Cervical ectropion

Cervical Ectropion
Other names	Cervical eversion
	Cervical ectropion
Specialty	Gynecology

Last updated October 14, 2019

Cervical ectropion is a condition in which the cells from the 'inside' of the cervical canal, known as glandular cells (or columnar epithelium), are present on the 'outside' of the vaginal portion of the cervix. The cells on the 'outside' of the cervix are typically squamous epithelial cells. Where the two cells meet is called the transformation zone, also known as the stratified squamous epithelium. Cervical ectropion can be grossly indistinguishable from early cervical cancer and must be evaluated by a physician to determine risks and prognosis. It may be found incidentally when a vaginal examination (or pap smear test) is done. The area may look red because the glandular cells are red. While many women are born with cervical ectropion, it can be caused by a number of reasons, such as:

The cervical canal is the spindle-shaped, flattened canal of the cervix, the neck of the uterus.

The cervix or cervix uteri is the lower part of the uterus in the human female reproductive system. The cervix is usually 2 to 3 cm long and roughly cylindrical in shape, which changes during pregnancy. The narrow, central cervical canal runs along its entire length, connecting the uterine cavity and the lumen of the vagina. The opening into the uterus is called the internal os, and the opening into the vagina is called the external os. The lower part of the cervix, known as the vaginal portion of the cervix, bulges into the top of the vagina. The cervix has been documented anatomically since at least the time of Hippocrates, over 2,000 years ago.

A stratified squamous epithelium consists of squamous (flattened) epithelial cells arranged in layers upon a basal membrane. Only one layer is in contact with the basement membrane; the other layers adhere to one another to maintain structural integrity. Although this epithelium is referred to as squamous, many cells within the layers may not be flattened; this is due to the convention of naming epithelia according to the cell type at the surface. In the deeper layers, the cells may be columnar or cuboidal. There are no intercellular spaces. This type of epithelium is well suited to areas in the body subject to constant abrasion, as the thickest layers can be sequentially sloughed off and replaced before the basement membrane is exposed. It forms the outermost layer of the skin and the inner lining of the mouth, esophagus and vagina.

Signs and symptoms

Cervical ectropion can be associated with excessive, non-purulent vaginal discharge due to the increased surface area of columnar epithelium containing mucus-secreting glands as well as intermenstrual bleeding (bleeding outside of regular menses).^[1] It may also give rise to post-coital bleeding, as fine blood vessels present within the columnar epithelium are easily traumatized.

Intermenstrual bleeding, previously known as metrorrhagia, is uterine bleeding at irregular intervals, particularly between the expected menstrual periods. It is a cause of vaginal bleeding.

Causes

Cervical ectropion is a normal phenomenon, especially in the ovulatory phase in younger women, during pregnancy, and in women taking oral contraceptive, which increases the total estrogen level in the body.^[2] It also may be a congenital problem by the persistence of the squamocolumnar junction which is normally present prior to birth.

Mucopurulent cervicitis may increase the size of the cervical ectropion.^[3]

Mechanism

The squamocolumnar junction, where the columnar secretory epithelium of the endocervical canal meets the stratified squamous covering of the ectocervix, is located at the external os before puberty. As estrogen levels rise during puberty, the cervical os opens, exposing the endocervical columnar epithelium onto the ectocervix. This area of columnar cells on the ectocervix forms an area that is red and raw in appearance called an ectropion (cervical erosion). It is then exposed to the acidic environment of the vagina and, through a process of squamous metaplasia, transforms into stratified squamous epithelium.^[4]

Estrogen, or oestrogen, is the primary female sex hormone. It is responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three major endogenous estrogens in females that have estrogenic hormonal activity: estrone, estradiol, and estriol. The estrane steroid estradiol is the most potent and prevalent of these.

In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vulva to the cervix. The outer vaginal opening is normally partly covered by a membrane called the hymen. At the deep end, the cervix bulges into the vagina. The vagina allows for sexual intercourse and birth. It also channels menstrual flow (menses), which occurs in humans and closely related primates as part of the monthly menstrual cycle.

Squamous metaplasia is a benign non-cancerous change (metaplasia) of surfacing lining cells (epithelium) to a squamous morphology.

Treatment

Usually no treatment is indicated for clinically asymptomatic cervical ectropions. Hormonal therapy may be indicated for symptomatic erosion. If it becomes troublesome to the patient, it can be treated by discontinuing oral contraceptives, cryotherapy treatment, or by using ablation treatment under local anesthetic. Ablation involves using a preheated probe (100 °C) to destroy 3–4 mm of the epithelium. In post-partum erosion, observation and re-examination are necessary for 3 months after labour.

Related Research Articles

The Papanicolaou test is a method of cervical screening used to detect potentially precancerous and cancerous processes in the cervix. Abnormal findings are often followed up by more sensitive diagnostic procedures and if warranted, interventions that aim to prevent progression to cervical cancer. The test was independently invented in the 1920s by Dr. Georgios Papanikolaou and Dr. Aurel Babeș and named after Papanikolaou. A simplified version of the test was introduced by Anna Marion Hilliard in 1957.

