Patient's question:
Cervical erosion, Cleanliness III, prepare to get pregnant in 3 months, can I still take medication? What medicine is best, with no impact on pregnancy.Doctor's answer:
Hello! First of all, I wish you a speedy recovery! Below, I will discuss "chronic cervical cervicitis." Chronic cervical cervicitis is the most common gynecological disease, which may occur after acute cervical cervicitis or due to various reasons causing cervical laceration and deformation of the cervix, making it easily susceptible to external bacterial infections. Due to the symptoms of chronic cervical cervicitis often being masked by other gynecological diseases, it is often discovered during routine gynecological examinations. Through colposcopy, visible signs of bright red fine granular erosion on the cervix and purulent mucopurulent discharge from the cervical canal can lead to a diagnosis. In some cases, the cervix may show local congestion and hypertrophy. After excluding malignant lesions and controlling specific or non-specific infections, local treatment is primarily used to allow the columnar epithelium on the erosion surface to necrose and fall off, eventually being covered by new squamous epithelium.1) Drug treatment—There are numerous drug treatment methods for chronic cervical cervicitis, commonly including the following:
1. Local vaginal irrigation and topical medication: This is the most commonly used treatment. Irrigation solutions may include 1:5000 permanganate solution, 1:1000 povidone-iodine solution, 1% acetic acid solution, or 0.5–1% lactic acid solution. For mild superficial cases, cotton swabs dipped in 5–10% tincture of iodine or 5–10% silver nitrate solution can be used to locally erode the erosion surface, once a week, which can promote healing. However, care must be taken to avoid the solution leaking to normal mucosa outside the affected area. After applying silver nitrate, physiological saline cotton balls are gently wiped to remove it, though this method is now rarely used. Local application of chlorocortisone tablets (containing 250 mg chloramphenicol and 5 mg prednisone) can be placed deep in the vagina nightly or every other night for 10 consecutive uses, with effects comparable to general disinfectant irrigation, and can be chosen based on the condition.
2. Vaginal lateral fornix closure: Refer to the other therapies chapter for details on closure therapy. This can be used for chronic cervical cervicitis combined with parametritis, lumbosacral pain, and significant cervical motion tenderness severely affecting sexual life.
3. Chinese herbal washes (Jie Er Yin): Suitable for various acute and chronic cervical inflammations. Its main ingredients include Cnidium monnieri, Phellodendron amurense, Sophora flavescens, and Atractylodes macrocephala. Generally, a 10% solution is used for vaginal irrigation or sitz baths, once daily, with two weeks constituting one course.
2) Physical therapy—Currently, physical therapy is the most effective and shortest-course method for treating cervical erosion, suitable for cases with large erosion areas and deep inflammation. Generally, only one treatment is needed for cure.
1. Electrocoagulation—Previously, radiant electrocautery was used, with longer healing times (6–8 weeks). Currently, electrocoagulation is preferred, flattening the entire erosion area, hence also known as electroironing. According to a summary of 2,095 cases from the Affiliated Hospital of Shandong Medical University, the effectiveness rate of electroironing therapy for cervical erosion is 100%. The specific procedure involves properly setting up the electroiron, disinfecting the external genitalia, vagina, and cervix. The cervix is exposed using a vaginal speculum, and the electroiron head is applied to the erosion area for even electroironing, slightly extending beyond the erosion. The depth of electroironing is about 0.2 cm; excessive depth can cause bleeding and slower healing, while excessive depth reduces effectiveness. After electroironing, the wound is sprinkled with furacilin powder or coated with tetracycline cream.
2. Cryotherapy—A cryotherapy treatment using liquid nitrogen as the refrigerant, with a temperature of -196°C. During treatment, appropriate probes are selected based on the erosion condition. To enhance efficacy, the freeze-thaw-freeze method (freezing for 1 minute, rewarming for 3 minutes, and freezing again for 1 minute) can be used. Its advantages include simple operation, minimal postoperative bleeding, and reduced cervical canal stenosis. The disadvantage is increased vaginal discharge after surgery.
