Cervical Endometriosis

Cervical endometriosis is the presence of endometrial glands and stroma on or in the cervix. It occurs after cervical surgery, biopsy or childbirth trauma, or by spread from pelvic disease.

• It is rare and often an incidental finding.
• Lesions respond to hormones and bleed with menses.
• Biopsy is needed to exclude cervical cancer.

Cyclical post-coital bleeding, intermenstrual spotting, dyspareunia, dysmenorrhoea and sometimes no symptoms.

• Blue, purple or dark red nodules or cysts on the cervix that bleed on touch and enlarge before menses.
• Differential diagnosis: cervical ectropion, nabothian cyst, cervical cancer, cervical polyp, cervical fibroid, cervical haemangioma.
• Complications: bleeding, anaemia, dyspareunia, pelvic endometriosis, infertility.

Diagnosis is by colposcopy with biopsy to exclude cancer.

• Speculum examination, timed in the week after menses and the week before menses.
• Colposcopy with biopsy for histology.
• Transvaginal ultrasound or MRI to look for deeper pelvic endometriosis.
• Cervical screening (HPV test, cytology, VIA).
• Full blood count for anaemia.

Control symptoms with analgesia and hormonal suppression, and destroy or excise symptomatic lesions.

• Supportive: heat packs for pain; reassurance; menstrual diary.
• Pharmacological: ibuprofen 400 mg oral 8-hourly with food (maximum 1.2 g in 24 hours) or naproxen 500 mg oral 12-hourly with food (maximum 1 g in 24 hours). Hormonal suppression: dienogest 2 mg oral daily; or norethisterone acetate 5 mg oral 8-hourly; or a combined oral contraceptive taken continuously. Refractory: leuprorelin 3.75 mg IM every 4 weeks for 3 to 6 months with norethisterone acetate 5 mg oral daily as add-back. Iron for anaemia: ferrous sulphate 200 mg oral 8-hourly until haemoglobin normalises, then for a further 3 months.
• Procedures: electrocautery, cryotherapy, laser vaporisation or excision of symptomatic lesions under local anaesthesia (1 percent lignocaine, maximum 3 mg/kg, absolute maximum 200 mg plain). Excision for diagnosis of an uncertain lesion.
• Special groups: in pregnancy avoid hormonal drugs and avoid destructive procedures; observe. When combined pills are used, check for contraindications such as migraine with aura, smoking above age 35 and venous thromboembolism.
• Red flags: friable irregular lesion, rapid growth, postmenopausal bleeding, positive screening, heavy bleeding.
• Follow-up: review at 3 months; repeat biopsy for persistent lesions; continue cervical screening.