Cervical ectropion is a benign condition that is regarded as a normal variant found in women of the reproductive age group. In this condition, the glandular cells (the columnar epithelium) that line the endocervix are present on the ectocervix, leading to exposure of the columnar cells to the vaginal milieu. It is also known as cervical ectopy or cervical eversion. This condition has also been referred to as cervical erosion, which is a misleading term because there is no actual erosion of the cervix.
Cervical ectropion is usually found on routine pelvic examination of women in the reproductive age group. It is an asymptomatic variant but has been correlated with chronic cervicitis. It is a common physiological condition amongst adolescents and pregnant women.
The occurrence of cervical ectropion is related to increased estrogen levels. The cervix is highly responsive to estrogen, causing the proliferation and differentiation of the cervical epithelium. Therefore cervical ectropion is usually found in the conditions of high estrogen exposure, which are as follows:
It may be a congenital condition due to the persistence of the squamocolumnar junction at its original neonatal location. During late fetal development and the first month of life, maternal hormone exposure stimulates hyperactivity of endocervical columnar epithelium and produce cervical ectropion.
It is uncommon in postmenopausal women. In the postmenopausal phase, the estrogen levels are declining, causing the cervix to shrink and invert, thus drawing the squamous cell epithelium of the ectocervix into the endocervical canal.
Cervical ectropion is one of the most commonly found gynecological conditions. The prevalence of cervical ectropion ranges between 17 percent and 50 percent. The prevalence increases with parity, but decreases with age 35 and above. Cervical ectropion can be found in up to 80% of sexually active adolescents. The prevalence also depends on the type of contraception used. It is seen more commonly in women taking oral contraceptive pills and less so in women using barrier methods of contraception.
Studies show that 54.9 percent of women in Benghazi, Libya, that use oral contraceptive pills and intra-uterine copper devices have cervical ectropion. Thus it was the most prevalent gynecological disorder in that population. 43.2 percent of women in China were reported as having cervical ectropion. The prevalence of cervical ectropion is about 29 percent in premature female infants, and 68 percent in the first month of life, that is due to the transfer of maternal estrogen through the placenta.
The cervix is the lower part of the uterus and is composed of two parts:
The squamocolumnar junction is the area in the cervix where the columnar and the squamous epithelium meet. The position of the squamocolumnar junction varies with age and hormone levels. The neonatal position of the squamocolumnar junction changes with hormonal influences in utero, at puberty, during pregnancy, and after menopause. At birth and menarche, it is located just within the cervical canal. During reproductive age, the columnar epithelium extends outward onto the ectocervix as the cervix events. This causes the squamocolumnar junction to move outwards as well, thus exposing it to the acidic pH of the vagina. In cervical ectropion, there is eversion of the squamous, columnar junction, as well as the columnar epithelium of the endocervix onto the ectocervix. Over time, the cells basal to the columnar cells proliferate and differentiate into squamous cells, thus replacing the overlying columnar cells. The cervical ectropion is decreased over time by two processes, squamous metaplasia, and epithelialization.
As the above two processes of progress, cervical ectropion decreases with age. As a result of these processes, a new squamocolumnar junction is formed. The transformation zone is the dynamic area located on the ectocervix. The transformation zone lies between the original squamocolumnar junction and the current squamocolumnar junction, where the metaplastic squamous epithelium has replaced the columnar epithelium, which is the area of ectropion.
Cervical ectropion is a common finding in pregnancy. The eversion process begins early but is most marked during the second and third trimesters. Reproductive hormones play the most significant role, but in the third trimester, venous obstruction might be one of the factors for cervical ectropion development. Postpartum, the everted columnar epithelium reverts back into the endocervix due to a decrease in cervical volume.
In postmenopausal women, the squamocolumnar junction is invisible because it recedes into the endocervix.
Cervical ectropion has been associated with infection due to Chlamydia trachomatis. This can be attributed to the fact that Chlamydia trachomatis has a preference for the glandular epithelium. Also, the areas of ectropion represent an area of low cell-mediated immunity. In these areas, the subpopulation of T lymphocytes, namely, T helper cells, CD8 cells, and CD1 lymphocytes are reduced in number. Therefore it is more susceptible to infections like Chlamydia. Moreover, hormonal contraceptives, mainly the depot medroxyprogesterone acetate, has been associated with both cervical ectropion and chlamydial infection, therefore further enhancing the susceptibility of women with cervical ectropion for chlamydial infection.
Women with cervical ectropion also have a higher susceptibility to infection with Neisseria gonorrheae. The risk of acquiring infection by the human immunodeficiency virus (HIV) is also higher in females with cervical ectropion. However, there is no association between cervical ectropion and syphilis, trichomoniasis, and infections caused by cytomegalovirus, yeast, and fungi.
Microscopic exam of normal cervix shows the following:
In cervical ectropion, the glandular endocervical cells are found on the ectocervix; thus, the area around the cervical os now appears red. Also, since the endocervical cells are more fragile and now exposed to the vaginal environment, they are more vulnerable to injury, for example, during sexual intercourse.
However, with time, the undifferentiated reserve cells of the endocervix multiply and differentiate. This is initially seen as a single (non-stratified) layer of small, round cells with darkly staining nuclei, that are situated very close to the nuclei of columnar cells, which further proliferate to produce a reserve cell hyperplasia. With the progression of the metaplastic process, the reserve cells of the endocervix proliferate and differentiate to form a thin epithelium of immature squamous cells without stratification. This newly formed epithelium is known as the immature squamous metaplastic epithelium. Over time, the immature metaplastic squamous cells differentiate into the mature stratified metaplastic epithelium.
