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Summary Table

Category	Details
Risk Factors	Women of reproductive age (most common in 40s-50s), multigravida, chronic cervicitis, hormonal stimulation (hyperestrogenic states), use of hormonal contraceptives
Etiology	Focal hyperplasia of endocervical columnar epithelium in response to chronic inflammation, estrogen stimulation, or localized vascular congestion
Patient Presentation	Intermenstrual bleeding, postcoital bleeding, abnormal vaginal discharge (mucoid or blood-tinged), often asymptomatic and found incidentally on routine pelvic exam
Classic Physical Exam	Smooth, red or reddish-purple, pedunculated mass protruding from the external cervical os; soft, friable, bleeds easily on contact
Key Diagnostic Results	Visual identification on speculum exam; histopathology after removal shows benign endocervical stroma with dilated glands and chronic inflammatory infiltrate
Management	Simple polypectomy (twist at the base with ring forceps); send specimen for histopathologic examination to rule out dysplasia or malignancy
Keywords	"Postcoital bleeding," "painless mass protruding from cervical os," "friable," "pedunculated," "bleeds on contact"

1. Pathophysiology

Cervical polyps arise from focal hyperplasia of the endocervical mucosa, driven by chronic inflammatory stimulation, estrogen excess, or localized vascular congestion within the cervical stroma. The endocervical canal is lined by mucin-secreting columnar epithelium, and when this epithelium is subjected to prolonged irritation or hormonal stimulation, it undergoes localized overgrowth. The result is a polypoid projection that gradually elongates and becomes pedunculated, eventually prolapsing through the external os where it becomes visible on speculum examination.

The surface of the polyp is richly vascularized with thin-walled, dilated capillaries that sit close to the epithelial surface. This is why the polyp is characteristically friable and bleeds easily on contact, which explains the hallmark symptom of postcoital bleeding. The mechanical trauma of intercourse or even a routine speculum exam is enough to disrupt these fragile vessels.

The connection between hyperestrogenic states and polyp formation explains why these lesions are more common in perimenopausal women, women on exogenous estrogen, and those with obesity (peripheral aromatization of androgens to estrogen in adipose tissue). Chronic cervicitis from recurrent infections further perpetuates the inflammatory milieu that drives mucosal proliferation.

Importantly, the overwhelming majority of cervical polyps are benign. Malignant transformation is rare (reported in fewer than 1% of cases), but the clinical significance lies in the fact that cervical or endometrial malignancy can occasionally present as a polypoid lesion. This is why histopathologic evaluation of every removed polyp is mandatory.

2. Classification and Clinical Manifestation

Type	Origin	Appearance	Clinical Features
Endocervical polyp (most common)	Endocervical canal columnar epithelium	Smooth, red, elongated, pedunculated; protrudes through external os	Postcoital and intermenstrual bleeding, mucoid discharge; more common in multiparous women aged 40-60
Ectocervical polyp	Ectocervix squamous epithelium	Pale, broad-based, firmer texture; arises from outer cervical surface	Less common; tends to occur in postmenopausal women; less likely to cause bleeding

Most exam vignettes describe the endocervical type. The classic presentation is a woman in her 40s or 50s who reports painless irregular vaginal bleeding, often triggered by intercourse, and on speculum examination a smooth, red, pedunculated mass is seen at the cervical os. The polyp may also produce excessive mucoid or blood-tinged vaginal discharge due to mucin hypersecretion from the glandular epithelium and surface erosion.

Larger polyps can occasionally cause cramping or a sensation of pelvic pressure if they distend the cervical canal, but the majority are small (typically 1-2 cm) and painless.

3. Diagnostic Workup

Test	Role	Key Findings
Speculum examination	Best initial test	Visible smooth, red, pedunculated mass protruding from external os; friable, bleeds on contact
Histopathology of excised polyp	Confirmatory / Gold standard	Benign endocervical stroma with dilated glands, chronic inflammatory cells, and vascular congestion; rules out dysplasia or malignancy
Pap smear	Routine screening (not diagnostic of polyp itself)	Should be up to date; may show inflammatory changes or atypical cells prompting further evaluation
Endometrial biopsy	Adjunctive in select patients	Indicated if the patient has concurrent abnormal uterine bleeding, is postmenopausal, or if the polyp base appears to originate from the endometrial cavity
Transvaginal ultrasound	Adjunctive	May identify polyps within the endocervical canal not visible on speculum exam; helps distinguish cervical from endometrial polyps

The best initial test is direct visualization on speculum examination. In a vignette, this is typically the step that identifies the polyp. The appearance is characteristic enough to guide the next step, but visual diagnosis alone is not sufficient to confirm the benign nature of the lesion.

The confirmatory test is histopathologic examination of the removed polyp. Every cervical polyp removed must be sent for pathology. This is the only way to definitively exclude dysplasia, carcinoma in situ, or invasive malignancy arising within the polyp.

