List of Abbreviations
AUB – abnormal uterine bleeding
COC – combined oral contraceptives (ATC Progestogens and estrogens, fixed combinations)
IMB – intermenstrual bleeding
HMB – heavy menstrual bleeding
CP – cervical polyp
DM – diabetes mellitus
US – comprehensive pelvic ultrasound (transvaginal and transabdominal)
CE – chronic endometritis
Terms and Definitions
Cervical polyp (CP) is a benign focal lesion of the cervix consisting of glands, fibrosed stroma, and blood vessels, frequently with squamous metaplasia [1].
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Cervical polyp (CP) is a benign focal lesion of the cervix consisting of glands, fibrosed stroma, and blood vessels, frequently with squamous metaplasia [1].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The etiology and pathogenesis of cervical polyps are not precisely known. Various mechanisms for the development of cervical polyps are considered. These include impaired expression of estrogen and progesterone receptors in the cervical canal mucosa, increased activity of signaling pathways inducing proliferation and angiogenesis, decreased apoptosis, and chronic inflammation [2], [3], [4].
The risk of developing cervical polyps increases from menarche to late reproductive age, and rises significantly in menopause. Risk factors for cervical polyp formation include chronic cervicitis, prior surgical interventions on the cervix, etc. [2], [3].
1.3 Epidemiology of the Disease or Condition
The prevalence of cervical polyps ranges from 2 to 5% and tends to increase in peri- and postmenopause [5], [6]. The risk of malignant transformation of cervical polyps is extremely low (0.1%) [7] and increases in peri- and postmenopause [8].
The recurrence rate of cervical polyps reaches 12.6% [9]. It is believed that cases of disease recurrence are associated with incomplete removal of the vascular stalk of the polyp [10], [11], [12].
1.4 Features of Coding the Disease or Condition
N84.1 Cervical polyp
1.5 Classification of the disease or condition
1) ectocervical polyps, which occur predominantly in postmenopausal women and develop from squamous cells of the ectocervix.
2) endocervical polyps, which occur mainly in premenopausal women and develop from endocervical crypts [13].
1.6 Clinical presentation of the disease or condition
Cervical polyps are asymptomatic in the majority of patients and are usually discovered during a routine appointment (examination, consultation) with an obstetrician-gynecologist [14], [15], [16].
The most common clinical manifestations of cervical polyps are intermenstrual bleeding, contact bleeding, heavy menstrual bleeding, and postmenopausal bleeding [17], [18], [19]. Cervical polyps reduce the likelihood of pregnancy [2], [18], [20], [21].
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis of cervical polyps is established based on patient complaints, medical history, physical examination, colposcopy, and comprehensive pelvic ultrasound (transvaginal and transabdominal). The definitive diagnosis of cervical polyp is confirmed by pathomorphological examination of the biopsy (surgical) material of the uterus (endometrium) [17], [22], [23].
2.1 Complaints and Anamnesis
Complaints are described in Section 1.6. "Clinical presentation".
2.2 Physical Examination
It is recommended that all patients with cervical polyps undergo a gynecological history taking, a physical examination according to standard propedeutics principles, a speculum examination of the cervix, and a bimanual vaginal examination in order to detect space-occupying lesions originating from the cervical canal [13].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Speculum examination of the cervix allows for the detection of a space-occupying lesion originating from the cervical canal [13], [24], [23], [25], [26], [27].
2.3 Laboratory Diagnostics
Specific laboratory diagnostics for cervical polyps have not been developed.
2.4 Instrumental Diagnostics
It is recommended to perform a comprehensive pelvic ultrasound (transvaginal and transabdominal) when cervical polyps are suspected, in order to establish the diagnosis and rule out concomitant gynecological pathology [13].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform microscopic examination of vaginal smears in patients with cervical polyps to rule out pelvic inflammatory disease [13], [28].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform a cytological examination of a cervical smear in patients with cervical polyps in order to detect cervical intraepithelial neoplasia [13], [28].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended for all patients to undergo pathomorphological examination of the uterine biopsy (surgical) material as the definitive diagnostic method [13].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.5 Other Procedures
It is recommended to perform (extended) colposcopy to detect altered areas of the cervix in all patients with cervical polyps [29], [30].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
It is not recommended to use hormonal therapy for the treatment of cervical polyps, including progestogens (ATC: progestogens), combined hormonal contraceptives ((CHC) – ATC: progestogens and estrogens, fixed combinations) as standalone treatment, or in the pre- and postoperative periods [13], [28].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Currently, there are no guidelines indicating the efficacy of drug therapy for cervical polyps.
