Cervical Endometriosis: An Unrecognized Mimic of HPV-Related Koilocytic Changes

Abstract Context: Koilocytic changes in the cervical squamous epithelium are commonly associated with human papillomavirus (HPV) infections. However, rare non-HPV-related causes, such as uterine prolapse, have been documented. This study explored an unusual association between koilocytic changes and cervical endometriosis, a finding that has not been previously reported. Design: We retrospectively analyzed six cases of cervical endometriosis from our institutional archives (2000–2024). Patients aged 34–51 years (median age: 48 years) presented with vaginal bleeding as the primary symptom. All patients underwent hysterectomy. Three of the six patients were virgins with intact hymens at the time of surgery. Histopathological examination revealed endometriosis extending to the exocervix in all patients. Cervicovaginal smears were not performed in any case. Histopathological evaluation, including HPV immunostaining, was performed on cervical tissue. Results: Histopathological analysis revealed koilocytic changes in all patients with no evidence of dysplasia. Endometriosis was observed in the exocervix in all cases. Acute and chronic inflammation were minimal. Serum CA-125 levels were elevated in all patients (range, 65–380 units/ml). HPV immunostaining of cervical tissue was negative in all cases. Follow-up data indicated no development of vulvar warts or HPV-related lesions. Conclusion: Although koilocytic changes are traditionally used to diagnose HPV infection, they are not pathognomonic. This study demonstrated that koilocytic changes can occur in the context of cervical endometriosis, independent of HPV infection. These findings highlight the importance of considering non-HPV etiologies, such as endometriosis, in the differential diagnosis of koilocytic changes, particularly in patients without HPV risk factors.