Discussion – Abnormal Vaginal Bleeding (Cervical Polyps)

Discussion – Abnormal Vaginal Bleeding (Cervical Polyps)

Vaginal bleeding is a common complaint presented among women in the emergency department (ED) (Jennings et al., 2019). In most cases, this bleeding is associated with normal physiological processes such as the menstrual cycle. However, in some instances, abnormal vaginal bleeding can occur. Such abnormal vaginal bleeding can be a symptom of an underlying gynecological or medical health issue. Abnormal vaginal bleeding is majorly associated with gynecological cancers, issues with the endocrine system, reproductive factors including pregnancy, infections, and other noncancerous vaginal and uterine growths such as cervical polyps. Although majorly benign, cervical polyps present an issue of gynecological health concern in reproductive-age women and among postmenopausal women. This paper reviews a case of a 45-year-old Asian female patient who presented herself to the clinic with a chief complaint of abnormal vaginal bleeding and recurrent spotting (See – Appendix A). She was diagnosed with cervical polyps, identified as the underlying condition for the persistent abnormal vaginal bleeding and spotting. The paper also reviews the topic of abnormal vaginal bleeding and cervical polyps, explains the rationale for selecting the topic in the context of client care, evaluates the key concepts related to the topic, and describes multiple viewpoints on cervical polyps. The paper further assesses the soundness of research on cervical polyps, the current care guidelines, and the applicable cultural, spiritual, and socioeconomic issues during client care.

Review of Topic and Rationale for Selection

The topic of cervical polyps and associated abnormal vaginal bleeding has been selected for a number of reasons and personal interests. The rationale for selection includes the current level of population awareness of the condition, prevalence rates, impact on women’s reproductive health, concerns over malignancy, and associated mental health outcomes. Other reasons include the desire to best understand the condition, management approaches, disparities, and the need to develop practice competencies as a reproductive health champion.

Cervical polyps are noncancerous growths on the surface (Alkilani & Apodaca-Ramos, 2023). Cervical polyps may vary in physical appearance, including shape and size. They majorly occur as protrusions from the cervical canal. However, they differ in categorization based on origin: ectocervical and endocervical polyps. Endocervical polyps originate from the cervical glands within the endocervix and are present in most cases, especially among premenopausal women (Alkilani & Apodaca-Ramos, 2023). Conversely, ectocervical polyps are usually observed in postmenopausal women and develop on the outer tissue of the cervix in the ectocervix (Alkilani & Apodaca-Ramos, 2023).

Every woman above 20 years of age is at risk of developing cervical polyps. An estimated 2 to 5 percent of women are affected during and after their productive years (Alkilani & Apodaca-Ramos, 2023). However, peak incidences are observed among multigravida women between the ages of 40 and 60 years (Uzzaman et al., 2020). This can create age-related disparities in gynecological health outcomes.

Early management of cervical polyps is important in gynecological and reproductive healthcare. Although cervical polyps are benign, a majority of patients express concerns over malignancy. The malignancy risk is very low, with around 0.1% of known cases (Alkilani & Apodaca-Ramos, 2023). However, noting that cervical cancer typically progresses from benign and precancerous conditions, usually cervical intraepithelial neoplasia (CIN) (Pereira & Garey, 2020), and that postcoital bleeding, a major symptom of cervical polyps, can be a predictive symptom of developing cervical dysplasia (Cohen et al., 2019), cervical polyps and associated symptoms can negatively impact the mental health of women and lead to the development of anxiety.

Other issues of concern that make this topic exciting to explore are the concerns over cervical polyps occurring early during pregnancy, increasing the risk of late abortion and unexpected preterm births (Hirayama et al., 2022); and cervical polyps contributing to irregular menstrual bleeding and contributing to infertility in rare cases where they fill the cervix blocking sperm from swimming up the cervix to fertilize the egg (Uzzaman et al., 2020). These concerns make cervical polyps an interesting topic and condition to explore and understand in terms of etiology, risk factors, and best management practices to ensure the best care outcomes and improve the quality of life for the patients.

Key Concepts Related to Cervical Polyps

The case of the 45-year-old Asian woman presenting with a complaint of abnormal vaginal bleeding and spotting highlights concepts related to cervical polyps, including the history and development of the condition, major symptoms and presentation of the condition, and risk of recurrence. The history of the present illness shows that the patient is 45 years old. Notably, 45 years of age for most women are considered premenopausal years. According to Alkilani and Apodaca-Ramos (2023), premenopausal women are at a higher risk of developing cervical polyps as compared to younger women. Although the etiology of cervical polyps is not yet clearly known, they are often associated with chronic inflammation, infections, or an abnormal response to increased levels of estrogen (Alkilani & Apodaca-Ramos, 2023). Other factors to consider from the history of the condition include the fact that cervical polyps can develop due to multigravida and a history of cervical polyps. The patient has gravida 3 para 3. She also has had a previous cervical polyps diagnosis and had them removed in 2023.

