Endometrial Polyp

Endometrial polyps are localised overgrowths of endometrial glands and stroma around a vascular core that protrude into the uterine cavity. They may be sessile or pedunculated, single or multiple, from a few millimetres to several centimetres.

They are common, found in 10 to 25 percent of women with abnormal bleeding and in up to 12 percent of asymptomatic women. Incidence peaks in the fifth and sixth decades.

Risk factors:

• age
• obesity
• hypertension
• tamoxifen use (the risk is up to 30 to 60 percent)
• unopposed oestrogen
• hormone replacement therapy
• Lynch syndrome

Most polyps are benign. Hyperplasia is found within a polyp in about 2 to 5 percent and malignancy in 1 to 3 percent. Rates are higher in postmenopausal women with bleeding and in those on tamoxifen.

• Many are asymptomatic and found incidentally.
• Abnormal uterine bleeding: intermenstrual bleeding, heavy menstrual bleeding, postcoital spotting, and postmenopausal bleeding.
• Infertility or recurrent pregnancy loss, as polyps may interfere with implantation.
• Large polyps may prolapse through the cervix, causing discharge, bleeding or cramp.
• Examination is usually normal; a polyp may be visible at the cervical os.

• Transvaginal ultrasound: thickened or focal echogenic endometrial lesion with a feeder vessel on colour Doppler (single vessel sign); saline infusion sonography improves detection, outlines the lesion and distinguishes polyp from fibroid and diffuse thickening.
• Hysteroscopy is the definitive method, allowing direct visualisation and targeted removal.
• Histology from the removed polyp: glands of variable size with fibrous stroma and thick walled vessels; exclude hyperplasia with or without atypia and carcinoma, with particular attention to the base.
• Blind biopsy and curettage have poor sensitivity for polyps.
• Assess hyperplasia or cancer risk factors (tamoxifen, obesity, age above 60, diabetes, postmenopausal bleeding).

• Asymptomatic premenopausal women with small polyps (less than 10 mm): observation is acceptable, since many regress (up to 25 percent), with review if symptoms develop.
• Removal is indicated for symptomatic polyps, polyps larger than 10 mm, those that prolapse through the cervix, postmenopausal polyps (with or without bleeding), polyps in women on tamoxifen who have bleeding, polyps in women with infertility, and polyps with suspicious features.
• Hysteroscopic polypectomy under direct vision is the treatment of choice. Options are an outpatient procedure with a small diameter hysteroscope (4 to 5 mm) using saline distension and mechanical or bipolar tools, or day case surgery under general anaesthesia for large or multiple polyps or when the patient prefers.
• Resect the polyp including its base, using a hysteroscopic morcellator or resectoscope loop, to reduce recurrence. Blind avulsion or curettage leaves residual tissue.
• Send all tissue for histology.
• Hysteroscopic complications: uterine perforation (rare, below 1 percent), fluid overload with non-electrolyte media (use saline with bipolar equipment), bleeding and infection.
• Hormonal therapy to prevent recurrence in women with recurrent polyps and heavy bleeding: levonorgestrel intrauterine system 52 mg.
• In women taking tamoxifen, polyps are removed if symptomatic and tamoxifen is continued if indicated, with surveillance. In women on hormone therapy, review the progestogen component.
• Recurrence occurs in about 10 to 15 percent, higher with multiple polyps and persistent risk factors.
• Fertility: polypectomy before intrauterine insemination or IVF raises pregnancy rates in infertile women (roughly doubling the chance in intrauterine insemination).
• Follow up: review of symptoms at 3 months; further evaluation if bleeding recurs, including repeat hysteroscopy and endometrial biopsy.
• Postmenopausal women with bleeding and a polyp: removal, and review for hyperplasia or cancer in the specimen. Women with no bleeding and a small incidental polyp may be observed.