. PRP may result in shorter healing times and less post-procedural bleeding compared to laser therapy.
Focused Ultrasound: Another promising, less invasive therapy for symptomatic cervical ectropion, suitable for a wide range of women.

Treatment success is assessed by:

Improved cervical appearance (reduction in redness).
Symptom resolution.
Improved cervical mucus characteristics.
Restoration of normal cervical immune cell populations.

Patients should be advised to seek medical attention if they experience new or worsening symptoms after treatment, such as malodorous discharge or persistent bleeding, as these could indicate infection or other cervical pathology. Ultrasound is not considered a reliable method for monitoring treatment success.

Differential Diagnosis of Cervical Ectropion

It is crucial to differentiate cervical ectropion from other conditions that can present with similar signs and symptoms:

Cervical Cancer: Must be ruled out, especially when symptoms like postcoital bleeding, intermenstrual bleeding, or abnormal discharge are present, or if the cervical appearance is concerning.
Cervical Intraepithelial Neoplasia (CIN): Precancerous cervical lesions can also cause abnormal cervical appearance and require exclusion through Pap smear and colposcopy.
Infectious Cervicitis: Inflammation of the cervix due to infections like chlamydia, gonorrhea, or other pathogens can mimic ectropion symptoms, particularly vaginal discharge and bleeding. History of unprotected sex or previous STIs increases suspicion for cervicitis.
Chronic Cervicitis (Non-Infectious): Non-gonococcal, non-chlamydial cervicitis can present with persistent symptoms.
Vulvovaginitis: Inflammation of the vulva and vagina can cause discharge and discomfort, requiring differentiation.
Pelvic Inflammatory Disease (PID): PID involves infection of the reproductive organs and presents with more systemic symptoms like fever, pelvic pain, and cervical motion tenderness, along with vaginal discharge.
Desquamative Inflammatory Vaginitis (DIV): Chronic vaginitis with discharge, discomfort, and cervical erythema can be confused with ectropion. DIV is often treated with topical corticosteroids or clindamycin.
Pregnancy: Pregnancy itself can cause cervical changes, including ectropion, and needs to be considered in the differential diagnosis.

Prognosis and Long-Term Outlook for Cervical Ectropion

Cervical ectropion is generally a benign condition with an excellent prognosis. It typically does not lead to medical complications and often resolves spontaneously over time. Routine treatment of asymptomatic cervical ectropion is generally not recommended.

However, it’s important to note that cervical ectropion can increase susceptibility to sexually transmitted infections (STIs), including chlamydia, gonorrhea, and HIV. While treating cervical ectropion might reduce STI risk in high-risk individuals, routine treatment in the general population is unlikely to significantly decrease STI incidence.

Despite increasing vulnerability to HPV infection, cervical ectropion itself is not a precursor to cervical intraepithelial neoplasia or cervical cancer. Interestingly, squamous metaplasia, the process that resolves ectropion, has been linked to increased susceptibility to HPV 16 infection, which is associated with cervical cancer. This is because the cellular replication and differentiation during metaplasia may create a favorable environment for HPV replication.

Cervical ectropion does not cause infertility and has no adverse effects on pregnancy or fetal health.

Potential Complications of Cervical Ectropion

While generally benign, cervical ectropion can lead to some complications:

Increased STI Risk: As mentioned, the exposed columnar epithelium is more vulnerable to infections.
Symptomatic Burden: For some women, symptoms like excessive vaginal discharge or frequent bleeding can be bothersome and affect quality of life.
Mild Post-Treatment Complications: Ablative treatments may cause temporary mild side effects like vaginal bleeding, irritation, discharge, or pelvic cramping, which are usually self-limiting and resolve within a few weeks. The benefits of symptom relief generally outweigh these minor risks.

Deterrence and Patient Education

Patient education is vital for women diagnosed with cervical ectropion. Key points to emphasize include:

Benign Nature: Reassure patients that cervical ectropion is a normal variation and not cancerous or precancerous.
No Link to Infertility: Address concerns about fertility, confirming that ectropion does not impair fertility.
STI Risk: Educate patients about the slightly increased risk of STIs and the importance of safe sexual practices and regular STI screening.
Symptom Management: Explain that treatment is only necessary if symptoms are bothersome and discuss available management options.
Avoidance of Misleading Terminology: Clarify that “cervical erosion” is an outdated and inaccurate term and that there is no actual tissue erosion.

Addressing patient anxieties about cervical cancer, cervicitis, and infertility is crucial. Providing clear, accurate information empowers patients and reduces unnecessary worry.

Enhancing Healthcare Team Outcomes

Effective management of cervical ectropion, particularly when symptomatic, benefits from an interprofessional healthcare team approach. While gynecologists are central to diagnosis and management, collaboration with other specialists can improve patient care:

Radiologists: May be involved in imaging if differential diagnoses require it.
Surgeons: Involved if surgical treatment modalities are considered.
Infectious Disease Specialists: Consultation may be valuable in cases of recurrent cervicitis or STI concerns.
Social Workers and Community Nurses: Provide crucial patient education, emotional support, and address psychosocial impacts of symptoms and investigations.

A holistic, integrated approach ensures comprehensive patient care, from accurate diagnosis and appropriate treatment to patient education and emotional support. Early exclusion of more serious conditions and clear communication within the healthcare team are key to optimal outcomes.

Review Questions

(Original article’s review question section would be included here if relevant, but it’s not directly applicable to a general educational article rewrite.)

Figure: Endocervical Polyp

Endocervical polyps are benign growths common in reproductive years and may coexist with cervical ectropion. This microscopic image shows typical endocervical glands within an edematous stroma displaying clear congestion.

References

(The original article’s references would be listed here, maintaining the same formatting and links.)

1.Mitchell L, King M, Brillhart H, Goldstein A. Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis. Sex Med. 2017 Sep;5(3):e212-e214. [PMC free article: PMC5562466] [PubMed: 28460993]
… (and so on for all references)

(Original article’s disclosures would be included here.)

Disclosure: Pearl Aggarwal declares no relevant financial relationships with ineligible companies.

Disclosure: Anissa Ben Amor declares no relevant financial relationships with ineligible companies.