Cervical ectropion

Cervical ectropion, also known as cervical ectopy or eversion, is a benign gynecological condition characterized by the extension of the glandular columnar epithelium from the endocervix onto the ectocervix, resulting in a reddened, velvety appearance of the cervical os during pelvic examination.^[1] This normal variant exposes the sensitive columnar cells to the acidic vaginal environment, but it is not a disease or precancerous state.^[2] It commonly affects women of reproductive age, with prevalence rates ranging from 17% to 50% overall and up to 80% in sexually active adolescents.^[1] The condition is primarily driven by elevated estrogen levels, which promote the eversion of the squamocolumnar junction; it frequently occurs during adolescence, pregnancy, the ovulatory phase of the menstrual cycle, or with the use of hormonal contraceptives such as oral pills or intrauterine devices.^[1] Congenital cases may also exist, and it can resolve spontaneously through squamous metaplasia as estrogen levels decline, such as after menopause or cessation of hormonal therapy.^[2] While often asymptomatic, cervical ectropion may cause increased vaginal discharge due to the columnar epithelium's higher mucus production, postcoital or intermenstrual bleeding in 5% to 25% of cases, or dyspareunia.^[1] It is associated with a modestly increased risk of acquiring sexually transmitted infections like chlamydia, gonorrhea, and HIV, though this link requires further confirmation.^[1] Diagnosis is typically incidental during routine pelvic examinations or Pap smears, where the cervix appears erythematous and friable; colposcopy or biopsy may be performed to exclude malignancy or cervical intraepithelial neoplasia, but these are rarely indicated.^[3] Treatment is unnecessary for asymptomatic individuals, as the condition is harmless and self-limiting; for symptomatic cases, options include discontinuing estrogen-containing contraceptives, cryotherapy (with high success rates), electrocautery, or laser ablation, all of which promote re-epithelialization.^[1] Boric acid suppositories may provide relief for discharge, and procedures are generally safe even during pregnancy when needed.^[2] Overall, cervical ectropion requires no long-term monitoring beyond standard cervical cancer screening guidelines.^[3]

Overview

Definition

Cervical ectropion is a benign gynecological condition characterized by the eversion of the endocervical columnar epithelium onto the ectocervix, exposing these glandular cells to the acidic vaginal environment.^[1] This physiological displacement results in a distinctive reddish appearance on speculum examination, often surrounding the external os in a circumferential pattern, due to the thinner and more vascular nature of the columnar epithelium compared to the surrounding squamous epithelium.^[4] Unlike the flat, pale pink squamous cells that normally cover the ectocervix, the exposed columnar cells create a textured, inflamed-looking surface.^[2] Historically termed "cervical erosion," this nomenclature is now recognized as inaccurate and misleading, as the condition involves no actual denudation or loss of epithelial tissue.^[1] Instead, cervical ectropion represents a non-erosive eversion of the endocervical lining, distinguishing it from true cervical erosions that entail pathological ulceration or tissue destruction.^[2] As a non-neoplastic entity, cervical ectropion is considered a normal anatomical variant, particularly prevalent among women of reproductive age, and does not indicate malignancy or precancerous changes.^[1] It differs from pathological eversions, which may arise from infection, trauma, or other disorders, by being a hormone-influenced physiological state without associated tissue damage.^[4]

Epidemiology

Cervical ectropion is a prevalent benign condition among women of reproductive age, with overall prevalence estimates ranging from 17% to 50% in the general female population. Higher rates, up to 80%, are observed in sexually active adolescents, while prevalence can reach 54.9% among users of oral contraceptives and intrauterine devices in certain regional studies, such as in Benghazi, Libya. During pregnancy, the condition is particularly common due to elevated estrogen levels, affecting a substantial proportion of pregnant women. Postmenopausal prevalence decreases significantly, becoming uncommon as estrogen levels decline, though it may reappear in women receiving estrogen replacement therapy.^[1]^[5]^[1] Demographically, cervical ectropion predominantly affects adolescents and young women in their reproductive years, with notable associations in pregnant individuals and those using hormonal contraceptives, where estrogen exposure promotes glandular cell eversion. It is rare in postmenopausal women without exogenous estrogen, reflecting the role of hormonal status in its occurrence. Studies indicate no substantial geographic variation in prevalence globally, though detection rates may be elevated in populations with routine cervical screening programs, as evidenced by reports from diverse regions including China (43.2%) and various family planning cohorts.^[1]^[5]^[1] Age-related trends show cervical ectropion peaking in the 20-30 age group, coinciding with peak reproductive activity and hormonal influences, and increasing with parity up to a point before declining after age 35. The condition often resolves spontaneously following pregnancy or menopause, aligning with reductions in estrogen levels that allow squamous metaplasia to restore cervical anatomy.^[1]^[6]^[1]

