Cervical Endometriosis, a Case Presenting With Intractable Spotting

Abstract and Introduction

Abstract

Cervix uteri is regarded as an infrequent localization for endometriosis. With widespread use of invasive cervical procedures, however, an increased incidence can be expected. Limited awareness of the clinical appearance of the disease may account for its apparent rarity. This presentation aims to refocus attention to the disease by reviewing the case of a woman who presented to us with minimal metrorrhagia, which is a rare symptom of cervical endometriosis.

Introduction

Although reports of cervical endometriosis were relatively frequent in the 1950s and 1960s, one finds few recent reports of cervical endometriosis; this may account for the common idea that cervix uteri is a rare localization for endometriosis. In a colposcopic examination series published in 1987,[1] the incidence of cervical endometriosis was reported to be between 0.11% and 2.4%.

Procedures traumatizing the cervix increase the likelihood of development of cervical endometriosis.[2] As biopsy, loop excision procedures, and laser treatments are more commonly performed than they were at the time of these earlier reports, an increase in the prevalence of cervical endometriosis can be expected.

The purpose of this report is 2-fold: to remind clinicians of the neglected topic of endometriosis of the uterine cervix and to show that cervical endometriosis can be encountered in different clinical presentations.

Case

A 32-year-old woman presented to our clinic with vaginal spotting of 8 months' duration. She had been examined by 2 gynecologists, 2 months apart. Each had diagnosed dysfunctional uterine bleeding, and both had prescribed cyclic use of a combined oral contraceptive pill. Her symptoms had not resolved after 4 months on the pill, and she presented to us with the same symptom.

A carefully taken history revealed that she had vaginal spotting almost every day. Further, her bleeding intensified for 3 to 4 days every 26 to 30 days. She reported that she had neither dysmenorrhea nor dyspareunia.

On speculum examination, her vulva and vagina appeared normal, but there were 2 macular lesions at the 3 and 9 o'clock positions on the cervix, both red to purple in color and about 0.5 cm in size; there was slight hemorrhage from the lesion at the 9 o'clock position. As a cervical smear had not yet been taken and a bimanual vaginal examination had not been performed, we thought that the bleeding was spontaneous rather than a result of contact to the lesion. A cervical smear was postponed because of the bleeding. Bimanual vaginal examination and transvaginal ultrasonographic examination findings, including endometrial thickness, were normal.

On colposcopic examination, the transformation zone was completely visible and normal. There were no findings suggesting neoplasia, other than the 2 previously described lesions. The lesions were punch biopsied. Pathologic examination revealed endometrial glandular and stromal cells. The lesions were then destroyed by electrocauterization. The patient was asymptomatic at the follow-up visit after 6 weeks. The cervix appeared clear on speculum examination. The Pap smear, taken 2 months later, was interpreted to exhibit benign cytologic changes. The patient was seen annually for the following 3 years; she remained asymptomatic, and the findings from colposcopic and cytologic examinations of the cervix were within normal limits.

Discussion

Endometriosis is one of the most commonly observed gynecologic pathologies among reproductive age women. Although endometriosis is most commonly observed on the ovaries, it is also observed on the uterus and its ligaments, in the abdominal cavity, on the cervix, pleura, and very rarely in the lungs, brain, and eyes. The most commonly reported symptoms are dysmenorrhea (60% to 80%), pelvic pain (30% to 50%), and infertility (30% to 40%). Menstrual irregularity is reported by only 10% to 20% of the patients.[3]

Some consider cervical endometriosis to be the leading cause of recurrent minimal metrorrhagia, particularly causing perimenstrual spotting and contact bleeding in the form of postcoital hemorrhagia.[4] On rare occasions, patients present with menorrhagia or vaginal discharge. Although most of the cited cases in the literature had small, flat, fragile, superficial lesions located on the fibrovascular stroma of the ectocervix, there are 2 noteworthy cases among these; one was reported to have a polypoid mass in the cervix[5] and the other had a uterus-like mass originating from the cervix.[6] The latter was at first thought to have a myoma in status nascendi. An endometrial-like polyp originating from a deep endometriotic focus and superficial cervical endometriosis with florid muscle hyperplasia were diagnosed in the pathologic examinations.

Most patients with endometriosis of the cervix are asymptomatic. A substantial number of patients reported in the literature only had abnormal smear results and were diagnosed during colposcopy or by pathologic examinations of their biopsy or hysterectomy specimens. In Veiga-Ferreira's series, only 2 of the 16 cases of cervical endometriosis complained of irregular bleeding (12.5%).[1] The presenting symptom of our case was continuous spotting. With a careful history, it was easily discerned that she had recurrent minimal metrorrhagia, and cervical endometriosis was considered with neoplastic lesions of the cervix in the differential diagnosis.

Cervical smears can be misleading in cases of cervical endometriosis. Particularly, when cervical endometriosis is present in patients previously treated with conization for preinvasive lesions of the cervix, cervical smears can be misinterpreted as high-grade squamous intraepithelial lesion, atypical glandular cells of undetermined significance or adenocarcinoma in situ.[7–10] The reason for this is that endometriosis undergoes different cytomorphologic changes under the influence of hormonal fluctuations during the menstrual cycle. Patients who have undergone hysterectomy after abnormal smears were obtained but were subsequently found to have cervical endometriosis on pathologic examinations have been reported in the literature.[8]

Cervical endometriosis can be encountered in patients who never underwent procedures traumatizing the cervix, as in our case. We believe that awareness of cervical endometriosis can minimize the misinterpretations mentioned above when a colposcopic examination is performed on a patient who had potentially neoplastic changes in cervical smear. Treatment is necessary when cervical endometriosis causes metrorrhagia. As procedures traumatizing the cervix are thought to be etiologic factors for the disease, locally destructive therapies, such as excision of the lesion or fulguration, have the potential to cause recurrences. Successful treatment of cervical endometriosis with superficial electrocauterization has been reported; however, this technique is also reported to be associated with a high rate of recurrence.[3] There are no reports on the results of more recent treatment modalities, such as cryotherapy or laser. Superficial electrocauterization was performed in our case, and the disease had not relapsed during 3 years of follow-up.