What is the initial management for a patient presenting with a cervical polyp?

Management of Cervical Polyps

The initial management for a patient presenting with a cervical polyp should be removal of the polyp (polypectomy) with histopathological examination of the specimen. 1, 2

Diagnostic Evaluation

Before proceeding with polypectomy, consider:

• Visual examination to confirm the polyp originates from the cervix
• Assessment for symptoms:
  • Intermenstrual bleeding
  • Postcoital bleeding
  • Heavy menses
  • Postmenopausal bleeding
  • Vaginal discharge
  • Asymptomatic (60% of cases) 2

Polypectomy Procedure

Office-Based Approach (Preferred for Most Patients)

• Simple removal using ring forceps with gentle twisting motion
• Procedure can be performed in an outpatient setting without anesthesia for most patients 3
• Base of the polyp should be cauterized or crushed to prevent bleeding

Indications for Hospital-Based Approach

• Large polyps (>2 cm)
• Broad-based polyps
• Symptomatic patients with risk factors for endometrial pathology
• Postmenopausal patients with abnormal bleeding
• When visualization is difficult in office setting 2, 4

Additional Evaluation Based on Risk Factors

For Asymptomatic Premenopausal Women

• Polypectomy alone is sufficient 2
• No additional endometrial evaluation needed if:
  • No abnormal bleeding
  • Normal cervical screening history
  • No risk factors for endometrial pathology

For Symptomatic or High-Risk Patients

• Consider additional endometrial evaluation:
  • Endometrial biopsy or sampling
  • Dilatation and curettage (D&C) if indicated
  • Hysteroscopy to evaluate the endometrial cavity 1, 4

Special Considerations for Postmenopausal Women

• Higher risk of concurrent endometrial pathology (10.9% vs 7.8% in premenopausal women) 4
• More thorough evaluation of the endometrium is warranted
• Consider hysteroscopy to rule out endometrial polyps, which coexist in up to 25% of cases 1

Histopathological Examination

• All removed polyps should be sent for histopathological examination
• While malignancy is rare (0.1%), dysplastic changes can be present (0.4%) 4
• Metaplastic and inflammatory changes are more common (2.1% and 1.0% respectively) 4

Follow-Up Management

• Resume routine cervical cancer screening as per guidelines
• No special follow-up needed if the polyp is benign and completely removed
• If symptoms recur, re-evaluation is warranted

Common Pitfalls to Avoid

1. Incomplete removal: Ensure the base of the polyp is completely removed to prevent recurrence
2. Failure to send for pathology: All polyps should be examined histologically
3. Missing concurrent endometrial pathology: Especially important in symptomatic and postmenopausal women
4. Overtreatment: Asymptomatic patients with incidental polyps do not require extensive procedures beyond simple polypectomy 2

By following this approach, most cervical polyps can be managed effectively in the primary care setting, avoiding unnecessary referrals while ensuring appropriate evaluation for higher-risk patients.