The symptomatology of cervical polyps is another key concept identified from the case. The patient’s chief complaint was abnormal vaginal bleeding and spotting. She noted that the bleeding is localized in the vaginal area. The client’s menstrual bleeding has also been persistent and has shown no signs of stopping. She also reported that the bleeding and spotting worsen with sexual activity. Postcoital bleeding is a major symptom of cervical polyps (Marnach & Laughlin-Tommaso, 2019). Notably, most cases are asymptomatic. Diagnoses may require a physical examination, like a pelvic exam, Pap smear, uterine biopsy, and transvaginal ultrasonography (Meybodi et al., 2020).

Recurrence of cervical polyps is another key concept. The patient’s current concerns are associated with past experiences with cervical polyps. She had been previously diagnosed with the condition, and the polyps were removed. She is currently concerned due to the manifestations of the condition. As cervical polyps are the main diagnosis in this case, it shows that cervical polyps have a high risk of recurrence. Concerningly, since most cases remain asymptomatic and detection is coincidental during pelvic and cervical examination, most patients may live with cervical polyps without noticing until the symptoms are severe.

Multiple Viewpoints and Controversies in Cervical Polyps

Multiple viewpoints and controversies exist regarding the origin and approach to the management of cervical polyps. First, the etiology of cervical polyps remains unknown. There are conflicting views and theoretical arguments on the etiology of cervical polyps. For instance, one view argues that cervical polyps grow due to congestion of cervical blood vessels, resulting in inefficient blood flow, while another suggests that cervical polyps result from infections or chronic cervical inflammation mainly due to chemical exposure over prolonged periods, resulting in abnormal cell development (Alkilani & Apodaca-Ramos, 2023). Other views on the etiology of cervical polyps suggest that such growth occurs due to abnormal response to hormonal fluctuations, including increased levels of estrogen, majorly due to the loss of apoptotic regulation and the overexpression of estrogen and progesterone receptors, leading to the overgrowth of the cervical tissue (Yuksel et al., 2020). Due to these conflicting theoretical viewpoints, a consensus on the actual etiology of cervical polyps is yet to be reached.

There are also varied viewpoints and controversies on the management of cervical polyps. A major controversy in the management of cervical polyps, despite the existence of guidelines, is whether it is necessary to remove polyps once identified. Some views hold that cervical polyps, whether symptomatic or asymptomatic, once identified in premenopausal women, need to be removed once diagnosed (Yuksel et al., 2020). The main procedure for the removal of cervical polyps is cervical polypectomy, which is in itself a controversial issue (Pegu et al., 2020). Despite the existence of guidelines for the management of cervical polyps, there is no justified argument for the removal or letting polyps disappear spontaneously. Additionally, there is insufficient evidence to support the argument that such polyps can disappear spontaneously (Yuksel et al., 2020). More recent views drawn from ongoing research relate the development of cervical polyps to human papillomavirus (HPV), which is not only controversial but complicates the overall management of the polyps (Kucukyıldız et al., 2022).

The viewpoint supporting the removal of polyps is sustained by the argument that for proper treatment and prevention of persistent symptoms such as abnormal vaginal bleeding, a complete removal of the polyps is necessary. However, arguing from the perspective that the polyps are benign and have a low risk of malignancy, removal may be unnecessary. This view necessitates weighing the benefits and risks of removal interventions such as cervical polypectomy. These diverse viewpoints and controversies complicate the understanding and management of cervical polyps. Regardless, all care decisions should be tailored to individual patient cases.

Soundness of Research on Cervical Polyps

Cervical polyps is a topic that has gained a lot of interest within research as the need to achieve better and patient-centered care in female reproductive health. However, a majority of the available evidence on cervical polyps is majorly drawn from case studies, observational studies, and expert opinions. Regardless, research has focused on developing knowledge of the etiology of cervical polyps and management approaches. For instance, in the article “Management of a Pregnant Woman with a Large Cervical Polyp and Moderate Genital Bleeding In The First Trimester,” Saitsu et al. (2024) present a case focused on managing cervical polyps in pregnant women. The case involves a woman in her 30s, gravida 4 para 2, with a history of spontaneous late miscarriage (sLMC) at 18 WG following rupture of membranes and gestational diabetes mellitus. She had been referred to the hospital at 7 WG due to a large cervical polyp. The authors identify cervical polyps occurring in early pregnancy as a major risk factor for sLMC/preterm delivery (PTD) due to reduced cervical efficiency (Saitsu et al., 2024). The evidence presented in the article argues that cervical polypectomy can reduce the risk of sLMC and the progression of infections associated with the development of large cervical polyps. On the other hand, the authors argue that polypectomy increases the risk of sLMC/PTD. The authors conclude that there is still no consensus on the management of cervical polyps during pregnancy.