3. Laser therapy—A high-temperature treatment with temperatures exceeding 700°C. It primarily carbonizes and forms crusts on the erosion tissue, which are later replaced by new squamous epithelium after the crust falls off. For cervical erosion treatment, carbon dioxide lasers with an infrared wavelength of 10.6 micrometers are commonly used. Preoperative preparation is similar to electroironing. In addition to thermal effects, laser therapy also has pressure, photochemical, and electromagnetic field effects, thereby reducing inflammation (stimulating the body to produce a stronger defensive immune function), alleviating pain (reducing chemical and mechanical stimulation of nerve endings by promoting tissue edema), and promoting tissue repair (enhancing the synthetic metabolism of epithelial cells, promoting epithelial hyperplasia, and accelerating wound healing). Thus, treatment time is short, and cure rates are high. Physical therapy should be performed 3–7 days after the menstrual period, and is contraindicated during acute genital inflammation. Postoperative vaginal discharge may increase, so external genital hygiene should be maintained., sexual intercourse, and vaginal irrigation should be avoided until the wound heals (4–8 weeks). If cryotherapy is performed, the patient's medical history of heart disease should be checked, and an electrocardiogram may be necessary if needed. Patients with heart disease should not undergo cryotherapy. The tendency of acute cervical inflammation to become chronic is mainly due to the numerous folds of cervical mucosa and grape-like glandular arrangement, making it difficult to eradicate pathogens once they invade deep glandular tissues, leading to recurrent and prolonged chronic infections. This is similar to how tonsillitis, sinusitis, or dental caries can cause other systemic inflammatory conditions such as arthritis or rheumatism, affecting overall health.
3) Chronic cervical cervicitis can present with various local manifestations: Cervical erosion is the most common local feature during the inflammatory process of chronic cervical cervicitis. The red lesions on the cervix surface result from the shedding of squamous epithelium, replaced by columnar epithelium, with exposed subepithelial blood vessels. The erosion surface has a clear boundary with the surrounding normal squamous epithelium. Since it is not true erosion, it is also called "pseudo-erosion." Depending on the severity of inflammation and the growth rate of columnar epithelium, cervical erosion can be classified into three types:
1. Simple type—In the early stages of inflammation, the erosion surface is covered by a single layer of columnar epithelium, appearing flat and smooth externally.
2. Granular type—Due to excessive proliferation of cervical glandular epithelium and stromal hyperplasia, the erosion surface becomes uneven and appears granular.
3. Papillary type—Significant glandular epithelial and stromal hyperplasia makes the surface even more uneven, forming papillary projections. Clinically, erosion areas are often classified as mild (I°), moderate (II°), or severe (III°) based on their size: less than one-third of the cervix area is mild; one-third to one-half is moderate; and more than one-half is severe.
A particularly noteworthy aspect is the healing process of cervical erosion. Under slightly weakened inflammation, adjacent squamous epithelium grows downward into the columnar epithelium layer, gradually pushing glandular epithelium aside, and eventually being completely covered by squamous epithelium for recovery. Although direct replacement by squamous epithelium occurs, indirect replacement is more common, where small round cells called basal cells or reserve cells exist under the columnar epithelium. During the healing process, these cells proliferate and eventually differentiate into squamous epithelium. Healing often occurs in patchy patterns, and since the newly formed squamous epithelium grows on an inflammatory tissue base, superficial cells are easily shed and thin, making them prone to recurrence of erosion under slight irritation. Thus, healing and inflammation alternately occur, making complete recovery difficult if treatment is incomplete. This healing process not only occurs on the surface but also in hidden glandular areas and columnar epithelium-covered glandular spaces, which are similarly replaced by stratified epithelium. This glandular epithelial stratification and epidermalization is called "squamous metaplasia." The degree of metaplasia varies greatly, sometimes entirely replacing glandular epithelium, sometimes only partially replacing one side of the gland or the gland opening, or sometimes forming solid cell clusters within the cervical stroma. Due to the high incidence of chronic cervical cervicitis, squamous metaplasia is found in 70–80% of cervical biopsies. Squamous metaplasia is a change in the healing process of erosion and does not carry a tendency to cancer; it is not a precancerous lesion and should not be confused with dysplasia or atypical hyperplasia.
4) Additionally, cervical erosion may be caused by the following two reasons:
1. So-called congenital erosion—During late embryonic development, both the vagina and the vaginal part of the cervix are covered by transitional epithelium. By the sixth month, this epithelium extends into the cervical canal, and by full term, columnar epithelium grows outward beyond the external cervical os. About one-third of newborn girls retain this state, appearing similar to adult inflammatory cervical erosion, hence the term "congenital cervical erosion." However, it usually persists for only a few days and naturally resolves after the estrogen level from the mother decreases.
