Cervical ectropion occurs when there is eversion of the endocervix, exposing the columnar epithelium to the vaginal milieu

Aetiology

• It is thought that cervical ectropion is induced by high levels of oestrogen; therefore, factors that increase the risk of ectropion are related to those that increase levels of oestrogen:
  • Use of the combined oral contraceptive pill
  • Pregnancy
  • Adolescence
  • Menstruating age (it is uncommon in post-menopausal women)

Pathophysiology

• The cervix is the lower portion of the uterus; it is composed of two regions - the ectocervix and the endocervical canal
  • Endocervical canal (endocervix) - the more proximal, and ‘inner’ part of the cervix, lined by a mucus-secreting simple columnar epithelium
  • Ectocervix - the part of cervix that projects into the vagina, normally lined by stratified squamous non-keratinised epithelium.
• A cervical ectropion is the presence of everted endocervical columnar epithelium on the ectocervix
• This change is thought to be induced by high levels of oestrogen, and does not represent metaplasia
• The columnar epithelium contains mucus-secreting glands, and thus some individuals with cervical ectropion experience increased vaginal discharge
• It may also give rise to post-coital bleeding, as the fine blood vessels present within the epithelium are easily broken during intercourse

Clinical features

• Cervical ectropion is most commonly asymptomatic
• It can occasionally present with post-coital bleeding, intermenstrual bleeding, or excessive discharge (non-purulent)
• On speculum examination, the everted columnar epithelium has a reddish appearance - usually arranged in a ring around the external os.

Investigations

• Cervical ectropion is a clinical diagnosis
• The main role of any investigation is to exclude other potential diagnoses:
  • Pregnancy test
  • Triple swabs - if there is any suggestion of infection (such as purulent discharge), endocervical and high vaginal swabs should be taken
  • Cervical smear - to rule out cervical intraepithelial neoplasia
    • If a frank lesion is observed, a biopsy should be taken (note that biopsies are not performed as routine)

Management

• Cervical ectropion is regarded as a normal variant, and does not require treatment unless symptomatic
• First-line treatment is to stop any oestrogen containing medications - most commonly the combined oral contraceptive pill
  • This is effective in the majority of cases
• If symptoms persist, the columnar epithelium can be ablated, typically using cryotherapy or electrocautery
  • This will result in significant vaginal discharge until healing is completed