3.2 Surgical Treatment
It is recommended to remove the polyp of female genital organs (polypectomy) in all women with cervical polyps, with mandatory pathomorphological examination of the uterine biopsy (surgical) material [13], [19].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform removal of the polyp of female genital organs (polypectomy) and uterine (endometrial) tissue biopsy in patients, including those of reproductive age presenting with abnormal uterine bleeding, infertility, pregnancy planning, or risk factors for malignancy, as well as in all women in the peri- and postmenopausal periods, with mandatory pathomorphological examination of the uterine biopsy (surgical) material [19].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: Pathomorphological examination of the uterine biopsy (surgical) material is the definitive diagnostic method for cervical polyps, allowing for differential diagnosis with adenocarcinoma (in situ and invasive) developed within a cervical polyp, adenomyoma, as well as adenosarcoma and carcinosarcoma of the cervix. It is advisable to perform uterine (endometrial) tissue biopsy under visual control via hysteroscopy [19].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended for all patients to undergo a consultation with a physical therapy physician to determine a rehabilitation program when cervical polyps are combined with chronic endometritis [28], [31].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
5. Prevention and Dispensary Observation
It is not recommended to routinely prescribe postoperative progestogens (ATC: progestogens), CHCs (ATC: progestogens and estrogens, fixed combinations), and antibacterial therapy for the purpose of reducing the risk of cervical polyp recurrence [13], [28].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Currently, there is no convincing evidence regarding the efficacy of medical prevention methods for cervical polyps [13], [22], [17], [28].
6. Organization of Medical Care
Indications for scheduled hospitalization in a medical organization:
1) Surgical treatment of cervical polyps.
7. Additional Information
-
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance evaluation |
|---|---|---|
1. | Speculum examination of the cervix and bimanual vaginal examination were performed. | Yes/No |
2. | Comprehensive pelvic ultrasound was performed (transvaginal and transabdominal) | Yes/No |
3. | Removal of the polyp of female genital organs was performed. | Yes/No |
4. | Pathomorphological examination of the uterine biopsy (surgical) material (removed macroscopic specimen) was performed. | Yes/No |
References
Show references
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[2] Tanos V., Berry K.E., Seikkula J., Abi Raad E., Stavroulis A., Sleiman Z., et al. The management of polyps in female reproductive organs. Int J Surg. 2017.
[3] Indraccolo U., Di Iorio R., Matteo M., Corona G., Greco P., Indraccolo S.R. The pathogenesis of endometrial polyps: a systematic semi-quantitative review. Eur J Gynaecol Oncol. 2013.
[4] Carvalho F.M.et al. Functional endometrial polyps in infertile asymptomatic patients: a possible evolution of vascular changes secondary to endometritis. Eur J Obstet Gynecol Reprod Biol. 2013.
[5] Fatemi H.M. et al. Prevalence of unsuspected uterine cavity abnormalities diagnosed by office hysteroscopy prior to in vitro fertilization. Hum Reprod. 2010.
[6] Capmas P., Pourcelot A.-G., Giral E., Fedida D., Fernandez H. Office hysteroscopy: A report of 2402 cases. J Gynecol Obstet Biol Reprod (Paris). 2016.
[7] Schnatz PF, Ricci S, O’Sullivan DM. Cervical polyps in postmenopausal women: is there a difference in risk? Menopause 2009.
[8] Schnatz P. F., Ricci S., O’Sullivan D. M. Cervical polyps in postmenopausal women: is there a difference in risk? //Menopause. – 2009.
[9] Tirlapur S. A. et al. Clinico-pathological study of cervical polyps // Archives of gynecology and obstetrics. – 2010. – Vol. 282. – P. 535-538.
[10] Paradisi R., Rossi S., Scifo M.C., Dall’O’ F., Battaglia C., Venturoli S. Recurrence of endometrial polyps. Gynecol Obstet Invest. 2014.
[11] Kanthi J.M., Remadevi C., Sumathy S., Sharma D., Sreedhar S., Jose A. Clinical Study of Endometrial Polyp and Role of Diagnostic Hysteroscopy and Blind Avulsion of Polyp. J Clin Diagn Res. 2016.
