Overview Of Cervical Ectropion
Cervical ectropion is a benign condition that is regarded as a normal variant found in women of the reproductive age group. In this condition, the glandular cells (the columnar epithelium) that line the endocervix are present on the ectocervix, leading to exposure of the columnar cells to the vaginal milieu. It is also known as cervical ectopy or cervical eversion. This condition has also been referred to as cervical erosion, which is a misleading term because there is no actual erosion of the cervix.
Cervical ectropion is usually found on routine pelvic examination of women in the reproductive age group. It is an asymptomatic variant but has been correlated with chronic cervicitis. It is a common physiological condition amongst adolescents and pregnant women.
Causes Of Cervical Ectropion
The occurrence of cervical ectropion is related to increased estrogen levels. The cervix is highly responsive to estrogen, causing the proliferation and differentiation of the cervical epithelium.
Therefore cervical ectropion is usually found in the conditions of high estrogen exposure, which are as follows:
● Adolescents
● Pregnancy
● Women on hormonal contraception
● During the years of menstruation, most commonly seen in the ovulatory phase
It may be a congenital condition due to the persistence of the squamocolumnar junction at its original neonatal location. During late fetal development and the first month of life, maternal hormone exposure stimulates hyperactivity of endocervical columnar epithelium and produces cervical ectropion.
It is uncommon in postmenopausal women. In the postmenopausal phase, the estrogen levels are declining, causing the cervix to shrink and invert, thus drawing the squamous cell epithelium of the ectocervix into the endocervical canal.
Symptoms Of Cervical Ectropion
Often there are no symptoms of a cervical ectropion and it is only noticed during a cervical smear examination.
Symptoms that can occur include:
• Vaginal discharge – With the mucus cells more exposed within the vagina, more mucus can cause a discharge.
• Postcoital bleeding – the mucus-producing cells are not very good at withstanding damage, and are more likely to cause bleeding after sexual intercourse. Bleeding after intercourse is potentially a sign of cervical cancer and if this occurs, you should see your GP.
Treatment Of Cervical Ectropion
Cervical ectropion requires no treatment unless the symptoms are affecting the patient’s daily life. First-line treatment is the discontinuation of the use of hormonal contraceptives like oral contraceptive pills, depot medroxyprogesterone acetate, and switching to nonhormonal methods of contraception.
If the symptoms persist, the following treatment can be offered:
● Cautery, it is an outpatient procedure, carried out without general or local anesthesia. There are 2 types of cautery:
1. Electrocautery also is known as cold coagulation. The cautery probe is held for 30 seconds against the area of ectropion, while the area is treated with heat to destroy the abnormal cells.
2. Cryotherapy (freezing): The cautery probe is held for two minutes against the area of ectropion, while the area is getting frozen. It has been observed that post-treatment with cryotherapy, shows an improvement in the quality of the cervical mucus. Therefore infertile women who also have cervical ectropion along with hostile cervical mucus can be treated with cryotherapy. It is safe in pregnancy.
● Microwave tissue coagulation. Although the appearance of the cervix is better after microwave tissue coagulation, no other benefits have been found out as compared with either interferon-alpha suppository therapy or cryotherapy.[28] Some studies show that there is less vaginal bleeding after microwave tissue coagulation as compared with vaginal bleeding after laser therapy.
● Laser therapy. In this procedure, the carbon dioxide laser beam is used to destroy the abnormal cervical epithelium seen on magnification by a colposcope. It is an outpatient procedure and is done under no general or local anesthesia. The advantages of laser therapy are better precision, insignificant pain post-procedure, and rapid healing.
● Alpha interferon suppository. It has an immunomodulatory effect and an anti-proliferative effect. Interferon-alpha enhances the function of the T lymphocytes.