Etiology and Pathophysiology

Causes and Risk Factors

Cervical ectropion primarily arises from elevated estrogen levels, which promote the eversion of the columnar epithelium from the endocervical canal onto the ectocervix.^[1] This hormonal influence is central to the condition's development, as estrogen stimulates the growth and exposure of glandular cells on the cervical surface.^[2] Key hormonal factors include physiological states associated with high estrogen, such as puberty and adolescence, where the cervix undergoes maturation and the squamocolumnar junction shifts.^[4] Pregnancy similarly elevates estrogen, often leading to transient ectropion that resolves postpartum.^[1] Use of oral contraceptives containing estrogen-progestin combinations increases the risk by mimicking these elevated levels, with studies showing higher prevalence among users.^[2] Hormone replacement therapy (HRT), particularly estrogen-based regimens in perimenopausal or postmenopausal women, can also trigger or exacerbate the condition.^[7] Additional risk factors encompass adolescent age, which overlaps with pubertal hormonal changes and is linked to up to 80% prevalence in sexually active teens.^[1] Multiparity contributes through potential cervical trauma during repeated vaginal deliveries, weakening structural integrity and facilitating epithelial eversion.^[2] Vaginal infections, such as bacterial vaginosis, may increase the visibility of ectropion by causing inflammation that highlights the exposed glandular tissue, though they do not directly cause the eversion.^[1] Non-hormonal contributors include congenital predisposition, where the squamocolumnar junction remains everted from birth due to in utero exposure to maternal estrogens, persisting into adolescence or resolving spontaneously.^[1] Estrogen's role in cervical physiology underscores these factors, as it influences epithelial proliferation without involving metaplastic changes.^[4]

Mechanism

Cervical ectropion develops through a process driven by elevated estrogen levels, which stimulate glandular activity in the endocervical epithelium, causing the squamocolumnar junction—the boundary between the squamous epithelium of the ectocervix and the columnar epithelium of the endocervix—to shift outward toward the vaginal canal.^[1] This eversion exposes the normally protected columnar epithelial cells to the vaginal environment, altering their physiological exposure.^[2] The columnar epithelium, characterized by its single layer of tall, mucus-secreting cells supported by a thin and highly vascular stroma, is more fragile than the overlying squamous epithelium, resulting in an appearance of inflammation due to increased vascularity and susceptibility to minor trauma, though no true epithelial erosion or ulceration occurs.^[1] Upon exposure, these cells encounter the acidic vaginal pH, typically ranging from 3.8 to 4.5, which irritates the delicate columnar tissue and may contribute to symptoms, but this interaction does not lead to malignant transformation or precancerous changes.^[1]^[8] Over time, the exposed columnar epithelium undergoes squamous metaplasia, a benign physiological process where reserve cells beneath the columnar layer proliferate and differentiate into stratified squamous epithelium, gradually covering the ectropion and restoring the normal cervical architecture.^[1] This metaplastic transformation is promoted by the acidic vaginal milieu and is a natural resolution mechanism, often completing within months to years depending on hormonal influences.^[1]

