Cervical polyps are small lumps that protrude from the mucous lining of the cervix. They are almost always benign, but occasionally can be precancerous, or very rarely, cancers.
Often completely asymptomatic and noted at pap smear, they sometimes cause bleeding after intercourse, or between periods, or a mucous discharge. They can usually be removed painlessly in the office.
Abnormal smear results are not what we expect when we go to the doctor. We have them regularly, and assume they will be normal, so when we get the dreaded call from the GP's office, shock sets in. What does this mean? Do I have cervix cancer? What will the gynaecologist do to me? How will this affect my fertility?
From December 2017, screening for cervical cancer risk will change. Read about it here. From this time forward the Australian Guidelines for managing abnormal smears will also change. They can be read here.
Sometimes, even if your pap smear or HPV test is normal, your GP will still want you to have your cervix further investigated by a specialist because of symptoms of bleeding after intercourse or because the cervix looks abnormal, because pap smears are not 100% accurate in picking up pre-cancerous problems.
Once your GP has decided you need further investigation with a specialist, you may be referred for a colposcopy which is an examination of a woman's cervix (or neck of womb) using a microscope called a colposcope. The colposcope can also be used to examine for abnormal cells or lesions elsewhere in the woman's genital tract, but is not an operation and no anaesthetic or stay in hospital is necessary.
It is important to remember that pap smears are designed to capture pre-cancerous disease, which is asymptomatic and easily treatable if a high grade lesion is found. It is very uncommon for women to develop invasive cancer if they have been having their smears at the recommended intervals.
At my office, my receptionists understand that women referred for colposcopy are usually very anxious to be seen quickly, and they will make every effort to assist you with a timely appointment, as well as fully informing you of the costs of the procedure, and the refund from Medicare (or your insurer if you are not eligible for Medicare).
When I see you we will discuss your full medical history, and any other gynaecologic issues you might have. The procedure of colposcopy is generally much like a longer pap smear test. If a biopsy is necessary. it is generally well tolerated. If you suffer from a lot of menstrual cramps normally you might find it beneficial to take a simple analgesic like ibuprofen an hour before your appointment (so long as you are not allergic to this class of medicines).
During and after the procedure I will explain what I have found, and if you have a biopsy I will suggest you refrain from using tampons or having intercourse for a few days. There may be some blood stained discharge for a few days which gradually settles as the biopsy site repairs itself.
It usually takes a few days for the biopsy report to return, and I will contact you as soon as it is available to advise you as to whether further treatment is necessary. Generally, only high grade lesions need treatment, as most low grade lesions will resolve with patient observation.
The most common procedure, especially in younger women in whom the whole abnormality is generally visible is a LLETZ, although in women where the abnormality is extending into the canal, a cone biopsy may be necessary.
I perform these at the Wesley Day Surgery, under a very light anaesthetic, and patients are discharged on the day of surgery, generally without any pain. You may have a light, sometimes blood stained discharge for some weeks, and because it can take 3-4 weeks for the cervix to heal, it is wise to refrain from intercourse or the use of tampons during this month post-op.
The main complication to watch out for in the first 2 weeks post op is heavy bleeding when you are not expecting your period, as this may be a sign your body is struggling with a low grade infection that requires antibiotics. Infections arise from the bacteria that naturally live in the vagina, and usually don't become apparent until 10-14 days after the procedure. You should call us and report any unusually heavy bleeding, especially with blood clots, or fever, and we will attend to you immediately. Most women will only require oral antibiotics; it is very rare to need to be re-admitted for IV antibiotics.
I will call you with the results of the pathology examination of the LLETZ/cone biopsy specimen within a few days, and see you at 6 weeks to check healing of the cervix. We will then discuss follow up colposcopy within the next 6 months, which is necessary as a small percentage of patients will have persistence or recurrence of disease.
Once this hurdle is jumped successfully, you will be released back to your GP for further follow up according to the NHMRC guidelines.
The guidelines in place until December 2017 recommend that women who have received ablative or excisional treatment for high grade lesions should have six tests using three modalities over a two year interval after the treatment. If these six tests are normal, it is recommended that these women return to the usual screening interval (currently two years). The six tests and three modalities are:
4 to 6 months after treatment: Pap test and colposcopy
12 months after treatment: Pap test and HPV test
24 months after treatment: Pap test and HPV test
For most women, they will be cured after their procedure, and can expect to have normal fertility and pregnancies in the future.
A special category is adenocarcinoma in situ. New guidelines will be coming into effect from December 2017.
Image borrowed from American Family Physician Journal
Some benign lesions of the cervix
Helping women with
Image borrowed from medcell.med.yale.edu
Image borrowed from well-woman.org
Nabothian follicles, or cysts, are formed when mucous secreting glands of the cervix become blocked by the skin cells of the cervix. They are full of mucous, and usually swell to a maximum size of 1 cm or less, then stop growing.
They can look alarming to your doctor when you are having a pap smear, because they are often irregular in appearance and associated with large blood vessels, but they are quite benign, cause no problems, and require no specific treatment, once they have been checked out at colposcopy.
1. Skin like "squamous" cells
2. Mucous secreting cells, sometimes known as an ectropian
3. Vaginal wall. Note how it is folded, so that it can expand during child birth.
4. "Squamocolumnar junction".
This is where most pre cancers and cancers form.
Cervical ectropian is a normal finding on the cervix of young women, which usually becomes smaller with age. It is not cancerous.
Sometimes incorrectly called an "erosion" it is in fact the presence of normal mucous secreting tissue on the outer part of the cervix. Because the blood vessels feeding the glandular tissue are close to the surface, it can result in a red appearance, and is more likely to bleed with pap smears and intercourse, as well as cause a heavier mucous discharge.
If these are significant problems, the woman might be offered a "diathermy" to facilitate the coverage of the external cervix with tougher skin like squamous cells (a process that occurs naturally with the passage of time).
Bathing the cervix in a weak solution of acetic acid (vinegar) causes cells that are growing more quickly than usual to turn white.
This directs our attention to the areas that need a biopsy.
The pathologist then takes the biopsy, and is able to report on whether the changes are normal, low grade, or high grade.
Your gynaecologist can then report back to you whether treatment is required, or, in the case of low grade change, whether a "wait and see" approach is appropriate.
Most low grade changes will resolve with patience. A small number can become high grade, so follow up is essential.
Dr Melissa Buttini m.b.b.s franzcog