[12] AlHilli M.M., Nixon K.E., Hopkins M.R., Weaver A.L., Laughlin-Tommaso S.K., Famuyide A.O. Long-term outcomes after intrauterine morcellation vs hysteroscopic resection of endometrial polyps. J Minim Invasive Gynecol. 20(2):215–21.
[13] Alkilani YG, Apodaca-Ramos I. Cervical Polyps. 2023 Sep 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.
[14] Clark T.J., Stevenson H. Endometrial Polyps and Abnormal Uterine Bleeding (AUB-P): What is the relationship, how are they diagnosed and how are they treated? Best Pract Res Clin Obstet Gynaecol. 2017.
[15] Elfayomy A.K., Soliman B.S. Risk Factors Associated with the Malignant Changes of Symptomatic and Asymptomatic Endometrial Polyps in Premenopausal Women. J Obstet Gynaecol India. 2015.
[16] Wolfman W. No. 249-Asymptomatic Endometrial Thickening. J Obstet Gynaecol Can. 2018; 40(5):e367–77.
[17] AAGL practice report: practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol. 19(1):3–10.
[18] Vitale S.G., Haimovich S., Laganà A.S., Alonso L., Di Spiezio Sardo A., Carugno J., et al. Endometrial polyps. An evidence-based diagnosis and management guide. Eur J Obstet Gynecol Reprod Biol. 2021. .
[19] Stamatellos I., Stamatopoulos P., Bontis J. The role of hysteroscopy in the current management of the cervical polyps //Archives of gynecology and obstetrics. – 2007.
[20] T. Pérez-Medina et al., “Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination: a prospective, randomized study.,” Hum. Reprod., vol. 20, no. 6, pp. 1632–5, Jun. 2005, doi: 10.1093/humrep/deh822.
[21] A. Di Spiezio Sardo et al., “Efficacy of hysteroscopy in improving reproductive outcomes of infertile couples: a systematic review and meta-analysis,” Hum. Reprod. Update, vol. 22, no. 4, pp. 479–496, Jun. 2016, doi: 10.1093/humupd/dmw008.
[22] T. N. S. of O. and Gynecology, “Endometrial polyps. National Guideline approved by The Norwegian Society of Obstetrics and Gynecology.,” 2015.
[23] Associated benign tumors and hyperplastic processes of the uterus (myoma, adenomyosis, endometrial hyperplasia). Adamyan L.V., Andreeva E.N., Bezhenar V.F., et al. Draft clinical guidelines for patient management. - Moscow, 2015.
[24] Uglietti A., Buggio L., Farella M., Chiaffarino F., Dridi D., Vercellini P., et al. The risk of malignancy in uterine polyps: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2019.
[25] E. Ferrazzi et al., “How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study.,” Am. J. Obstet. Gynecol., vol. 200, no. 3, pp. 235.e1–6, Mar. 2009, doi: 10.1016/j.ajog.2008.09.876.
[26] L. M. P. Sasaki, K. R. C. Andrade, A. C. M. G. Figueiredo, M. da S. Wanderley, and M. G. Pereira, “Factors Associated with Malignancy in Hysteroscopically Resected Endometrial Polyps: A Systematic Review and Meta-Analysis.,” J. Minim. Invasive Gynecol., vol. 25, no. 5, pp. 777–785, doi: 10.1016/j.jmig.2018.02.004.
[27] NICE Guideline, “Heavy menstrual bleeding: assessment and management,” 2020.
[28] Savelyeva G. M. et al. Gynecology. National guidelines // M.: GEOTAR-Media. – 2020.
[29] “World Health Organization. Reproductive Health et al. Comprehensive cervical cancer control: a guide to essential practice. – World Health Organization, 2014.”
[30] Bonde J. H. et al. Clinical Utility of Human Papillomavirus Genotyping in Cervical Cancer Screening: A Systematic Review // Journal of lower genital tract disease. – 2020. – Vol. 24. – No. 1. – P. 1-13.
[31] Strugatsky V.M., Malanova T.B., Arslanyan K.N. Physiotherapy in the practice of an obstetrician-gynecologist (clinical aspects and formulations). - 2nd ed. – Moscow: MEDpress-inform, 2008.
