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 is polypectomy, which can be performed as an office procedure for asymptomatic patients or those with minimal symptoms. 1

Diagnostic Evaluation

• Cervical polyps are benign growths from the cervical epithelium, found in 2-5% of the population, typically appearing as small, stalk-attached lesions 2
• Initial evaluation should include:
  • Visual inspection during gynecological examination to confirm the presence of a polyp 1
  • Assessment of symptoms (intermenstrual bleeding, postcoital bleeding, heavy menses, postmenopausal bleeding, vaginal discharge) 1
  • Routine cervical cancer screening (Pap smear and HPV testing) should be performed as per guidelines 3

Management Algorithm

For Asymptomatic Patients:

• Simple removal of the polyp as an outpatient procedure is recommended 4
• Technique: Twisting or avulsion of the polyp using ring forceps 3
• Histopathological examination of the removed polyp is advised to rule out malignancy, though malignancy is rare 2

For Symptomatic Patients:

• Polypectomy with concurrent endometrial sampling is recommended 4
• Options include:
  • Office-based polypectomy using ring-forceps technique for appropriate patients 3
  • Surgical polypectomy under anesthesia with fractionated dilatation and curettage (D&C) for patients with:
    • Abnormal uterine bleeding
    • Postmenopausal bleeding
    • Risk factors for endometrial cancer 4

Advanced Techniques:

• Hysteroscopic polypectomy is preferred when:
  • The origin of the polyp is unclear (cervical vs. endometrial)
  • Concurrent endometrial pathology is suspected
  • Complete removal cannot be assured with simple avulsion 1

Special Considerations

• Up to 25% of patients with cervical polyps have coexisting endometrial polyps, making evaluation of the endometrial cavity important, especially in symptomatic patients 1
• Giant cervical polyps (>4 cm) are rare and may mimic cervical neoplasia; these cases typically require electrosurgical resection 5
• For patients with atypical glandular cells (AGC) on cervical cytology and a cervical polyp, further evaluation with colposcopy, endocervical curettage (ECC), and HPV DNA testing is indicated 6

Referral Criteria

• Referral to gynecology is indicated for:
  • Giant polyps (>4 cm) 5
  • Suspected malignancy based on appearance or symptoms 2
  • Recurrent polyps 1
  • Polyps in patients with abnormal cervical cytology 6
  • Cases where office-based removal is technically challenging 3

Follow-up

• For patients with benign polyps and normal cervical cytology, routine cervical cancer screening can be resumed 3
• For patients with abnormal findings on histopathology, management should follow appropriate guidelines for the specific pathology identified 6

Pitfalls and Caveats

• Simple twisting or avulsion may leave residual polyp fragments in the cervical canal, potentially leading to recurrence 1
• Blind curettage without visual confirmation of complete removal is not recommended 1
• Difficulty may occur in differentiating endocervical from endometrial lesions without hysteroscopic visualization 1
• While most cervical polyps are benign, histopathological examination is still necessary to exclude malignancy 2