How should cervical ectropion in a reproductive‑age woman using combined oral contraceptives be evaluated and managed?

Management of Cervical Ectropion in Combined Oral Contraceptive Users

Cervical ectropion in a woman using combined oral contraceptives requires no treatment and should not prompt discontinuation of contraception, as ectropion is not a risk factor for cervical cancer and restriction of hormonal contraceptive use is unnecessary. 1

Understanding Cervical Ectropion and Oral Contraceptives

What Cervical Ectropion Is

• Cervical ectropion (also called cervical erosion) is a normal developmental finding in reproductive-age women where the squamocolumnar junction appears on the exocervix rather than within the cervical canal. 1
• This condition represents columnar epithelium extending onto the visible portion of the cervix and is a benign, physiologic finding that typically regresses into the cervical canal with advancing gynecologic age. 1
• Ectropion is influenced by reproductive hormones and commonly develops during late fetal life, puberty, pregnancy, and with oral contraceptive use. 2

Relationship to Combined Oral Contraceptives

• Combined oral contraceptives are positively associated with cervical ectropion development, independent of age and cervical infection status. 3
• The radius (extent) of ectropion correlates with oral contraceptive use, and among users, ectropion is associated with duration of contraceptive use. 3
• Oral contraceptives may cause edema and erythema of the ectopic zone even in women without cervical infection. 3

Clinical Evaluation Approach

When to Evaluate

• Routine pelvic examination during contraceptive follow-up visits allows detection of cervical ectropion, but the finding itself does not require intervention. 4
• The U.S. Medical Eligibility Criteria assigns cervical ectropion a Category 1 classification for combined hormonal contraceptive use, meaning no restriction is necessary. 1

What to Rule Out

• If a patient presents with abnormal vaginal bleeding or discharge, exclude pregnancy, sexually transmitted infections, and underlying pathological conditions (such as pelvic malignancy) before attributing symptoms to ectropion. 1, 5
• Cervical friability and hyperemia may indicate sexually transmitted infection rather than simple ectropion and warrant testing for Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex virus, and cytomegalovirus. 1, 3
• Ensure cervical cytology screening is current according to standard guidelines, as ectropion itself does not increase cervical cancer risk but should not delay appropriate screening. 1

Key Distinctions

• Distinguish true ectropion from cervicitis: cervicitis is independently associated with cervical infection by C. trachomatis, gonorrhea, herpes simplex virus, and cytomegalovirus, whereas ectropion is a hormone-related epithelial change. 3
• Do not confuse ectropion with cervical intraepithelial neoplasia or other pathologic lesions; colposcopy may be needed if abnormal cytology is present. 1, 5

Management Strategy

No Treatment Required

• Cervical ectropion does not require treatment in asymptomatic women, and combined oral contraceptives may be continued without restriction. 1
• The decision to treat ectropion remains controversial even when symptomatic, as there is no established benefit to routine intervention. 4

When Symptoms Are Present

• If the patient reports bothersome vaginal discharge attributed to prominent ectropion after excluding infection, treatment options include cervical painting with antiseptic agents or observation. 4
• Antibiotics should only be prescribed when cervical infection is documented, not for ectropion alone. 4
• Switching from combined oral contraceptives to progestin-only methods or non-hormonal contraception is an option if the patient desires, though not medically necessary. 1

Contraceptive Continuation Guidance

Safety of Continued Use

• Women with cervical ectropion can safely continue combined oral contraceptives (U.S. MEC Category 1), as the condition does not increase risk of adverse outcomes. 1
• Combined hormonal contraceptives do not worsen cervical ectropion in terms of malignant potential or require more frequent monitoring beyond standard cervical cancer screening intervals. 1

Alternative Contraceptive Options

• Hormone-releasing intrauterine devices and progestin-only pills are not associated with significant increases in venous thromboembolism risk and may be considered if the patient has other contraindications to estrogen. 6
• Intrauterine devices receive a Category 1 classification for cervical ectropion, meaning they are also safe to use without restriction. 1

Common Pitfalls to Avoid

• Do not discontinue effective contraception solely because of cervical ectropion, as this increases unintended pregnancy risk without medical benefit. 1
• Avoid attributing all vaginal discharge or bleeding to ectropion without first excluding sexually transmitted infections and pregnancy complications. 5, 3
• Do not perform unnecessary treatments (cautery, cryotherapy) for asymptomatic ectropion, as these interventions lack evidence of benefit and may cause harm. 4
• Recognize that ectropion prevalence decreases with age and smoking but increases with oral contraceptive duration; these associations do not mandate treatment. 3