When the clinical picture raises concern for a higher origin of the polyp (for example, a postmenopausal woman with abnormal bleeding where an endometrial polyp may be prolapsing through the cervix), transvaginal ultrasound and endometrial biopsy become important adjuncts to rule out endometrial pathology.

4. Management and Treatment

Setting	Intervention	Details
Standard management	Office polypectomy	Grasp the polyp base with ring forceps (or Kelly clamp) and twist until avulsion is complete; no anesthesia typically required for small pedunculated polyps
Hemostasis	Chemical cautery or electrocautery	Apply silver nitrate or Monsel solution (ferric subsulfate) to the base if bleeding persists after removal
Post-removal	Histopathologic examination	Mandatory for all removed polyps
Large or broad-based polyps	Surgical excision under direct visualization	Hysteroscopic polypectomy if the polyp is large, sessile, or has a thick pedicle; allows controlled excision and adequate hemostasis
Recurrent polyps	Repeat polypectomy + evaluate for underlying cause	Consider hormonal evaluation and endometrial sampling; reassess for endocervical or endometrial pathology

The next best step when a cervical polyp is identified on exam is removal (polypectomy) followed by sending the specimen for histopathology. This is both diagnostic and therapeutic.

For the typical small, pedunculated endocervical polyp, office-based removal is straightforward. The polyp is grasped at its base with ring forceps and twisted with gentle traction until it detaches. The procedure is generally well tolerated without anesthesia because the endocervical stroma has limited sensory innervation. If minor bleeding occurs at the base, silver nitrate application or light electrocautery achieves hemostasis.

Larger polyps, sessile polyps, or those with a broad base warrant hysteroscopic excision because blind avulsion risks incomplete removal and more significant hemorrhage. This is also the preferred approach when the polyp origin is uncertain and an endometrial source must be excluded.

There is no role for pharmacologic treatment of cervical polyps. Observation alone (without removal) may be considered only for very small, asymptomatic polyps in young patients, but even then, removal is generally favored given the minimal procedural risk and the need for histologic confirmation.

In postmenopausal women presenting with a cervical polyp, the threshold for concurrent endometrial sampling should be low because the differential includes endometrial polyps and endometrial carcinoma presenting as a prolapsing mass.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Cervical carcinoma	Can present as a cervical mass with irregular bleeding and postcoital bleeding	Carcinoma is typically firm, irregular, ulcerated, or necrotic rather than smooth and pedunculated; biopsy is definitive
Endometrial polyp prolapsing through os	Polypoid mass visible at external os with abnormal bleeding	Originates from the endometrial cavity; ultrasound shows endometrial thickening or a stalk extending into the uterine cavity; more common in postmenopausal women
Cervical fibroid (leiomyoma)	Firm mass at the cervix with bleeding	Firmer consistency compared to the soft, friable polyp; broader base; histology shows smooth muscle bundles
Nabothian cyst	Cervical lesion found on speculum exam	Nabothian cysts are retention cysts of cervical glands, appearing as small, round, smooth, yellow-white or translucent bumps on the ectocervix; they do not protrude from the os and are asymptomatic
Cervical ectropion (ectopy)	Red appearance on cervical exam with postcoital bleeding	Ectropion is eversion of columnar epithelium onto the ectocervix, appearing as a symmetrical red ring around the os; no pedunculated mass is present
Sarcoma botryoides (embryonal rhabdomyosarcoma)	"Grape-like" mass protruding from vagina/cervix with bleeding	Occurs in young children (typically under age 5); not in adult women; histology shows rhabdomyoblasts and a cambium layer

6. Traps and High-Yield Pearls

The most common way students get questions about cervical polyps wrong is by failing to send the specimen for histopathology after removal. The exam tests whether you understand that benign appearance on gross inspection is not sufficient to exclude malignancy. The correct management sequence is always: identify the polyp on speculum exam, remove it, and send it to pathology. Choosing "observation" or "reassurance" without removal and histologic evaluation is the classic trap answer.

A second common pitfall involves confusing a prolapsing endometrial polyp with a cervical polyp. When a vignette describes a postmenopausal woman with abnormal uterine bleeding and a mass at the cervical os, consider that the origin may be endometrial rather than cervical. The test is checking whether you will order an ultrasound and endometrial biopsy in addition to polypectomy.

Another tested concept is distinguishing cervical polyps from cervical ectropion (ectopy), which also causes postcoital bleeding and a reddish appearance on exam. The key discriminator is that ectropion presents as a diffuse red zone around the os without a discrete pedunculated mass.

Finally, remember that cervical polyps are overwhelmingly benign, and malignant transformation is exceedingly rare. The exam will not ask you to treat a cervical polyp as cancer. Instead, it tests your understanding that histopathologic confirmation is a non-negotiable step in the workup, regardless of how benign the lesion appears clinically.

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