Pictorial Case Study

Contributed by Dr Jean Watkins, a retired GP in Hampshire

Endocervical polyps should be removed and sent for histology
Endocervical polyps should be removed and sent for histology

The case
This 40-year-old woman attended the surgery with complaints of a profuse, clear vaginal discharge, and some intermenstrual and occasional post-coital bleeding for some weeks. She had two teenage children and had been taking the oral contraceptive pill for about 10 years.

Her last cervical smear, three years previously, had been normal. She felt well and had no other symptoms. Her periods were regular, although a bit heavier recently. General and vaginal examinations were normal.

What is the diagnosis, management and differential diagnosis?

DIAGNOSIS AND MANAGEMENT
A cervical smear was taken to exclude malignant change. During the smear, an endo-cervical polyp was found protruding from the os.

The cause of cervical polyps is in doubt but they do appear to be associated with chronic inflammation, blocked blood vessels in the cervix or as an increased response to raised levels of estrogen. They are relatively common, may be single or multiple and tend to occur in the 30-50 years age group.

Examination reveals a red or purple sessile polyp at the cervix. These are usually benign but malignant change is seen in about 1 per cent of cases. Sometimes it may be possible to 'twist off' the polyp with forceps or excise the lesion with laser or electrocautery to its base.

Swabs should be taken to exclude infection and an antibiotic is often prescribed as polyps are often infected. Once removed, the polyp should be sent for histology to exclude malignant change.

POSSIBLE DIFFERENT DIAGNOSES

  • Carcinoma of the cervix
  • Cervical warts
  • Endometrial warts
  • Fibroids

DIFFERENTIAL DIAGNOSIS
Carcinoma of the cervix

  • Squamous cell carcinoma or, occasionally, adenocarcinoma in the cervical canal.
  • Most common in the 45-55 age group.
  • More common in those with a history of coitus at a young age and/or multiple partners.
  • Associated with HPV types 16 and 18.
  • More common in smokers and the immunosupressed.
  • Symptomless in early stages. Later, watery, bloodstained, offensive discharge and pain.
  • Postcoital, intermenstrual or postmenopausal bleeding.

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