Although Saitsu et al. (2024) have presented detailed information based on the observations from the case, the quality of the evidence is low as there is insufficient scientific rigor. This makes most of the evidence ungeneralizable across larger populations. In another article, “Preliminary Outcomes of Cervical Cerclage for Shortened Cervix with Decidual Polyp,” Misugi et al. (2022) present a retrospective observational study aimed at validating the use of cerclage to treat decidual polyp in pregnancy women with a history of cervical polyps. The authors present similar arguments on the dilemmas healthcare practitioners face when treating cervical polyps in pregnant women, with the option for polypectomy remaining controversial. Although the authors have presented their arguments well based on valid observations and the use of readily available data, the quality of evidence presented in the article is still low as it is a retrospective observational study.

The evidence on cervical polyps, although wide, can be considered to be of low quality. Most of the evidence, as noted, is from case studies and observational studies. Majorly collected data from clinical databases may not be ideal for research. The sample size in either type of research design is low, making it hard to replicability or generalizability. There is a need for professionals in gynecological and reproductive health to work collaboratively in research to develop enough evidence and reach a consensus on the management of the condition.

Evaluation of Current Evidence-Based Guidelines and Standardized Procedure for Cervical Polyps Diagnosis

The current guidelines are from the American College of Obstetricians and Gynecologists (ACOG) and the US Preventive Services Task Force (USPSTF) and endorsed by the Society of Gynecologic Oncology (SGO). The guidelines focus majorly on cervical cancer and gynecological conditions screening and management. These practice guidelines are applicable in the screening and management of cervical polyps since a majority of cases are identified coincidentally during regular cervical and pelvic cancer examinations. The USPSTF guidelines recommend that cervical cancer screening among individuals aged 30 years and above be done every five years and include human papillomavirus (hrHPV) testing (Fontham et al., 2020).

The ACOG guidelines recommend that screening begin earlier for women aged 21 and above who are considered at average risk and those older than 65(American College of Obstetricians and Gynecologists (ACOG), 2021). The USPSTF recommends cytology alone for average-risk individuals aged 21-29 years (Fontham et al., 2020). The updated USPSTF guidelines, which replace the previous ACOG and ASCCP guidelines, agree on the need for 3-year testing and examination using cervical cytology and a combined 5-year testing using both cervical cytology and hrHPV testing. This is backed by evidence from multiple clinical trials, which show that the use of cervical cytology and hrHPV co-testing were more efficient and accurate in detecting and identifying high-grade cervical intraepithelial neoplasia for individuals aged between 25 and 65 years, as compared to the use of individual cytology or hrHPV-based tests (Melnikow et al., 2018).

The recommended screening options for cervical cancer and polyps include pelvic exam, Pap smear, uterine biopsy, and transvaginal ultrasonography, as they evaluate the cervix, uterus, and the pelvic and endometrial structure and can help detect endometrial abnormalities and associated pathologies (Meybodi et al., 2020). Regular screening for cervical cancer is recommended as it can help detect the presence of any cervical polyps

There is no standardized protocol for the removal of asymptomatic polyps due to arguments on whether there is a possibility of spontaneous regression of such polyps (Yuksel et al., 2020), and the removal of symptomatic polyps as per the ACOG through cervical polypectomy.

Guidelines such as those provided by Sherlock and Chow (2024) suggest a comprehensive histopathological examination to determine the extent of the polyp growth to necessitate the removal of the polyps. At the same time, others suggest that only symptomatic need to be removed. Whether symptomatic or asymptomatic, Pegu et al. (2020) suggest that the need for a cervical polypectomy should be based on the outcomes of a comprehensive cervical evaluation.

Impact of Evidence on Practice

The reviewed evidence has only confirmed the appropriateness of the actions taken during the management of the 45-year-old Asian woman diagnosed with cervical polyps. All diagnostics were approached as per the recommendations of the evidence-based practice guidelines from the USPSTF and ACOG, including the use of a pelvic exam, Pap smear, uterine biopsy, and transvaginal ultrasonography. As directed by the current practice guidelines, the case was referred to an OB/Gynecologist for histopathological examination and to oversee the treatment of cervical polyps using polypectomy. A consideration of the new evidence and guidelines would delve into determining the need to remove the polyps or allow for spontaneous regression if possible. Additionally, the evidence reviewed would help distinguish benign cervical polyps from malignant lesions to avoid unnecessary processes, including polypectomy.

