CLINICAL ACTIONS:

Endometrial polyps are a common cause of menstrual abnormalities and postmenopausal bleeding, with a prevalence of 7.8-35% depending on the population studied.

• To diagnose polyps, transvaginal ultrasound is reliable and can be augmented by saline infusion sonohysterography
  • Addition of color Doppler is sometimes helpful in identifying a feeding vessel
• Consider annual observation if polyp is < 10 mm, as up to 25% of polyps will resolve spontaneously
• Hysteroscopy with resection under direct vision is effective and reduces recurrence rate
• Blind dilation and curettage or biopsy should not be used for the diagnosis of polyps

SYNOPSIS:

Although uncommon, both endometrial hyperplasia and endometrial cancer can occur in polyps. When symptomatic, premenopausal women present with abnormal uterine bleeding (AUB-P), and postmenopausal women may have postmenopausal bleeding. Prevalence appears to be higher in women seeking fertility treatment but cause and effect have yet to be established. It is important to know when to intervene and when to observe.

KEY POINTS:

• Indications for polyp removal include
  • Abnormal uterine bleeding
  • Infertility
  • Recurrent pregnancy loss
• Management includes
  • Expectant vs surgical, depending on symptoms and malignancy risk factors within the polyp
• Risk of malignancy increases with age and size of the polyp with the highest rates in postmenopausal women with bleeding
  • However, asymptomatic polyps in postmenopause are not likely to be malignant
  • Observation is an option following discussion of risk/benefit with the patient
• Malignancy is unlikely in premenopausal women even if symptomatic
• Women on tamoxifen (a SERM) are at increased risk for the development of polyps
• Polypectomy in subfertile women appears to improve fertility
  • Recurrence rate is 2.5-3.7% up to 9 years after resection
• ACOG states

For polypectomy, direct hysteroscopic removal is preferred over blind procedures, which are associated with inaccurate detection and ineffective removal of intrauterine lesions

Learn More – Primary Sources:

AAGL Practice Report: Practice Guidelines for the Diagnosis and Treatment of Endometrial Polyps

ACOG Committee Opinion 800: The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology

Surgical Management of Endometrial Polyps in Infertile Women: A Comprehensive Review

Related ObG Topics:

Endometrial Hyperplasia – Current Nomenclature and Treatment

Ovarian or Endometrial Cancer? Consider Lynch Syndrome

Endometrial Cancer: Beyond The Basics

How Well Does Sonohysterography Match Up Against the Gold Standard of Hysteroscopy?

AAGL and “Choosing Wisely”: Five Practices to Question

Tamoxifen Therapy and Uterine Cancer Risk: The Data and Clinical Implications