● Polydeoxyribonucleotide vaginal suppository. It leads to re-epithelialization of the area of the ectropion, therefore reducing the size of the ectropion. The efficacy of this modality is explained by the excellent tolerability and compliance among the users, reduced inflammation, increased iodine-dark areas, the reestablishment of normal balance in T- and B-lymphocytes, and a reduction in the intensity of symptoms.
● Boric acid vaginal suppositories can be used to make the pH acidic.
● Autologous platelet-rich plasma application. It is a promising therapy. The tissue healing time is short, and post-procedural bleeding is much less than laser therapy.
● Focused ultrasound is another promising therapy for symptomatic cervical ectropion as it can be used for a wide variety of women.
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Other information
The cervix is the lower part of the uterus and is composed of two parts:
1. Endocervix. It is the proximal portion of the cervix.
2. Ectocervix. It is the distal portion of the cervix that projects into the vagina.
The squamocolumnar junction is the area in the cervix where the columnar and the squamous epithelium meet. The position of the squamocolumnar junction varies with age and hormone levels. The neonatal position of the squamocolumnar junction changes with hormonal influences in utero, at puberty, during pregnancy, and after menopause. At birth and menarche, it is located just within the cervical canal. During reproductive age, the columnar epithelium extends outward onto the ectocervix as the cervix events. This causes the squamocolumnar junction to move outwards as well, thus exposing it to the acidic pH of the vagina. In cervical ectropion, there is eversion of the squamous, columnar junction, as well as the columnar epithelium of the endocervix onto the ectocervix. Over time, the cells basal to the columnar cells proliferate and differentiate into squamous cells, thus replacing the overlying columnar cells. The cervical ectropion is decreased over time by two processes, squamous metaplasia, and epithelialization.
● Squamous metaplasia. It is a normal and irreversible physiological process in which the columnar epithelium is replaced by squamous epithelium. Low pH, sexual activity, and cervical infections may play a role in this process as well. This process is most pronounced when the progesterone/estrogen ratio is high, like during pregnancy, hormonal contraceptive use, and late fetal life. As the metaplasia progresses, the transformation zone moves downwards from its original squamocolumnar junction position, towards the external os, thus decreasing the area of the ectopy (ectropion).
● Squamous epithelialization. This is an additional process of cervical remodeling. It is a reactive change due to inflammation or regeneration.
As the above two processes of progress, cervical ectropion decreases with age. As a result of these processes, a new squamocolumnar junction is formed. The transformation zone is the dynamic area located on the ectocervix. The transformation zone lies between the original squamocolumnar junction and the current squamocolumnar junction, where the metaplastic squamous epithelium has replaced the columnar epithelium, which is the area of ectropion.
Cervical ectropion is a common finding in pregnancy. The eversion process begins early but is most marked during the second and third trimesters. Reproductive hormones play the most significant role, but in the third trimester, venous obstruction might be one of the factors for cervical ectropion development. Postpartum, the everted columnar epithelium reverts back into the endocervix due to a decrease in cervical volume.
In postmenopausal women, the squamocolumnar junction is invisible because it recedes into the endocervix.
Cervical ectropion has been associated with infection due to Chlamydia trachomatis. This can be attributed to the fact that Chlamydia trachomatis has a preference for the glandular epithelium. Also, the areas of ectropion represent an area of low cell-mediated immunity. In these areas, the subpopulation of T lymphocytes, namely, T helper cells, CD8 cells, and CD1 lymphocytes are reduced in number. Therefore it is more susceptible to infections like Chlamydia. Moreover, hormonal contraceptives, mainly the depot medroxyprogesterone acetate, has been associated with both cervical ectropion and chlamydial infection, therefore further enhancing the susceptibility of women with cervical ectropion for chlamydial infection.
Women with cervical ectropion also have a higher susceptibility to infection with Neisseria gonorrheae. The risk of acquiring infection by the human immunodeficiency virus (HIV) is also higher in females with cervical ectropion. However, there is no association between cervical ectropion and syphilis, trichomoniasis, and infections caused by cytomegalovirus, yeast, and fungi.
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