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Many clinicians encounter cervical lesions that may or may not be associated with cytologic abnormalities.

Such abnormalities as ectropion, Nabothian cysts, and small cervical polyps are quite benign and need not generate concern for patient or clinician, whereas others, including those associated with a history of exposure to diethylstilbestrol, cervical inflammation, abnormal cervical cytology, and postcoital bleeding, should prompt additional evaluation.

Further, in some patients, the cervix may be difficult to visualize. Several useful clinical suggestions for the optimal examination of the cervix are presented. The ability to visualize the cervix is necessary to identify cervical abnormalities. In many patients, visualization is straightforward; however, patients who are nulliparous or postmenopausal, those with a retroverted uterus that results in an anterior cervical displacement, or those with prior vaginal surgery, a full Images of the cervix and vagina, constipation, uterine enlargement, a pelvic mass, substantial pelvic scarring, or a high body Images of the cervix and vagina index present challenges to the adequate examination of the Images of the cervix and vagina. If this is the patient's first examination, outlining the examination in advance alleviates the patient's anxiety.

Explaining the next step may also Porno naruto hinata et sakura the patient's comfort during the examination. A chaperone should be available if requested. The Table provides useful suggestions to clinicians for optimizing the cervical examination.

Nabothian cysts also called mucinous retention cysts or epithelial cysts are common and benign and are considered a normal feature of the adult cervix Figure 1, C. Many women have multiple cysts. They may be translucent or opaque, whitish to yellow, and range from a few millimeters to 3 to 4 cm in diameter.

The transformation zone of the cervix where columnar and squamous cells meet is in a continuous process of repair, and squamous metaplasia and inflammation may block a gland orifice. The endocervical columnar cells continue to secrete but are covered by squamous epithelium, forming a mucinous retention cyst.

Rarely, a woman with several large Nabothian cysts may develop gross enlargement of the cervix. Nabothian cysts may also occur after childbirth or minor trauma. They are generally asymptomatic and require no treatment.

From references 1 - 3. Therefore, we recommend that women with Nabothian cysts measuring greater than 1 cm be referred to a gynecologist. Most are small and asymptomatic. On occasion, they protrude through the cervical os and become ulcerated and infected. The expanding myoma may cause symptoms related to mechanical pressure, including dysuria, urgency, urethral or ureteral obstruction, dyspareunia, and obstruction of the cervix. Menorrhagia and dysmenorrhea may also occur. Cervical myomas are generally diagnosed on pelvic examination but may need additional imaging such as ultrasonography to delineate size and location and to monitor growth.

Myomas that have prolapsed through the cervix are difficult to differentiate from cervical polyps and are typically removed. They may be observed for rate of growth if asymptomatic or referred to a gynecologist if enlarging, sizeable, or symptomatic. Cervical ectropion occurs when eversion of the endocervix exposes columnar Images of the cervix and vagina to the vaginal milieu also called cervical ectopy or erosion Figure 1, A.

The everted epithelium has a reddish appearance, similar to granulation tissue. Ectropion is common in adolescents, pregnant women, or those taking estrogen-containing contraceptives. Vaginal discharge is the most common symptom.

Postcoital bleeding may also occur, especially in pregnant women. Malignancy should be excluded by cervical cytology. An ablative procedure using cryotherapy or electrocautery performed by a gynecologist is effective for symptomatic ectropion. Cervical polyps may present with postcoital, intermenstrual, or postmenopausal bleeding but are more often incidentally found at pelvic examination Figure 1, B.

The ability Images of the cervix and vagina manipulate the lesion away from the cervical canal in 4 directions with a small swab differentiates a polyp from a polypoid irregularity of the cervix. The etiology of cervical polyps is unclear. Most are benign; the incidence of malignancy is Larger polyps should be evaluated and removed Images of the cervix and vagina a gynecologist.

Removal is typically a straightforward office procedure. The patient may be asymptomatic or report symptoms of discharge, dysmenorrhea, pelvic pain, or deep dyspareunia. Symptoms beyond discharge would suggest additional implants in the pelvis. Adenomyosis is endometrial tissue present within the myometrium or uterine muscle. It may involve the endocervical canal or form a polypoid mass protruding into the endocervical canal.

Biopsy will help differentiate other lesions of concern, such as endocervical glandular dysplasia and adenocarcinoma. From references 7 - Cervicitis, which most commonly presents as vaginal discharge or postcoital bleeding, Images of the cervix and vagina be acute or chronic, with an infectious or noninfectious etiology Figure 2, E. Mucopurulent discharge, cervical friability, and cervical edema are characteristic of gonococcal and chlamydial cervicitis.

Herpes simplex viral infection presents as multiple small vesicular or ulcerative lesions. Testing and treatment for likely organisms or referral to a gynecologist is appropriate for suspected infectious cervicitis. Postcoital bleeding, which can arise from the cervix or other genital area, may be of benign or malignant etiology.

The cervical epithelium associated with cervical intraepithelial neoplasia CIN and invasive cancer most commonly of the squamous type is thin and Images of the cervix and vagina, readily detaching from the cervix Figure 2, A.

