What are the different appearances of the cervix on per speculum examination?

Different Appearances of Cervix on Per Speculum Examination

The cervical appearance during speculum examination can reveal critical diagnostic information about various physiological and pathological conditions, with specific visual characteristics corresponding to normal variations, infections, pregnancy, and malignancies.

Normal Cervical Appearances

• The normal cervix appears pink, smooth, and uniform in color and texture 1, 2
• Ectropion (cervical eversion) is a normal developmental finding, especially in adolescents, where the squamocolumnar junction is visible on the exocervix; this typically regresses with advancing gynecologic age 1
• Nabothian cysts appear as small, raised, yellowish or whitish bumps on the cervical surface and represent blocked mucus glands; these are benign findings 3
• Small cervical polyps may be visible as soft, red, finger-like projections from the cervical os; these are generally benign 3

Pathological Cervical Appearances

Infectious Conditions

• Friability and hyperemia (increased redness) of the cervix can indicate infection with sexually transmitted infections 1
• White plaques on the cervix that cannot be removed with a swab may indicate condylomata acuminata (genital warts) caused by human papillomavirus 1
• Red punctate lesions creating a "strawberry cervix" appearance are characteristic of Trichomoniasis infection 1
• Condylomata lata appear as flesh-colored papules on mucous membranes and are a manifestation of secondary syphilis 1

Pregnancy-Related Changes

• Cervical cyanosis (Chadwick's sign) presents as a bluish hue of the cervix and is an early sign of pregnancy 1
• The pregnant cervix may also appear softer and more vascular compared to the non-pregnant state 2

Pre-malignant and Malignant Changes

• Abnormal cervical appearance after application of 4% acetic acid (acetowhite changes) may indicate cervical intraepithelial neoplasia or cancer 4
• Low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL) may present with various visual changes including acetowhite areas, mosaicism, or punctation 5, 6
• Frank malignancy may appear as an ulcerated, friable mass with irregular borders and abnormal vasculature 5

Proper Technique for Optimal Cervical Visualization

• Lubricating the speculum with warm water only (not lubricant) facilitates insertion while allowing for accurate specimen collection 7
• The speculum should be completely inserted before opening the blades to minimize discomfort and optimize visualization 1, 7
• Adequate lighting is essential for proper visualization of cervical characteristics 4
• For adolescents or patients with intact hymen, using the smallest appropriate speculum (such as a Pederson speculum) minimizes discomfort 7

Clinical Significance and Follow-up

• An "unhealthy cervix" on per speculum examination is associated with higher risk of cervical squamous intraepithelial lesions and should prompt appropriate follow-up 6
• Visual inspection alone has limitations in detecting cervical abnormalities, with sensitivity of 68.4% in some studies, highlighting the importance of cytology and other testing methods 4
• Routine screening pelvic examinations in asymptomatic, nonpregnant adult women are not recommended by the American College of Physicians, as they have not been shown to reduce morbidity or mortality 1

Common Pitfalls to Avoid

• Misinterpreting normal variations in cervical appearance, particularly ectropion in adolescents, as pathological findings 1
• Failing to collect appropriate specimens when abnormal cervical appearance is noted 1
• Opening the speculum before complete insertion increases patient discomfort and may limit proper visualization 7
• Relying solely on visual inspection without appropriate laboratory testing when abnormalities are suspected 4