Cultural, Spiritual, and Socioeconomic Considerations

Cervical polyps affect all women regardless of their cultural, spiritual, or socioeconomic backgrounds. The current case involves a 45-year-old Asian woman. The management of the case requires an understanding of the individual and Asian cultural and spiritual views on gynecological conditions and certain treatment interventions, including cervical polypectomy. It also requires a review of the client’s socioeconomic background to ensure equitable access to the available treatment options. These considerations promote cultural sensitivity and help tailor the communication approach to an individual patient. It also ensures that the management interventions for cervical polyps are centered on the patient’s needs and preferences, as well as support informed consent. As argued by Shandley et al. (2020), patient-centered care in fertility clinics is associated with improved patient-physician relationships, better patient experiences, and improved care outcomes.

Conclusion

The case of the 45-year-old Asian patient diagnosed with cervical polyps presents an example of the complexity of managing cervical polyps. The case highlights the need to review the available literature to develop evidence and inform approaches to evaluating and managing cervical polyps. HPI from the present case also identifies the risk for the recurrence of cervical polyps and the need to evaluate the benignity of the polyps to rule out instances of malignancy. Regardless, the quality of evidence on cervical polyps is still low, and further research is needed to arrive at a consensus on the right approach to the management of cervical polyps.

 

References

Alkilani, Y. G., & Apodaca-Ramos, I. (2023). Cervical polyps. The American Journal of Surgery, 36(1), 239. https://doi.org/10.1016/S0002-9610(37)90821-3

American College of Obstetricians and Gynecologists (ACOG). (2021). ACOG publications: June 2021. Obstetrics and Gynecology, 137(6), 1129–1130. https://doi.org/10.1097/AOG.0000000000004400

Cohen, O., Schejter, E., Agizim, R., Schonman, R., Chodick, G., Fishman, A., & Klement, A. H. (2019). Postcoital bleeding is a predictor for cervical dysplasia. PLOS ONE, 14(5), e0217396. https://doi.org/10.1371/JOURNAL.PONE.0217396

Fontham, E. T. H., Wolf, A. M. D., Church, T. R., Etzioni, R., Flowers, C. R., Herzig, A., Guerra, C. E., Oeffinger, K. C., Shih, Y. T., Walter, L. C., Kim, J. J., Andrews, K. S., DeSantis, C. E., Fedewa, S. A., Manassaram‐Baptiste, D., Saslow, D., Wender, R. C., & Smith, R. A. (2020). Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA: A Cancer Journal for Clinicians, 70(5), 321–346. https://doi.org/10.3322/CAAC.21628

Hirayama, E., Ebina, Y., Kato, K., Akabane-Nakagawa, K., & Okuyama, K. (2022). Cervical polyps in early pregnancy are a risk factor for late abortion and spontaneous preterm birth: A retrospective cohort study. International Journal of Gynecology & Obstetrics, 156(1), 64–70. https://doi.org/10.1002/IJGO.13608

Jennings, L., Presley, B., & Krywko, D. (2019). Uterine Artery Pseudoaneurysm: A life-threatening cause of vaginal bleeding in the emergency department. The Journal of Emergency Medicine, 56(3), 327–331. https://doi.org/10.1016/J.JEMERMED.2018.12.016

Kucukyıldız, I., Karaca, M., Akgor, U., Turkyılmaz, M., Keskinkılıc, B., Kara, F., Ozgul, N., & Gultekin, M. (2022). Endocervical polyps in high-risk human papillomavirus infections. Ginekologia Polska, 93(1), 7–10. https://doi.org/10.5603/GP.A2021.0207

Marnach, M. L., & Laughlin-Tommaso, S. K. (2019). Evaluation and management of abnormal uterine bleeding. Mayo Clinic Proceedings, 94(2), 326–335. https://doi.org/10.1016/J.MAYOCP.2018.12.012

Melnikow, J., Henderson, J. T., Burda, B. U., Senger, C. A., Durbin, S., & Weyrich, M. S. (2018). Screening for cervical cancer with high-risk human papillomavirus testing: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA, 320(7), 687–705. https://doi.org/10.1001/JAMA.2018.10400

Meybodi, N. F., Karimi-Zarchi, M., Allahqoli, L., Sekhavat, L., Gitas, G., Rahmani, A., Fallahi, A., Hassanlouei, B., & Alkatout, I. (2020). Accuracy of the triple test versus colposcopy for the diagnosis of premalignant and malignant cervical lesions. Asian Pacific Journal of Cancer Prevention: APJCP, 21(12), 3501. https://doi.org/10.31557/APJCP.2020.21.12.3501