Clinical Presentation

Signs

Cervical ectropion is typically identified during speculum examination as a circumferentially distributed red, granular, or velvety area surrounding the external os of the cervix, arising from the eversion and exposure of the underlying glandular columnar epithelium.^[1]^[9] This epithelium's thin, transparent structure allows underlying blood vessels to show through, imparting the characteristic reddish hue and textured surface with fine, finger-like villous projections.^[9] The extent of the ectropion varies, without ulceration or significant friability in uncomplicated cases; however, the fragile epithelium may exhibit contact bleeding if irritated.^[1]^[2] Colposcopic evaluation reveals the diagnostic vascular pattern of the columnar epithelium, featuring a fine network of branching vessels without acetowhite changes upon acetic acid application, distinguishing it from neoplastic lesions.^[10]^[11] In most instances, cervical ectropion is asymptomatic and discovered incidentally during routine pelvic examinations or cervical screening.^[1]^[2]

Symptoms

Cervical ectropion is most commonly asymptomatic, with the majority of cases detected incidentally during routine pelvic examinations or cervical screening without any patient-reported complaints.^[1] Among symptomatic cases, the most frequent complaint is increased vaginal discharge, typically mucoid and non-foul-smelling, resulting from the greater mucus production by the exposed columnar epithelial cells.^[1] This discharge is often white or clear and may be exacerbated by sexual activity or hormonal changes, such as those during ovulation or with estrogen-containing contraceptives.^[2] Another common symptom is postcoital spotting or bleeding, occurring in 5-25% of women with cervical ectropion due to the fragility of the exposed vascular tissue, as well as intermenstrual spotting unrelated to intercourse.^[1] Less common symptoms include dyspareunia, or pain during sexual intercourse, and chronic pelvic discomfort, which may arise from irritation of the sensitive glandular epithelium.^[2] These symptoms are often triggered by friction during intercourse or fluctuations in estrogen levels, such as in pregnancy or adolescence, and tend to resolve spontaneously as the ectropion regresses through natural squamous metaplasia, particularly after menopause or cessation of hormonal influences.^[1]

Diagnosis

History and Physical Examination

The evaluation of suspected cervical ectropion begins with a detailed history to identify symptoms and contextual factors. Patients should be questioned about vaginal discharge, which is the most common presentation and often described as increased, non-purulent, white or yellow mucus due to the glandular nature of the exposed epithelium.^[1] Inquiries should include bleeding patterns, such as postcoital spotting or intermenstrual bleeding, which occurs in 5 to 25% of cases and may be linked to friable tissue.^[1] Additionally, sexual history is relevant to assess for dyspareunia or recurrent cervicitis, while contraceptive use—particularly estrogen-containing methods—and current pregnancy status should be explored, as both elevate risk through hormonal influences.^[2] Common symptoms like spotting between periods can guide this assessment.^[4] Risk assessment during history taking focuses on factors that predispose to or influence the condition. Age is a key element, with ectropion more prevalent in adolescents and reproductive-age women, often resolving after age 35 as estrogen levels stabilize.^[1] Hormonal status, including high estrogen from puberty, pregnancy (especially in the second or third trimester), or oral contraceptives, should be evaluated for its role in promoting columnar epithelium eversion.^[2] The duration and chronicity of symptoms, such as persistent discharge or bleeding, help differentiate benign ectropion from other pathologies.^[4] The physical examination includes a bimanual pelvic assessment to palpate for cervical tenderness or pelvic pain, which may accompany symptoms like dyspareunia.^[2] Speculum visualization is essential, revealing the characteristic reddish, velvety appearance of the everted columnar epithelium around the external os, often forming a ring-like pattern.^[4] This finding is typically incidental during routine exams but warrants documentation when symptoms are present.^[1] Red flags in the history or exam, such as irregular or heavy bleeding unresponsive to initial observation, necessitate prompt further investigation to exclude malignancy or cervical intraepithelial neoplasia.^[1] Persistent or atypical discharge similarly prompts evaluation beyond the basic exam.^[4]

