Abstract
The management of cervical polyps has evolved dramatically over the last 30 years, but still remains controversial. As late as the 1990s, in many settings the standard treatment for cervical polyps in nonpregnant women of any age included hospitalization, polypectomy and dilation and curettage (endometrial and endocervical sampling) done under general anesthesia [1,2]. The justification for such an extensive workup was the concern that the cervical polyp might represent focal de novo premalignancy or malignancy, adjacent (cervical or endometrial) pathologies or more distant metastases [3,4]. Since the endocervical canal is diff-cult to sample, some argued that the only way to assess a cervical polyp was to completely remove it [5]. Endometrial polyps have been found to coexist with cervical polyps in over one quarter of cases, so some experts have recommended that that routine endometrial sampling be done [6,7]. The final rationale offered for routine removal of asymptomatic polyps has been that the polyp is unlikely to spontaneously resolve and it may cause problems in the future [8].
Today polyps are treated on an outpatient basis, but there are no uniform recommendations or guidelines for management of asymptomatic cervical polyps. In the absence of practice guidelines from professional societies, reliance is placed on conclusions from published studies. These conclusions vary considerably, including expectant management in select cases [9–11], polypectomy [12], polypectomy under colposcopic visualization [13], polypectomy with endocervical curettage [14], polypectomy with hysteroscopy [2,6], and polypectomy with endocervical and endometrial curettage [4]. Most of these strategies for nonpregnant women are in sharp contrast to recommendations made for management of cervical polyps in pregnancy, which recognize that polypectomy should be reserved for situations in which the risk of malignancy is high [15,16].
Rates of premalignant and malignant disease in cervical polyps have been low in most studies, but the sources of the samples reviewed have differed. Early studies in the 1930s and 1940s reported that the incidence of malignancy in cervical polyps was as high as 6% [17,18]. However, those estimates were inflated by the inclusion of metaplastic changes as abnormal and by the fact that routine cervical cancer screening was not operational at that time. In the 1990s, a review of 1477 endocervical polyps reported one case of cervical carcinoma extending into the polyp from its primary site in the cervix [19]. In a later series of 362 patients, where analysis was done separately for asymptomatic women (60%) compared with symptomatic women, no malignancy was detected in the polyps or the endometrial specimens of women with no symptoms [1]. Another review of 1500 endocervical polyps yielded nine cases of dysplasia in otherwise clinically benign endocervical polyps (0.5%) [5]. Five of these cases were low-grade squamous intraepithelial lesion and four were diagnosed as high-grade squamous intraepithelial lesion (one of which was associated with invasive squamous cell carcinoma). Seven of these nine women had normal cytology, but 88% had tested positive for high-risk HPV. The authors concluded that dysplasia may develop de novo in endocervical polyps in areas difficult to assess with standard cytology [5]. In a histological review of 4328 Mayo Clinic patients with endocervical polyps from 1994–2010, no primary malignancy was detected; the overall risk of dysplasia was 0.018%, with moderate to severe dysplasia in 0.012% [12]. Dysplasia was more likely to be found in younger women and those with abnormal cytology [12]. A similar retrospective study of 2246 endocervical polyps from the Hartford Hospital pathology database from 1999–2006 found that the prevalence of malignancy was 0.1% while that of dysplasia was 0.5% [8]. The authors concluded that while removal of asymptomatic polyps is not mandatory, because prevalence of dysplasia is high (0.5%) and the fact that polyps can identify pathology from different sites, routine polypectomy is justifiable [8]. Interestingly, the Hartford Hospital pathology database was retrospectively analyzed by another group for the years 1999–2008 during which 2458 polyps were analyzed for the presence of malignancy and dysplasia by menopausal status. For premenopausal women those rates were 0.1 and 0.7% versus 0.1 and 0.2% for women over 50 [20].
