Polip Serviks

01Pathophysiology

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.

02Classification and Clinical Manifestation

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.

03Diagnostic Workup

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.

04Management and Treatment

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.

05Differential Diagnosis and Distractors

06Traps 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.