Diagnostic Tests

Diagnosis of cervical ectropion primarily involves ruling out more serious conditions through targeted tests, as the condition often presents with a characteristic red, velvety appearance on speculum examination.^[1] The Pap smear is a key initial test, typically yielding normal results or showing reactive cellular changes and inflammation due to the exposure of columnar epithelium to the vaginal environment, helping to exclude dysplasia or malignancy.^[1]^[3] In one study of symptomatic women with cervical ectropion, approximately 55% had inflammatory findings on Pap smear, underscoring its role in identifying benign inflammatory processes rather than neoplastic changes. Colposcopy provides magnified visualization of the cervical surface to evaluate lesion borders, vascular patterns, and any atypical features, such as irregular vessels or acetowhite areas that might suggest dysplasia.^[1] It is particularly useful when symptoms like postcoital bleeding are present, allowing differentiation from precancerous lesions missed by cytology alone.^[3] If colposcopy reveals suspicious areas, a directed biopsy is performed to obtain tissue for histopathological analysis.^[1] Biopsy is indicated in cases of suspected infection, neoplasia, or persistent symptoms unresponsive to conservative management, as it provides definitive histological confirmation.^[1] Histology of ectropion typically demonstrates benign glandular columnar epithelium without dysplastic or malignant features, distinguishing it from other pathologies.^[12] For instance, biopsies in women with ectropion and normal cytology occasionally reveal coexisting low-grade cervical intraepithelial neoplasia, emphasizing the test's value in comprehensive evaluation.^[12] Key differential diagnoses include cervicitis (infectious or chronic), cervical polyps, cervical intraepithelial neoplasia or early invasive cancer, and cervical endometriosis, all of which may mimic the erythematous appearance of ectropion.^[1]^[3] Confirmation of ectropion relies on the absence of infectious agents, neoplastic cells, or ectopic endometrial tissue on biopsy, with columnar epithelium extending onto the ectocervix as the hallmark finding.^[1]

Management

Indications for Treatment

Cervical ectropion is typically asymptomatic and does not require treatment in such cases, as it is a benign condition that often resolves spontaneously without intervention.^[1] For instance, ectropion that develops during pregnancy frequently regresses within three to six months postpartum due to hormonal normalization.^[13] Treatment is indicated when symptoms persistently impact the patient's quality of life and do not respond to initial conservative measures, such as discontinuing estrogen-containing contraceptives.^[1] Common symptomatic thresholds include excessive vaginal discharge, postcoital or intermenstrual bleeding occurring in 5-25% of cases, and dyspareunia that interferes with sexual activity or daily functioning.^[1]^[2] Additionally, treatment is warranted if there is diagnostic uncertainty, such as when symptoms mimic infection, inflammation, or precancerous changes, necessitating exclusion of these via swabs or colposcopy prior to proceeding.^[14] For untreated cases, regular follow-up examinations are recommended as part of standard cervical cancer screening to monitor for any underlying pathology.^[15]

Treatment Options

For asymptomatic cases of cervical ectropion, conservative management is typically recommended, involving observation without intervention, as the condition often resolves spontaneously over time.^[1] If symptoms are linked to hormonal influences, discontinuing or switching from estrogen-containing contraceptives, such as oral contraceptive pills or depot medroxyprogesterone acetate, to nonhormonal methods serves as a first-line approach and may lead to regression of the ectropion.^[1] Additionally, boric acid suppositories can be used to acidify the vaginal environment and alleviate symptoms like excessive discharge.^[2] When conservative measures fail to relieve persistent symptoms, ablative therapies are employed to destroy the ectopic columnar epithelium and promote squamous metaplasia. Cryotherapy, which involves freezing the affected tissue using a probe or spray under no anesthesia, is a common outpatient procedure.^[1] Electrocautery (or diathermy), utilizing heat from an electric current via a coagulation ball under local anesthetic, achieves a cure rate of up to 92%.^[1] Laser ablation with a CO2 laser offers precise treatment with minimal pain and rapid healing, though its success rate is around 79%.^[1] Other options include microwave tissue coagulation, which reduces vaginal bleeding compared to laser, and chemical cautery with silver nitrate applied directly to smaller lesions.^[1]^[14] Cryotherapy is considered safe during pregnancy when treatment is indicated for symptomatic cases.^[1] Surgical excision is rarely indicated and reserved for extensive lesions or when diagnostic uncertainty necessitates removal, such as to rule out dysplasia.^[1] The prognosis following treatment is excellent, with most cases achieving resolution and low recurrence rates; importantly, cervical ectropion and its management do not affect fertility or increase cancer risk.^[1]