Women with unexplained postcoital bleeding should be referred to a gynecologist for a colposcopic examination. In the United States, diethylstilbestrol DES was prescribed to prevent miscarriage and preterm labor between and Although shown to lack efficacy for these indications init was still widely prescribed until the early s, when women exposed to DES in India fuck hot girl jpeg image were shown to develop clear cell adenocarcinoma CCA of the vagina and cervix at a significantly higher rate than the general population.

AfterDES continued to be prescribed to pregnant women outside the United States 19 and is still available in oral form for human use in some countries, making this a consideration for our international patients. Inthe youngest women exposed in the United States to DES are in their forties and the oldest in their early seventies. Most have no reproductive tract abnormalities, although others have an increased risk of anomalies.

Most CCA has been reported in women younger than 35 years; however, it is essential to identify DES daughters and continue Images of the cervix and vagina them through midlife and beyond.

Clear cell adenocarcinoma may present as an abnormal lesion of the vagina or cervix or be identified through cytology. About one-third of DES daughters have vaginal adenosis Figure 2, D and abnormalities of the cervix, including the cockscomb cervix Figure 2, C and the cervical collar or hood.

Up to two-thirds of DES daughters experiencing infertility have a uterine anomaly, most commonly a T-shaped uterus. In appropriately aged women, clinicians should elicit an accurate history of cervical and vaginal abnormalities, including a history of recurrent miscarriage or preterm labor in the patient's mother.

DES daughters should receive the following testing annually because routine screening intervals do Images of the cervix and vagina apply: physical examination including breast examination and mammography; pelvic examination with inspection and palpation of the vulva, vagina, and cervix; vaginal and cervical cytology; and bimanual examination including rectal examination.

All grossly abnormal cervical and vaginal lesions on examination should Images of the cervix and vagina biopsied or referred to a gynecologist for evaluation and management. Cervical cytology may be performed to guide the specialist to colposcopy or clinical follow-up but does not rule out cancer in Images of the cervix and vagina presence of a lesion.

The optimal examination of the cervix is aided by appropriate patient positioning, speculum size, and labial retraction. Search for the cervix should begin in the posterior vagina. Most Nabothian cysts, endocervical polyps, and cases of cervical ectropion may be managed conservatively. Cervicitis may also be managed in the primary care setting, provided that infections are treated.

Gynecology referral is triggered by cervical lesions associated with abnormal cervical cytology, unexplained postcoital bleeding, DES exposure, and suspected cervical endometriosis or adenomyosis. In which one of the following cases is it unnecessary to remove a cervical polyp? Which one of the following situations warrants referral to a gynecologist? With which one of the following cervical abnormalities is prenatal diethylstilbestrol DES exposure not associated?

With which one of the following cervical conditions is a cervix of normal appearance most often associated? Because the Concise Review for Clinicians contributions are now a CME activity, Images of the cervix and vagina answers to the questions will no longer be published in the print journal.

For CME credit and the answers, see the link on our Web site at mayoclinicproceedings. National Center for Biotechnology InformationU. Journal List Mayo Clin Proc v. Mayo Clin Proc. Petra M. CaseyMD, Margaret E. LongMD, and Mary L. MarnachMD. Author information Copyright and License information Disclaimer. Address reprint requests and correspondence to Petra M. This article has been cited by other articles in PMC. Abstract Many clinicians encounter cervical lesions that may or may not be associated with cytologic abnormalities.

Suggestions for Performing an Optimal Cervical Examination. Open in a separate window. Cervical Ectropion Cervical ectropion occurs when eversion of the endocervix exposes columnar epithelium to the vaginal milieu also called cervical ectopy or erosion Figure 1, A. Cervical Polyps Endocervical Polyps Cervical polyps may present with postcoital, intermenstrual, or postmenopausal bleeding but are more often incidentally found at pelvic examination Figure 1, B.

Cervicitis Cervicitis, which most commonly presents as vaginal discharge or postcoital bleeding, can be acute or chronic, with an infectious or noninfectious etiology Figure 2, E.

Postcoital Bleeding Postcoital bleeding, which can arise from the cervix or other genital area, may be of benign or malignant etiology. Clear Cell Adenocarcinoma Most CCA has been reported in women younger than 35 years; however, it is essential Images of the cervix and vagina identify DES daughters and continue screening them through midlife and beyond.

When it is associated with vaginal bleeding When is larger than about 5 mm When it is asymptomatic When it is an endometrial polyp When it is associated with an abnormal cervical cytology Which one of the following situations warrants referral to a gynecologist?

In multiparous women who are sexually active In women with a low body mass index In women with retroverted uteri that result in anterior cervical displacement After hysterectomy After bladder emptying With which one of the following cervical abnormalities is prenatal diethylstilbestrol DES exposure not associated?

Cervical hood Cervical laceration Cockscomb cervix Clear cell carcinoma of the cervix Cervical collar With which one of the following cervical conditions is a cervix of normal appearance most often associated?

Brookside Associates Endocervical polyp.


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