Appendix A1. Working Group Composition
Leyla V. Adamyan – Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Deputy Director of the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health, Honored Scientist of Russia, Head of the Department of Obstetrics, Gynecology and Reproductive Medicine at the Russian University of Medicine, Chief Freelance Gynecologist of the Russian Ministry of Health, member of the Society for Reproductive Medicine and Surgery, Russian Association of Gynecological Endoscopists, Russian Association for Endometriosis, and the Russian Society of Obstetricians and Gynecologists.
Alexandra V. Asaturova – Doctor of Medical Sciences, Head of the 1st Pathomorphological Department at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health.
Vitaly F. Bezhenar – Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics, Gynecology and Neonatology at the First Pavlov State Medical University of St. Petersburg of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics and Gynecology for the Healthcare Committee of St. Petersburg, member of the Society for Reproductive Medicine and Surgery, Russian Association of Gynecological Endoscopists, and the Russian Society of Obstetricians and Gynecologists.
Ilya A. Ivanov – Obstetrician-gynecologist, researcher at the Department of Gynecological Endocrinology at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Candidate of Medical Sciences.
Apollon I. Karseladze – Professor, Doctor of Medical Sciences, Chief Researcher at the N.N. Blokhin National Medical Research Center of Oncology of the Russian Ministry of Health, Advisor to the Director of the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology.
Narine M. Tonoyan – Candidate of Medical Sciences, Obstetrician-Gynecologist at the Department of Operative Gynecology of the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health.
Oleg S. Filippov – Doctor of Medical Sciences, Professor, Honored Doctor of the Russian Federation, Chief Freelance Obstetrician-Gynecologist of the Federal Medical-Biological Agency (FMBA) of Russia, Deputy Director of the Federal Research and Clinical Center of Children and Adolescents of the FMBA of Russia, Professor at the Department of Obstetrics, Gynecology and Reproductive Medicine of the Russian University of Medicine.
Galina E. Chernukha – Doctor of Medical Sciences, Professor, Chief Researcher at the Department of Gynecological Endocrinology at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health, President of the Interregional Public Organization "Association of Gynecological Endocrinologists".
Maria I. Yarmolinskaya – Professor of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Head of the Department of Gynecology and Reproductive Endocrinology at the D.O. Ott Research Institute of Obstetrics and Gynecology, Professor at the Department of Obstetrics and Gynecology at the I.I. Mechnikov North-Western State Medical University of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.
Conflict of interest:
All members of the working group declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Obstetricians-gynecologists, general practitioners, family physicians;
Students, residents, postgraduate students;
Faculty members, researchers.
Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
These clinical guidelines have been developed taking into account the following regulatory legal and other documents:
Order of the Ministry of Health of the Russian Federation No. 1130n dated October 20, 2020, "On approval of the Procedure for the provision of medical care in the field of 'obstetrics and gynecology (excluding the use of assisted reproductive technologies)'" (as amended and supplemented).
Order of the Ministry of Health of the Russian Federation No. 803n dated July 31, 2020, "On the procedure for the use of assisted reproductive technologies, contraindications and restrictions on their use."
Savelyeva G. M. et al. Gynecology. National guidelines // M.: GEOTAR-Media. – 2017. – Vol. 1008.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
The occurrence of any pathological processes localized on the cervix carries a potential danger to a woman's health.
This area is characterized by a high risk of developing oncological diseases: according to statistics, about 270,000 cases of cervical cancer are diagnosed worldwide every year (mostly in developing countries). Therefore, every woman should pay increased attention to this zone of her body and react in a timely manner if any cervical diseases are detected. The treatment of these pathologies and monitoring of their condition is the key to women's health.
Cervical polyp is a benign lesion of the glandular epithelium of the cervix, which can occur at any age, although it is more commonly diagnosed in patients over 40 years of age.
The clinical course of a cervical polyp is typically asymptomatic; however, spotting or vaginal bleeding may occur.
There are currently no medical treatments for cervical polyps. It should be noted that therapy with progesterone preparations or combined oral contraceptives has not proven effective. Given the frequent episodes of bleeding, obstruction to pregnancy, and the need for cancer prevention, all women with diagnosed cervical polyps are recommended to have them removed.
Further follow-up and the frequency of pelvic ultrasound examinations are determined individually by the obstetrician-gynecologist (preferably annually).