In a large-scale study, in which information about the woman's clinical presentation was included, 1366 reports from the Department of Cellular Pathology at the John Radcliff Hospital from the years 2002–2005 were analyzed along with the costs of the testing. Overall, 67% (919) polyps were classified as asymptomatic; none of those polyps had any abnormal histological features. All of the pathology was detected in women with abnormal bleeding patterns or those who had polypectomy performed under colposcopic evaluation of abnormal Pap smears. These authors calculated that if asymptomatic polyps were not removed, there could be substantial savings [10].
Despite these studies, the practice of routine polypectomy persists in many clinical settings. Removal of a cervical polyp is generally quite straightforward, but occasionally causes the patient discomfort, hemorrhage, infection and/or anxiety. There is also financial cost associated with the procedure. Because the indigent population served at Harbor-UCLA Medical Center has very high rates of carcinoma, it was thought that evaluation of histology reports of all cervical polyps from that setting might provide useful information about safety of conservative management of asymptomatic polyps in women of all ages, by determining the frequency of significant disease being identified within polyps by patient age group and polyp size, excluding any abnormal specimens from symptomatic women.
Materials & methods
Approval for this study was obtained from the John R Wolfe Human Subjects Committee and the Research Committee at the Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center. A waiver for informed consent was granted because no personal identifying information was collected. The electronic pathology reports were searched using ‘cervical polyps’ and ‘cervical polyp, cervical curettage’ for all specimens between 1 January, 2006 and 31 December, 2013. Specimens were derived from the hospital clinics, urgent care settings and gynecology clinics in the comprehensive health centers and neighborhood health centers in the Harbor catchment area. All cervical polyp specimens that were submitted alone or with endocervical curettage were counted. Incidental polyps discovered in hysterectomy specimens or in conjunction with endometrial biopsies were excluded on the basis that those procedures would not have been performed on asymptomatic women with normal cytological tests.
If any significant histological abnormality (dysplasia or malignancy) was reported in either the polyp or on the endocervical curettage, the patient's medical records were reviewed to determine if the polypectomy had been done in response to complaints of abnormal bleeding or as part of an evaluation of an abnormal cytology. If that review determined that the woman had presented with symptoms of abnormal bleeding or for evaluation of abnormal cervical cytology, the specimen was excluded from the study. All data were entered into Excel spreadsheets. Chi square testing was planned to test for statistical differences with p < 0.05 set as the threshold for statistical significance.
Results
Review of the pathology reports yielded 915 polyps that had been assessed during those 8 years as ‘polyps’ or ‘polyps with endocervical curettage‘. These 915 polyps were obtained from 854 nonpregnant women. Seventeen of these specimens were excluded because they were abnormal and they had been obtained from women with abnormal bleeding or who were being evaluated for abnormal Pap smears. The resultant study population included 898 polyps removed from 837 women. The average age of these women (based on year of birth) was 48.2 with a range from 18–82 years. The median age was 49 years. A significant proportion of the women (42.3%) were over the age of 50. Only two women had three polyps; the others all had only one or two polyps.
The polyps varied in size and appearance. The mean value of the largest dimension of the polyps was 15 mm (range 2–112 mm), with a median of 12 mm. The mean volume of the polyps was 1132 mm3, but the range was 1.1–106,814 mm3. The median volume was 157.1 mm3.
Table 1 displays the pathologic findings of each of the 898 polyp specimens first for the total study population, then grouped by age <50 and >50 years. Overall, the most common report was of ‘endocervical cervical’ polyp (57.1%); inflammation was reported in another 20%. In 12% of the cases, histologic examination of the specimen revealed that the polyp originated from the endometrium or was composed of a mixture of endometrial and endocervical cells. None of these histological findings would have added anything to the management of the women from whom these specimens were obtained.
Cervical polyp histology (n = 898).
In 21% of the cases, endocervical curettage was also performed, usually done routinely as part of an evaluation of a cervical polyp. Table 2 displays the pathology reports of the endocervical specimens that were subject of this study. Again no malignancy or premalignancies were detected; these biopsies made no contribution to the management of the women upon whom they were performed.
Endocervical curettage histology (n = 190).
