A 28-year-old woman attends her annual gynaecological check-up. On speculum examination, the structure marked **A** appears bright red and everted, with a smooth surface and no contact bleeding. The patient is on combined oral contraceptive pills and denies any vaginal discharge or bleeding. What is the most likely explanation for this appearance?

Explanation

## Why Physiologic ectropion of columnar epithelium secondary to oral contraceptive use is right The structure marked **A** (cervix/external os) in this patient shows the classic appearance of physiologic ectropion: bright red, smooth, everted columnar epithelium visible on the external cervix. This is a normal variant, particularly common in young women on oral contraceptive pills, during pregnancy, and from puberty onwards. The absence of contact bleeding, friability, and purulent discharge rules out pathologic cervicitis. Per Williams Gynecology 4e, ectropion represents benign eversion of the endocervical canal epithelium and requires no treatment—it is often mistaken for "cervical erosion" but is entirely physiologic. ## Why each distractor is wrong - **Cervicitis due to Chlamydia trachomatis infection**: Cervicitis presents with purulent or mucopurulent discharge from the os, cervical erythema that is friable with contact bleeding, and often cervical tenderness. This patient has no discharge, no contact bleeding, and a smooth surface—inconsistent with infectious cervicitis. - **Early cervical malignancy with friable surface**: Cervical cancer typically presents as a mass, ulceration, or friable lesion with contact bleeding and abnormal appearance. This patient's smooth, non-bleeding, everted cervix is benign. Malignancy would require biopsy, but the clinical picture here is reassuring. - **Nabothian cyst with secondary inflammation**: Nabothian cysts appear as small yellow-translucent bumps on the cervix from blocked endocervical glands and are benign. They do not cause the diffuse red, everted appearance seen here, nor do they typically cause inflammation. The presentation here is ectropion, not cystic lesions. **High-Yield:** Ectropion = red, smooth, everted cervix in young women / OCP users / pregnancy = physiologic, no treatment; friable + contact bleeding = pathologic cervicitis. [cite: Williams Gynecology 4e — Cervical examination on speculum: assessment of appearance, discharge, ectropion, Nabothian cysts, and polyps]