Endometrial polyps are a common condition that may be associated with abnormal uterine bleeding, infertility, and pre-malignant and malignant conditions. Reported prevalence ranges between 7.8 to 32.9%, depending on diagnostic method and population studied (Salim, Dreisler, Fabres). Prevalence tends to increase with age and has been reported more with post menopausal (12%) than premenopausal women (6%) (Salim).
An endometrial polyp is defined as a localized hyperplastic overgrowth of endometrial glands and stroma that projects from the endometrial surface (Kim). They may be single, multiple, sessile, or pedunculated. The exact cause is unknown, however identified risk factors include: age, HTN, obesity, tamoxifen use (Salim). Both estrogen and progesterone regulate the balance of proliferation and apoptosis in the endometrium, and therefore appear to contribute to growth of polyps. However there have also been studies that show that women’s age and menopausal status do not significantly affect growth rate of polyps, suggesting that not all polyps are necessarily hormone dependent (Wong).
Roughly 44% of polyps in women are asymptomatic, therefore incidental findings are very common (Hassa). Abnormal uterine bleeding, including intermenstrual bleeding and post menopausal bleeding, is the most common symptom, occurring in 68% of women with polyps and (Salim, Golan). However, studies have also shown that symptomatology does not consistently correlate with polyp number, diameter, or site (Salim, Hassa). A recent study of 112 women managed for a mean of 22.5 months shows that there is no association between development on symptoms and polyp growth rate, so routine ultrasound to monitor growth cannot necessarily predict the onset of symptoms. This finding supports the rationale to encourage women with asymptomatic polyps to report symptoms rather than undergo routine U/S scans to monitor growth.The same study found that only 6.3 percent of polyps spontaneously regressed and that no identifiable factors were reliably associated with polyp growth and regression (Wong).
TVUS is the first line imaging study of choice to evaluate women with abnormal bleeding. The best time to evaluate women with TVUS is day 10 of a woman’s cycle when endometrium is the thinnest. For those patients for whom U/S findings are inconclusive, postmenopausal women, or those who are candidates for expectant management, a diagnostic hysteroscopy or saline infused sonohysterogram are suggested as both are able to give a better indication of the presence and shape of the lesion of question.
Diagnosis can only definitively be made with histologic examination after specimen has been removed. Hysteroscopic polypectomy is the gold standard when it comes to removal of polyps as it carries a relatively low risk, and enables removal of the entire lesion in question under direct visualization (Salim).
Approximately 95% of polyps are benign (Baiocchi). The prevalence of malignant lesions among post menopausal women with polyps ranges in literature between 3-6%. A retrospective study by Bel at al identified risk factors associated with malignant polyps. These risk factors include: age, BMI, hormone replacement therapy, first degree episodes of GYN cancer in their family hx. This study concluded that the risk of malignancy is highest (12.3%) in patients at least 59 years old with abnormal uterine bleeding. The risk among other subgroups varied between 2.31-3.78%. Clinically, therefore, hysteroscopy should be performed with menopausal patients over 59 yo with endometrial polyp and postmenopausal bleeding (Bel).
There has been conflicting evidence regarding the size of polyp and its association with malignancy. Some studies report that polyps >1.5 cm in diameter are associated with an increased risk of malignancy. However a systematic review found that data was inconclusive with regard to polyp size and malignancy potential. (Baiocchi)
Hysteroscopic polypectomy is the gold standard in terms of removal of polyps. It provides safe and effective management that enables histologic assessment and direct visualization. Blind curettage may miss small polyps or structural abnormalities and is therefore not recommended.
Symptom free premenopausal women with polyps <10mm may be managed conservatively as long as they don’t have other risk factors for endometrial hyperplasia or cancer. In patients with infertility, removal has been shown to improve subsequent pregnancy (Bosteels). In post-menopausal women with endometrial polyps we recommend hysteroscopic polypectomy, as they carry the highest risk of malignancy. However, asymptomatic postmenopausal polyps, specially is smaller than 10mm, are unlikely to be malignant and observation is an option after counseling. A blind biopsy should never be used as a reliable means of polyp removal, as there is no way to know whether the entire lesion was removed. Even if an EMB yields histologically diagnosed polyp, this should be followed with hysteroscopy to ensure adequate removal.
Douglas B Timmons Jr MD MPH
Ashley K Ulker MD
Jose Carugno MD FACOG
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