Objective
The purpose of this study was to analyze the clinicopathologic characters and explore the possible cause of cervical endometriosis.
Study Design
By retrospective review, among 13,566 cases of endometriosis that had been treated in our hospital, 33 cases of pathologically proven cervical endometriosis were extracted.
Results
Of 33 cases, 17 women had abnormal vaginal bleeding or visible cervical lesions; the other 16 women had no obvious clinical manifestations but were diagnosed retrospectively on histopathologic reports. Vaginal delivery or curettage procedures had occurred in 84.8% of patients. Only 2 patients had undergone cervical surgery of cryotherapy or electric excision. Seven cases were misdiagnosed before final surgery with the primary suspicion of cervical myoma, inflammatory cyst, cervical polyp, uterine submucous myoma, melanoma or melanin mole, and cervical cancer. Surgical treatment was performed for all symptomatic patients. No recurrence was seen.
Conclusion
Cervical endometriosis should be distinguished from other benign or malignant cervical lesions. Surgical excision is suggested for symptomatic patients.
Endometriosis is one of the most common benign gynecologic disorders and occurs in approximately 15% of women at reproductive age. Cervical endometriosis is a rarely seen type of endometriosis and usually is found retrospectively on histopathologic reports. Although the most cases are asymptomatic, the condition could also be abnormal vaginal bleeding or variable appearance of cervix. Therefore, the diagnosis before surgery or histologic examination is difficult. To the best of our knowledge, most literature describes cervical endometriosis as sporadic case reports. Here, we report the case series of cervical endometriosis was treated and obtained histologic identification in Peking Union Medical College Hospital, China.
Materials and Methods
During the past 27 years (January 1983-April 2010), 13,566 patients with endometriosis have undergone surgical treatment in Peking Union Medical College Hospital. The diagnosis of endometriosis for these cases was all identified by microscopic pathologic examination. With a review of the medical records and archived pathologic sections, 33 cases of pathologically proven cervical endometriosis were extracted; these cases were identified by data regarding the endometrial glands and the surrounding endometrial stromal cells beneath normal cervical squamous epithelium ( Figures 1 and 2 ) . The clinical features of this case series are described and summarized in the Table . We specifically introduced 4 cases in detail to present their rarely seen or particular clinical manifestations or severe complications.
| Clinical characteristic | Patient, n |
|---|---|
| Total | 33 |
| Symptoms | |
| Main symptoms | 5 |
| Irregular intermenstrual bleeding | 3 |
| Postcoital spotting | 1 |
| Massive vaginal hemorrhage | 1 |
| Asymptomatic | 28 |
| Speculum examination findings | |
| Positive | 17 |
| Bluish, bluish-black, or red nodule 0.2-1.5cm in diameter | 12 |
| Polypoid lesion 3 cm in diameter | 1 |
| Cystic red mass 3-6 cm in diameter | 2 |
| Myoma-like mass 4 cm in diameter | 1 |
| Pelvic mass 5 cm in diameter on residual cervix | 1 |
| None | 16 |
| Parity history | |
| Full-term parturition | 23 (25 times) |
| Vaginal delivery | 17 (18 times) |
| Cesarean section delivery | 7 |
| None | 6 |
| Abortion history | |
| Curettage | 22 (32 times) |
| None | 10 |
| History of cervical surgery | |
| Yes (cryotherapy/electric excision) | 2 (1/1) |
| No | 31 |
Case 1
A 35-year-old woman (no offspring) experienced irregular and gradually intensifying intermenstrual vaginal bleeding for 5 years. On examination, there was a localized hemorrhagic nodule 0.5 cm in diameter that bled easily on contact on the posterior lip of the cervix adjacent to the vaginal vault. Transvaginal ultrasonography revealed the cystic lesion that was 1.8 × 1.6 × 1.4 cm on the posterior lip of the cervix; intracystic blood flow was observed. Excision of the nodule was undertaken. Histologic examination showed a focus of endometriosis that was characterized by endometrial glands and endometrial type stroma. Three injections of Leuprorelin acetate were prescribed postsurgery. Two months later, she was admitted to our hospital again because of hypermenorrhea and anemia with a hemoglobin concentration of 79 g/L. Vaginal examination showed that the hemorrhage was coming from a small fresh red focus on the posterior lip of the cervix. Excision of the lesion was performed, and histologic findings were consistent with a polyp of the endocervical glands. Intermittent 5-month Leuprorelin acetate injections were used subsequently. However, 18 months after the second cervical surgery, massive hemorrhage from the cervix occurred again. Cervical smear test results were normal. Because of the coexisting adenomyosis and severe pelvic endometriosis, transabdominal hysterectomy with excision of the lesions on the posterior vaginal wall and anterior rectal wall was undertaken. Grossly, a 3-cm cyst was located at the posterior lip of the cervix and vaginal vault; the histologic finding was in keeping with cervical endometriosis.
Case 2
A 41-year-old woman (2 pregnancies; 1 offspring) was referred for persistent intermenstrual spotting for >20 days. Pelvic and ultrasound examinations revealed an enlarged cervix and a cystic mass (6 cm in diameter) in the endocervical canal, with neither intracystic nor peripheral blood flow observed on color Doppler examination. A fine-needle biopsy was performed, and 80 mL of red fluid was aspirated with no neoplastic cells found. Because of the malignant potential of cervical lesion, laparoscopic hysterectomy was undertaken; histologic examination showed endometriosis of the uterine cervix.
Case 3
A 50-year-old woman (1 pregnancy; 1 offspring) was referred to the outpatient department with the finding of pelvic mass during postsurgical routine visits. Four years before, she had received subtotal hysterectomy and left salpingo-oophorectomy for adenomyosis, ovarian chocolate cyst, and pelvic endometriosis. Pelvic examination revealed an enlarged cervix and a pelvic mass of approximately 5 cm in diameter that was sitting on the top of the residual cervix. On ultrasound examination, a 6.5 × 5.6 × 4.7–cm heterogeneous low-level echo mass with dot-like high-level echo and internal septa revealed solid components. Color Doppler examination showed abundant signal from blood flow of either the artery or the veins inside the mass. Serum cancer antigen 125 (CA 125) level was elevated to 1488 U/mL. Cytologic examination of the cervix revealed a low-grade squamous intraepithelial lesion. Laparotomy exploration revealed the mass located at the top right of cervix; excision of the mass and residual cervix was performed. Histologic examination of the specimen revealed cervical endometriosis and paracervical polypoid endometriosis.
Case 4
A 43-year-old woman (1 pregnancy) with leiomyoma was referred to our hospital for a regular surveillance visit. On speculum examination, a myoma-like mass 4 cm in diameter on the posterior lip of the cervix was found, with mild erosion on the surface of the cervical external os. The body of the uterus was enlarged because of a 10-week gestation. Other than multiple leiomyoma of uterine corpus, cervical myoma was diagnosed primarily before surgery. Transabdominal hysterectomy was performed. By inspection of cut-open specimen, the chocolate-like cystic contents were seen inside the cervical mass; cervical endometriosis was confirmed on pathologic evaluation. Additionally, leiomyoma, adenomyosis, and chronic cervicitis were identified by histologic examination.
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