Cervical Ectropion

Cervical ectropion is the extension of glandular (columnar) epithelium from the endocervical canal onto the ectocervix, which gives a red, velvety ring around the external os.

• It is a normal finding in adolescence, pregnancy and with combined oral contraceptive use, because of high oestrogen.
• It is not a precancerous condition.
• Treatment is needed only when it causes troublesome discharge or bleeding.

Most women have no symptoms.

• Increased clear or mucoid vaginal discharge, post-coital spotting, intermenstrual spotting and, rarely, dyspareunia.
• On speculum examination the cervix shows a central red zone around the os that bleeds easily on touch.
• Differential diagnosis: cervicitis, cervical intraepithelial neoplasia, cervical cancer, cervical polyp, endometriosis of the cervix, cervical tuberculosis.
• Complications: contact bleeding, persistent discharge, secondary infection and anaemia (rare).

Diagnosis is by speculum examination, with screening to exclude neoplasia and infection.

• Speculum examination of the cervix.
• Visual inspection with acetic acid (VIA) or cervical cytology or HPV test to exclude neoplasia.
• Endocervical swab for chlamydia and gonorrhoea by NAAT or Gram stain; high vaginal swab for trichomoniasis and bacterial vaginosis.
• Colposcopy and biopsy for any irregular, ulcerated or acetowhite area.
• Pregnancy test in women of reproductive age.

Reassure when asymptomatic, and treat only troublesome discharge or bleeding after neoplasia and infection are excluded.

• Supportive: reassure that the finding is normal; avoid douching; use sanitary pads for discharge; review the need for combined oral contraceptives.
• Pharmacological: no drug for asymptomatic ectropion. If symptoms are linked to the combined pill, change to a progestogen-only method, for example norethisterone enantate 200 mg IM every 8 weeks or depot medroxyprogesterone acetate 150 mg IM every 13 weeks. Treat any infection found: for chlamydia, doxycycline 100 mg oral 12-hourly for 7 days; for gonorrhoea, ceftriaxone 500 mg IM single dose; for bacterial vaginosis, metronidazole 400 mg oral 12-hourly for 7 days. Paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for cautery discomfort.
• Procedures: for persistent troublesome discharge or bleeding after neoplasia and infection are excluded, cryotherapy (3 minutes freeze, 5 minutes thaw, 3 minutes freeze), electrocautery or silver nitrate cautery of the ectropion, with antiseptic cover. Advise abstinence from intercourse for 4 weeks afterwards.
• Special groups: in pregnancy leave the ectropion alone and reassure; do not cauterise. In HIV infection check cervical screening is up to date before any treatment.
• Red flags: irregular or ulcerated cervix, bleeding that does not settle, positive screening test, foul discharge.
• Follow-up: review at 6 weeks after cautery; repeat cervical screening at the usual interval.