GYN 19-20

• Cervical ectopy (erosion)


  Condition where the squamous epithelium of the ectocervix is replaced by columnar epithelium, which is continuous with the endocervix. It is not an ulcer.

  
• Etiology of cervical ectopy

  • Congenital
  • Acquired

  
• Congenital cervical ectopy


  • At birth, in about one-third of cases, the columnar epithelium of the endocervix extends beyond the external os. This condition persists only for a few days until the level of estrogen derived from the mother falls. Thus, the congenital ectopy heals spontaneously.
• Acquired cervical ectopy

  • Hormonal: The squamocolumnar junction (SCJ) moves out when estrogen level is high, so the columnar epithelium extends onto the vaginal portion of the cervix replacing the squamous epithelium. This is observed during pregnancy and amongst 'pill users'. The SCJ returns back to its normal position after 3 months following delivery and little earlier following withdrawal of 'pill'.
  • Infection: The role of infection as the primary cause of ectopy has been discarded. However, chronic cervicitis may be associated or else the infection may supervene on an ectopy because of the delicate columnar epithelium which is more vulnerable to trauma and infection.
• Pathogenesis of cervical ectopy

  1. In the active phase, the squamocolumnar junction moves out from the os. The columnar epithelium of the endocervix maintains its continuity while covering the ectocervix replacing the squamous epithelium. The replaced epithelium is usually arranged in a single layer (flat type) or may be so hyperplastic as to fold inwards to accommodate in the increased area—a follicular ectopy. At times, it becomes heaped up to fold inwards and outwards—a papillary ectopy.

  2. During the process of healing, the squamocolumnar junction gradually moves up towards the external os. The squamous epithelium grows beneath the columnar epithelium until it reaches at or near to its original position at the external os. Alternatively, the replacement is probably by squamous metaplasia of the columnar cells. The possibility of squamous metaplasia of the reserve cells is also likely.

  3. During the process, the squamous epithelium may obstruct the mouth of the underlying glands (normally not present in ectocervix) → pent up secretion → retention cyst → nabothian follicle. Alternatively, the epithelium may burrow inside the gland lumina. This process of replacement by the squamous epithelium is called epidermidization.
• Cervical ectopy

  • It is not a precancerous state

  
• Symptoms of cervical ectopy

  • Vaginal discharge—the discharge may be excessively mucoid. It may be mucopurulent, offensive and irritant in presence of infection; may be even blood-stained.
  • Contact bleeding especially during pregnancy and 'pill use' either following coitus or defecation may be associated.
  • Associated cervicitis may produce backache, pelvic pain and at times, infertility.

  
• Signs of cervical ectopy

  • Per speculum—there is a bright red area surrounding and extending beyond the external os in the ectocervix. The outer edge is clearly demarcated. The lesion may be smooth or having small papillary folds. It is neither tender nor bleeds to touch. On rubbing with a gauze piece, there may be multiple oozing spots (sharp bleeding in isolated spots in carcinoma).
  • The feel is soft and granular giving rise to a grating sensation.

  
• Differential diagnosis of cervical ectopy

  • Ectropion: The lips of the cervix are curled back to expose the endocervix.
  • Early carcinoma: It is indurated, friable and usually ulcerated which bleeds to touch. Confirmation is by biopsy.
  • Primary lesion (chancre): The ulcer has a punched-out appearance.
  • Tubercular ulcer: There is indurated ulcer with caseation at the base. Biopsy confirms the diagnosis.

  
• Management of cervical ectopy

  1. All cases should be subjected to cytological examination from the cervical smear to exclude dysplasia or malignancy.

  2. Symptomatic cases: Detected during pregnancy and early puerperium, the treatment should be withheld for at least 12 weeks postpartum. In pill users, the 'pill' should be stopped and barrier method is advised.

  3. Persistent ectopy with troublesome discharge should be treated surgically by—(a) thermal cauterization; (b) cryosurgery; and (c) laser vaporization.

  
• All the methods employed for treating cervical ectopy are based on the principle of destruction of the columnar epithelium to be followed by its healing by the squamous epithelium.

  
• Eversion (ectropion)

  In chronic cervicitis, there is marked thickening of the cervical mucosa with underlying tissue edema. These thickened tissues tend to push out through the external os along the direction of least resistance. The entity is most marked where the cervix has already been lacerated. As a result the SCJ lies external to the cervical os.

