What is the recommended evaluation and management of cervical polyps in women of reproductive age, including indications for removal, removal technique, timing in pregnancy, and follow‑up?

Management of Cervical Polyps in Women of Reproductive Age

Indications for Removal

All symptomatic cervical polyps should be removed, while asymptomatic polyps can be managed conservatively with continued routine cervical cancer screening. 1

• Symptomatic polyps (causing intermenstrual bleeding, postcoital bleeding, heavy menses, or vaginal discharge) warrant removal to alleviate symptoms and obtain histologic diagnosis 2, 1
• Asymptomatic polyps discovered incidentally do not require routine removal if the patient is up-to-date with cervical cancer screening 1, 3
• Cervical polyps themselves are rarely associated with dysplasia or malignancy (premalignant lesions in 2%, malignancy in 0.3%), making routine Papanicolaou and HPV testing more important than the polyp itself for identifying cervical dysplasia 4

Removal Technique

Office-based ring-forceps polypectomy is the preferred technique for symptomatic endocervical polyps in primary care settings. 1

• Apply ring forceps to grasp the polyp at its base, twist gently, and remove completely 1
• The procedure is typically painless and does not require anesthesia in most cases 1
• Send all removed polyps for histopathologic examination to exclude premalignant or malignant lesions 4
• Hysteroscopic polypectomy may be considered when the exact origin of the polyp pedicle is uncertain or when concurrent endometrial pathology is suspected 2

Additional Evaluation Based on Patient Characteristics

Reproductive-Age Women (Premenopausal)

• Asymptomatic patients: Simple polypectomy without additional procedures is sufficient 3
• Symptomatic patients: Consider endometrial sampling only if abnormal uterine bleeding persists after polyp removal or if other risk factors for endometrial pathology exist 3, 5
• Routine dilatation and curettage (D&C) is not indicated in premenopausal women with cervical polyps, as the incidence of associated endometrial abnormalities is low 3, 5

Women ≥35 Years or Postmenopausal

For women ≥35 years with symptomatic cervical polyps, perform colposcopy with endocervical sampling and endometrial sampling in addition to polypectomy. 6

• Approximately 7% of women ≥35 years with abnormal bleeding harbor significant endometrial pathology 6
• Postmenopausal women with symptomatic cervical polyps have a marked incidence of associated severe endometrial pathology and require mandatory endometrial sampling 5
• Up to 25% of patients with cervical polyps have coexisting endometrial polyps, necessitating evaluation of the endometrial cavity 2

Management During Pregnancy

Cervical polyps discovered during pregnancy should generally be left in place unless causing significant bleeding or other complications.

• Endocervical curettage is unacceptable in pregnant women 7
• Polypectomy can be deferred until at least 6 weeks postpartum unless the polyp is causing problematic bleeding 7
• If removal is necessary during pregnancy, simple excision without additional endocervical or endometrial sampling is appropriate

Post-Polypectomy Management Based on Histology

Benign Polyp

Return to routine age-appropriate cervical cancer screening (co-testing every 5 years or cytology every 3 years for women 30-65 years) after confirmation of benign histology. 8

CIN I (Low-Grade Dysplasia)

• Follow-up with HPV DNA testing annually or repeat cytology every 6-12 months, as >90% regress spontaneously within 24 months 9
• If associated with high-grade cytology (HSIL) or atypical glandular cells, either diagnostic excisional procedure or observation with colposcopy and cytology every 6 months is acceptable if colposcopy is satisfactory and endocervical sampling is negative 9

CIN II/III (High-Grade Dysplasia)

Treatment with excisional procedure (LEEP or cold-knife conization) is mandatory, followed by surveillance. 8, 9

• Diagnostic excisional procedure is required when colposcopy is unsatisfactory or endocervical sampling reveals CIN 9
• After treatment, perform cervical cytology at 6 months or HPV DNA testing at 12 months 7

Glandular Neoplasia or Malignancy

Immediate diagnostic excisional procedure (preferably cold-knife conization) is mandatory to obtain an intact specimen with interpretable margins. 8

• Perform immediate colposcopy with endocervical sampling and endometrial assessment for women ≥35 years or those with risk factors for endometrial pathology 8
• About 45% of patients with atypical glandular cells have clinically significant lesions (CIN, adenocarcinoma in situ, or invasive cancer) 7, 6

Key Clinical Pitfalls to Avoid

• Do not assume a cervical polyp is benign based solely on appearance; always obtain histologic confirmation after removal 4
• Do not rely on cervical cytology alone to exclude dysplasia in a visible polyp; cytology has low sensitivity for grossly visible lesions 9
• Do not perform routine D&C in asymptomatic premenopausal women with cervical polyps, as it adds unnecessary cost and risk without clinical benefit 3
• Do not defer endometrial sampling in postmenopausal women with symptomatic cervical polyps, as the risk of concurrent endometrial pathology is significantly elevated 5