Cervical ectropion is most commonly asymptomatic. In symptomatic cases, females may present with any of the following:
On speculum examination, the everted columnar epithelium appears reddish, arranged in a ring around the external os. The postcoital bleeding and reddish appearance of the cervix on the speculum exam may be confused for the early signs of cervical cancer. Cervical ectropion is not an early sign or a symptom of cervical cancer.
The presentation of symptomatic cervical ectropion and desquamative inflammatory vaginitis may overlap. Desquamative inflammatory vaginitis is chronic vaginitis with vaginal discharge, vulvovaginal discomfort, dyspareunia, erythematous macules on the cervix, on speculum examination. No causal relationship between cervical ectropion and desquamative inflammatory vaginitis has been found.
Being asymptomatic in most cases, cervical ectropion is diagnosed during a routine pelvic examination or at the time of pap screening. Cervical ectropion is assessed and quantified by a direct and unaided speculum examination that shows a reddish area around the cervical os.
Further investigations are carried out to exclude other possibilities. They include the following:
A urine beta hCG qualitative test is carried out as the reproductive hormonal pattern during pregnancy often leads to the development of cervical ectropion.
Cervical ectropion requires no treatment unless the symptoms are affecting the patient's daily life. First-line treatment is discontinuation the use of hormonal contraceptives like oral contraceptive pills, depot medroxyprogesterone acetate, and switching to nonhormonal methods of contraception. If the symptoms persist, the following treatment can be offered:
There is a cure rate of 92 percent with treatment with cautery or microwave tissue coagulation therapy. A cure rate of 79 percent has been seen with laser treatment.
Treatment success is determined by the following,
Ultrasound is not a reliable modality to monitor the treatment success of cervical ectropion.
The following symptoms after appropriate treatment should prompt the patient to return to the clinic for further evaluation for cervical infection or neoplasia.
Cervical ectropion usually does not lead to medical complications. Studies show that there is no benefit from the routine treatment of cervical ectropion. Only symptomatic women should consider treatment. Otherwise, it usually resolves itself, overtime.
However, cervical ectropion does increase the vulnerability of acquiring sexually transmitted infections, including chlamydia cervicitis, gonorrhea, and HIV. Studies have shown that the benefit of the treatment of cervical ectropion is seen only in some groups, for example, high-risk women who are more likely to acquire these infections. Otherwise, treating women for cervical ectropion in the general population, provides the little benefit of protection against these infections, given the large number of women to be treated.
Though cervical ectropion may cause a predisposition to HPV infection, it is not a precursor to cervical intraepithelial neoplasia and cervical cancer. Instead, it has been found that not cervical ectropion, but the process of squamous metaplasia leads to increased vulnerability to HPV 16 infection, which has malignant potential. This is because the host cell replication and differentiation process during squamous metaplasia may serve as a favorable ground for HPV virus replication.
Cervical ectropion does not lead to infertility. It has no adverse effects on pregnancy or the fetus.
Although cervical ectropion resolves itself over time, it creates a vulnerable ground for the seeding of various sexually transmitted infections, chlamydial cervicitis being the most common. Cervical ectropion may be debilitating for females who experience excessive vaginal discharge or frequent vaginal bleeding. However, appropriate treatment is successful in relieving these symptoms.
Mild complications may be noted after ablative treatment modalities. These complications include slight vaginal bleeding, vaginal irritation, scant vaginal discharge, or cramp-like pelvic pain. However, these do not interfere with day to day life and resolve themselves in a few weeks postprocedure. The benefits of the therapy, including long term relief of symptoms, and being an outpatient procedure that is safe, simple, and inexpensive far outweigh the minor risks.
Patients with cervical ectropion might not even be aware that they have it until it is diagnosed on a routine pelvic exam or a pap smears. The presence of symptoms like vaginal bleeding, dyspareunia, the excessive vaginal discharge might be alarming for patients. Patients usually worry about the possibility of cervical cancer, cervicitis, and infertility.
It is essential to educate the patient about cervical ectropion's benign nature and that it has no association with pathological conditions, but that carrying out other tests is required to rule out the possibility of these conditions. The patient should be fully informed about the treatment modalities available and offered treatment if the symptoms are bothersome. It will help to ease the fear of unnecessary financial burden, effects on work due to frequent hospital visits, and the interference with reproductive and sexual health.
Cervical ectropion poses a diagnostic dilemma. These patients may present with non-specific signs and symptoms such as white to yellow vaginal discharge, post-coital or intermenstrual bleeding, pelvic pain, and dyspareunia. Such signs and symptoms lead to a myriad of differential diagnosis, including conditions that could be cervical, vaginal, or vulvar in origin. An interprofessional team that provides a holistic and integrated approach to the formulation of a management plan can help achieve the best possible outcomes.
While the gynecologist is always involved in the care of patients with cervical ectropion, it is essential to consult with an interprofessional team of specialists that include a radiologist, surgeon, and infectious disease. The interventions carried out to rule out more severe conditions have a detrimental effect on a women's mental, social, and sexual life. Therefore, consultation should be made with a social worker and community nurse, as being vital members of the interprofessional group, they assist with the education and support of the patient and family. The earlier that the possibilities of infections, benign growths, and malignancy are ruled out, the better the prognosis and outcome will be. Collaboration, shared decision making, and communication are key elements for a good outcome.
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