  
• Cervical tear

  Varying degrees of cervical tear is invariable during vaginal delivery. One or both the sides may be torn or the tear may be irregular (stellate type). If there is no superimposed infection and the tear is small, the torn surfaces may appose leaving behind only a small notch. However, if infection supervenes, eversion occurs confusing the diagnosis of ectopy.
• Causes of cervical stenosis

  • Congenital: Hypoplasia of the lower part of Müllerian ducts.
  • Acquired: Operative trauma (forceps delivery), LLETZ, D/E, cervical amputation, infection, neoplasia, radiation or cone biopsy.

  
• Diagnosis and management of cervical stenosis

  1. Diagnosis: Resistance to pass a dilator of 1 to 2 mm into the uterine cavity. USG demonstrates the enlarged uterine size with fluid-filled cavity.

  2. Management: Slow dilatation of the cervical canal under anesthesia is done. It may be done under ultrasound guidance to minimize injury. Misoprostol may be used to soften the cervix. A latex tube may be kept in the cervical canal for sometime to maintain the patency. In postmenopausal women endometrial biopsy when needed, should be done after 7 days following drainage of the pyometra or hematometra.

  
• Cervical polyps


  Polyps are the most common benign neoplastic growth of the cervix. Polyps may arise from the endocervical canal (common) or from the ectocervix. Polyps develop secondary to the effect of chronic inflammation or due to hormonal stimulation. Endocervical polyps are usually reddish in color whereas the cervical polyps are grayish white.

  
• Histology of cervical polyps

  • Surface epithelium is columnar or squamous epithelium (squamous metaplasia). The pedicle is composed of vascular connective tissue which is loose, inflamed and edematous.

  
• Histologic subtypes of cervical polyps

  • Adenomatous
  • Fibromyomatous
  • Malignant change of an endocervical polyp is rare (0.5%).
• Treatment of cervical polyps

  Avulsion of the polyp with a sponge forceps and removal on twisting mostly is done. The specimen is sent for histological examination. The pedicle of the polyp when present may be treated with electro-diathermy. Endometrial curettage may be done following polypectomy in women older than 40 years to rule out any coexisting pathology.

  
• Elongation of the cervix

  The normal length of the cervix is about 2.5 cm. The vaginal and the supravaginal parts are of equal length. The elongation may affect either part of the cervix.
• Causes of cervical elongation

  • Elongation of the supravaginal part is commonly associated with the uterine prolapse.
  • Vaginal part is always elongated congenitally. Chronic cervicitis may produce some hypertrophy and makes the cervix bulky.
• Signs of supravaginal elongation of the cervix

  • Associated uterine prolapse
  • Shallow fornix
  • Normal length of vaginal cervix
  • Normal size of uterine body
  • Increased length of uterocervical canal evidenced by introduction of an uterine sound
• Congenital (circumoral) ectopy

  Ectopy that is present from birth
• Acquired ectopy


  Ectopy that develops due to hormonal effects, as observed during pregnancy and in 'pill users'
• The role of infection as the primary cause of ectopy has been discarded
• Types of ectopic erosion

  • Flat
  • Papillary
  • Follicular
• Healing of ectopy


  1. Replacement of columnar epithelium by downgrowth of squamous epithelium

  2. Squamous metaplasia of columnar cells or reserve cells

  3. Process called epidermidization
• Ectopy is not a precancerous state
• Ectopy is not an ulcer as it is entirely lined by columnar epithelium
• All cases should be subjected to cytological examination to exclude dysplasia or malignancy
• In asymptomatic cases, treatment should be withheld
• If detected during pregnancy, treatment should be withheld for at least 12 weeks postpartum
• Treatment of persistent ectopy with troublesome discharge

  1. Thermal cauterization

  2. Cryosurgery

  3. Laser vaporization
• Types of cervical cysts

  • Nabothian
  • Endometriotic
  • Mesonephric

  
• Confirmation of cervical cyst diagnosis is by histology

  
• Supravaginal elongation of the cervix


  Associated with uterine prolapse
• Congenital elongation of the cervix

  Characterized by deep fornix, elongated vaginal cervix, normal uterine body size, and increased uterocervical canal length
• Treatment of supravaginal elongation

  Same as treatment for uterine prolapse

  
• Treatment of congenital elongation

  1. Cervical amputation

  2. Cervicopexy (in presence of congenital prolapse)

  
• Leiomyomas are the most common benign tumors of the uterus and also the most common benign solid tumor in female