Misugi, T., Kitada, K., Fudaba, M., Tanaka, S., Kurihara, Y., Tahara, M., Hamuro, A., Nakano, A., Koyama, M., & Tachibana, D. (2022). Preliminary outcomes of cervical cerclage for shortened cervix with decidual polyp. Healthcare 2022, Vol. 10, Page 1312, 10(7), 1312. https://doi.org/10.3390/HEALTHCARE10071312

Patel, B. M. (2019). Endometrial hyperplasia: Diagnosis and management. Preventive Oncology for the Gynecologist, 25–43. https://doi.org/10.1007/978-981-13-3438-2_3

Pegu, B., Srinivas, B. H., Saranya, T. S., Murugesan, R., Thippeswamy, S. P., & Gaur, B. P. S. (2020). Cervical polyp: Evaluating the need of routine surgical intervention and its correlation with cervical smear cytology and endometrial pathology: a retrospective study. Obstetrics & Gynecology Science, 63(6), 735. https://doi.org/10.5468/OGS.20177

Pereira, D., & Garey, S. L. (2020). Cancer, cervical. Encyclopedia of Behavioral Medicine, 350–351. https://doi.org/10.1007/978-3-030-39903-0_157

Saitsu, Y., Yoneda, S., & Fukuta, K. (2024). Management of a pregnant woman with a large cervical polyp and moderate genital bleeding in the first trimester. BMJ Case Reports, 17(3), 258163. https://doi.org/10.1136/BCR-2023-258163

Shandley, L. M., Hipp, H. S., Anderson-Bialis, J., Anderson-Bialis, D., Boulet, S. L., McKenzie, L. J., & Kawwass, J. F. (2020). Patient-centered care: Factors associated with reporting a positive experience at United States fertility clinics. Fertility and Sterility, 113(4), 797–810. https://doi.org/10.1016/J.FERTNSTERT.2019.12.040

Sherlock, K., & Chow, C. (2024, July). Cervical polyps management pathway from primary to secondary care Version 1. Kingston Hospital NHS Foundation Trust. https://kingstonhospital.nhs.uk/wp-content/uploads/2021/07/Cervical-Polyp.pdf

Uzzaman, S., Sobnom, S., Mahata, R., Hasan, N., & Shethil, T. A. (2020). Survey report of cervical polyp disease affected patent in the north site of Bangladesh. International Journal of Case Studies in Clinical Research, 4, 1–05.

Yuksel, S., Tuna, G., Celik, H. G., & Salman, S. (2020). Endometrial polyps: Is the prediction of spontaneous regression possible? Obstetrics & Gynecology Science, 64(1), 114–121. https://doi.org/10.5468/OGS.20242

a:link {text-decoration: none;}a:visited {text-decoration: none;
}a:hover {text-decoration: underline;} a:active {text-decoration: underline;}

We’ll write everything from scratch

---

Select a client from your past or current FNP clinical rotations with an acute health problem or complaint that required at least two visits.

Based on this client’s condition, conduct a literature search for two research articles that discuss various approaches to the treatment of this condition. Peer-reviewed articles must address the standardized procedure or guidelines for this diagnosis. The research articles must be original research contributions (no review articles or meta-analysis) and must have been published within the last five years. Incorporate the research findings into the decision-making for this client’s treatment.

Attach the initial visit/comprehensive SOAP note and follow-up visit /focused SOAP note as appendices. You may include SOAP notes that have already been submitted in your clinical courses. If you are at a clinical site that does not see follow-ups (Urgent Care, ER, minute-clinic, etc), you may create a fictitious follow-up SOAP note addressing the issue with attention to items you would need to assess in the history and physical during the visit. The discussion on relating research to practice should be approximately 3-4 pages, and the total paper should be no longer than 10 pages, excluding references and appendices.

Cover the criteria listed below:

Review the topic and explain the rationale for the topic selection in the context of client care.
Evaluates key concepts related to the topic.
Describes multiple viewpoints if this is a controversial issue or one for which there are no clear guidelines.
Assess the merit of evidence found on this topic, i.e., soundness of research
Evaluates current guidelines, if available. Or, recommends what these guidelines should be based on available research. Discuss the Standardized Procedure for this diagnosis.
Discuss how the evidence did impact/would impact practice. What should have been done differently based on the knowledge gained?
Consider cultural, spiritual, and socioeconomic issues as applicable.
See the sample paper

Last Completed Projects