2. Cervical erosion caused by excessive proliferation of columnar epithelium beyond the external cervical os, similar in appearance to inflammatory erosion, occurs only during the fertile age of ovarian function, not during puberty or postmenopause, and is more common during pregnancy, often resolving spontaneously after delivery. Although patients may experience increased leukorrhea, it is clear and mucoid, with no inflammatory cell infiltration or only a few lymphocytes observed under columnar epithelium in pathological examination, and is characterized by papillary and glandular erosion tissue patterns. All these phenomena suggest that this type of erosion may be caused by hormonal imbalance rather than inflammation, though secondary inflammation may develop on the erosion base. This is merely a consequence rather than the cause of erosion. Erosion may be due to estrogen effects, but animal experiments have shown that testosterone injections can induce similar glandular erosion changes in humans. Thus, it is believed that androgens can transform cervical epithelium into mucoid and glandular tissue, while progesterone has a similar effect, and estrogen promotes epithelial hyperplasia into highly keratinized stratified squamous epithelium.
In summary, the etiology of cervical erosion is mostly due to inflammation, but it may also be caused by endocrine disorders. Differential diagnosis should focus on the timing of onset, presence of inflammatory triggers or signs, and pathological examination may also be helpful. Treatment approaches may vary slightly. In chronic cervical cervicitis, cervical glands and surrounding tissues proliferate. When glandular ducts are compressed by surrounding tissues and blocked, secretions cannot be expelled and accumulate, causing glandular dilation and forming cystic tumors called "cervical glandular retention cysts" or Nabothian cysts. The contained mucus is usually clear and transparent but may appear purulent if infected. These cysts are generally small and scattered, sometimes protruding from the cervix surface. Small ones are as big as millet grains, while larger ones can reach the size of corn kernels, appearing bluish-white and may be accompanied by erosion but are also commonly found on smooth cervix surfaces. Due to long-term chronic inflammation stimulation, cervical tissues repeatedly undergo congestion, edema, inflammatory cell infiltration, and connective tissue hyperplasia, leading to cervical hypertrophy, which can be more than twice the size of a normal cervix in severe cases. After inflammation subsides, congestion and edema may reduce or disappear, but due to fibrosis, the cervix remains enlarged even after being fully covered by squamous epithelium with a smooth surface. Cervical glandular cysts also retain their protruding cystic shapes.
5) Clinical manifestations
1. Increased leukorrhea—Sometimes the only symptom of chronic cervical cervicitis. Usually mucoid or purulent. Occasionally, blood streaks or small amounts of blood may be present, or contact bleeding may occur. Leukorrhea irritation may cause external genital itching.
2. Pain—Lower abdominal or lumbosacral pain often occurs, sometimes extending to the upper abdomen, thighs, and hip joints, worsening during menstruation, defecation, or sexual intercourse. Particularly when inflammation spreads along the uterosacral ligaments or broad ligament base to form chronic parametritis or hypertrophied cervical main ligaments, pain intensifies. Touching the cervix may immediately cause iliac fossa or lumbosacral pain, and some patients may even experience nausea, affecting sexual life.
3. Bladder and intestinal symptoms—Chronic cervical cervicitis can spread via lymphatic channels or direct extension to the bladder trigone or surrounding connective tissue, causing the bladder to feel full with urination, leading to frequent urination or difficulty urinating, but urine is clear with normal urinalysis. In some cases, inflammation may continue to spread through lymphatic pathways connecting the cervix to the bladder trigone or ureters, causing secondary urinary tract infections. The incidence of chronic pyelonephritis in adult women is much higher than in men, which may be related to this condition. Intestinal symptoms are less common, with some patients experiencing pain during defecation.
4. Other symptoms—such as menstrual disorders, dysmenorrhea, pelvic heaviness, and infertility.
6) Differential diagnosis
- Acute vaginitis extending to the cervix versus cervical canal endometritis. Cervical inflammatory lesions limited to the cervical canal are rare. Both have smooth cervical surfaces, but the latter shows purulent mucus plugs at the external cervical os, while cervical inflammation from acute vaginitis, though with significant vaginal inflammation, still has clear and transparent cervical mucus.
- Cervical erosion must be differentiated from early cervical cancer, which is generally hard, brittle, and prone to bleeding, while cervical erosion is softer and more lubricated, with bleeding tendency only when touched, leaving bloodstains on the speculum. However, most early cervical cancers cannot be differentiated from cervical erosion without other diagnostic methods. Therefore, routine cervical scraping for cancer cells and biopsy under colposcopy are recommended if necessary.
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