Discussion
The management of cervical polyps found incidentally on routine pelvic examination has evolved considerably over the last few decades. The trend has been to reduce the number of procedures needed. For example, polypectomy with D&C done under general anesthesia was replaced by office-based procedures as theoretical concerns for possible disease were replaced by data derived from studies reporting the histological results of these procedures. The same studies report no cases of malignancy and dysplasia (usually CIN 1 lesions), only in 0.12–0.25% [1,5,12]. However, among asymptomatic women, who do not have abnormal Pap smears, no cases of significant pathology were reported in the more recent work [10,11]. Despite these recent studies, there are still no formal guidelines to direct the treatment of asymptomatic cervical polyps in women without abnormal cervical cytology. This study reviews our data to assist in the development of practice recommendations. We found that the only cases of premalignant or malignant disease occurred among women who presented with complaints of abnormal bleeding (postcoital bleeding, prolonged or intermenstrual bleeding) or who were being evaluated colposcopically for abnormal Pap smear results. Also, our results found no benefit from the routine endocervical curettage in asymptomatic women found to have polyps. Our findings do not support any different management for different polyp sizes or for different patient age groups as has been advocated by others, since none of our specimens demonstrated any dysplasia or malignancy [4,20,14].
One limitation of this study is that it is a retrospective study. Our approach of starting with pathology databases and reviewing the clinical presentation of only those women with pathology can verify that all the women who had pathology detected were symptomatic or had pre-existing evidence of dysplasia. It is possible that some of the specimens without significant pathologic findings may have been obtained from women with symptoms.
Polypectomy can be done during the visit in which the polyp is discovered. However, in situations where nurse practitioners or family physicians are performing the well woman visit, this often involves referring the patient to another provider at a separate visit. Even if the procedure can be integrated into the same visit, it requires time for informed consent; additional staff must be involved for conducting the time out procedures. In addition, there are the specimen handling costs and the pathology costs. Finally, the patient generally is booked a follow-up appointment to provide her with the results and to confirm she had no complications after the procedure. While each institution will have its own cost structure, it is clear that there are costs to the healthcare system for this procedure. As such, routine polypectomy in asymptomatic women represents an example of overtreatment and iatrogenically induced overuse of the healthcare system. There is also the cost to the patient in terms of time off work, travel and parking costs, one must also consider the toll imposed on her by unnecessary stress.
There may be some individual exceptions to the recommendation for conservative management of asymptomatic polyps. Although polyps are expected to recur in one in eight women [21], more frequently recurrent polyps may be more likely to be associated with significant pathology [22]. Polyps with uncertain insertion points on clinical examination may need to be further evaluated with saline infusion sonography or hysteroscopy, especially in postmenopausal women in whom the risk of malignancy being detected in asymptomatic endometrial polyps may be higher [6,23,24].
Conclusion
This study adds to the work of MacKenzie which showed that no malignancy or premalignancy were found in 2216 polyps from asymptomatic women. It reinforces the findings of other large-scale studies, which combined with our results, yielded a total of 5488 polyps with no evidence of primary malignancy [10]. These findings should encourage clinicians to manage cervical polyps as a normal variant if they are found in asymptomatic women with no concerning history and normal cervical cytology.
Future perspective
The next logical research question would be to investigate the yield of polypectomy in symptomatic women. That would best be done prospectively in order to accurately capture information about the indications for polypectomy.
There needs to be more professional recognition that isolated, asymptomatic cervical polyps represent variants of normal findings when they are found in women without abnormal cytology. It is hoped that professional societies will develop guidelines to help mainstream this concept. We believe that such guidelines will become even more important in the near term. With less frequent pelvic examinations, clinicians may become even more likely to routinely remove such polyps for fear of missing pathology unless there is more formalized support for conservative management.
Executive summary
Cervical polyp with normal cytology screening may be managed as a normal variant unless symptoms, such as abnormal bleeding, are present.
Histopathology adds little to the management of this population. Routine polypectomy is not warranted.
Women with frequently recurrent polyps may need histologic examination of those polyps.
Postmenopausal women with polyps which might arise from the endometrium may need to be evaluated differently than women with cervical polyps.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Ethical conduct of research
The authors state that they have obtained appropriate institutional review board approval or have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.