Cervical cancer is a cancer arising from the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer.

Epithelium is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the outer surfaces of organs and blood vessels throughout the body, as well as the inner surfaces of cavities in many internal organs. An example is the epidermis, the outermost layer of the skin.

Breakthrough bleeding (BTB) is any of various forms of vaginal bleeding, usually referring to mid-cycle bleeding in users of combined oral contraceptives, as attributed to insufficient estrogens. It may also occur with other hormonal contraceptives. Sometimes, breakthrough bleeding is classified as abnormal and thereby as a form of metrorrhagia, and sometimes it is classified as not abnormal.

Vaginal bleeding is any bleeding through the vagina, including bleeding from the vaginal wall itself, as well as bleeding from another location of the female reproductive system, often the uterus. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Antepartum bleeding, also known as antepartum haemorrhage or prepartum hemorrhage, is genital bleeding during pregnancy after the 20th to 24th week of pregnancy up to delivery.

Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer. More specifically, CIN refers to the potentially precancerous transformation of cells of the cervix.

Hormonal contraception refers to birth control methods that act on the endocrine system. Almost all methods are composed of steroid hormones, although in India one selective estrogen receptor modulator is marketed as a contraceptive. The original hormonal method—the combined oral contraceptive pill—was first marketed as a contraceptive in 1960. In the ensuing decades many other delivery methods have been developed, although the oral and injectable methods are by far the most popular. Altogether, 18% of the world's contraceptive users rely on hormonal methods. Hormonal contraception is highly effective: when taken on the prescribed schedule, users of steroid hormone methods experience pregnancy rates of less than 1% per year. Perfect-use pregnancy rates for most hormonal contraceptives are usually around the 0.3% rate or less. Currently available methods can only be used by women; the development of a male hormonal contraceptive is an active research area.

In cell biology and pathophysiology, cellular adaptation refers to changes made by a cell in response to adverse environmental changes. The adaptation may be physiologic(al) (normal) or pathologic(al) (abnormal). Five minor types of adaptation include atrophy, hypertrophy, hyperplasia, dysplasia, and metaplasia.

Postcoital bleeding is bleeding from the vagina in women after sexual intercourse and may or may not be associated with pain. The bleeding can be from the uterus, cervix, vagina and other tissue or organs located near the vagina. Postcoital bleeding can be one of the first indications of cervical cancer. There are other reasons why a woman may bleed after intercourse. Some women will bleed after intercourse for the first time but others will not. The hymen may bleed if it is stretched since it is thin tissue. Other activities may have an effect on the vagina such as sports and tampon use. Postcoital bleeding may stop without treatment. In some instances, postcoital bleeding may resemble menstrual irregularities. Postcoital bleeding may occur throughout pregnancy. The presence of cervical polyps may result in postcoital bleeding during pregnancy because the tissue of the polyps is more easily damaged. Postcoital bleeding can be due to trauma after consensual and non-consensual sexual intercourse.

Vaginal adenosis is a benign abnormality in the vagina, commonly thought to be caused by intrauterine and neonatal exposure of diethylstilbestrol and other progestogens and nonsteroidal estrogens, however it has also been observed in otherwise healthy women and has been considered at times idiopathic or congenital. Postpubertal lesions have also been observed to grow de novo. It has a rather common incidence, of about 10% of adult women.

Microglandular hyperplasia (MGH) of the cervix is an epithelial benign abnormality (lesion) associated with gland proliferation. It can terminate in mature squamous metaplasia, and it is suspected reserve cells are involved in this process, perhaps in the form of reserve cell hyperplasia with glandular differentiation.

Pediatric gynaecology or pediatric gynecology is the medical practice dealing with the health of the vagina, vulva, uterus, and ovaries of infants, children, and adolescents. Its counterpart is pediatric andrology, which deals with medical issues specific to the penis and testes.

The vaginal epithelium is the aglandular inner lining of the vagina consisting of multiple layers of (squamous) cells. The basal membrane provides the support for the first layer of the epithelium-the basal layer. The intermediate layers lie upon the basal layer and the superficial layer is the outermost layer of the epithelium. Anatomists have described the epithelium as consisting of as many as 40 distinct layers. The mucous found on the epithelium is secreted by the cervix and uterus. The rugae of the epithelium create a involuted surface and result in a large surface area that covers 360 cm³. This large surface area allows the trans-epithelial absorption of some medications via the vaginal route.

Combined hormonal contraception(CHC), or combined birth control, is a form of hormonal contraception which combines both an estrogen and a progestogen in varying formulations.

References

↑ https://www.uptodate.com/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women
↑ Standring: Gray's Anatomy, 40th ed.
↑ Bope: Conn's Current Therapy 2011, 1st Edition.
↑ Standring: Gray's Anatomy, 40th ed.

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[1] ttps://www.uptodate.com/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women

[2] Standring: Gray's Anatomy, 40th ed.

[3] Bope: Conn's Current Therapy 2011, 1st Edition.

[4] Standring: Gray's Anatomy, 40th ed.