ENDOMETRIC POLYPIPES: from diagnosis to treatment

Reading Time: 3 minutes

Today, 2D ultrasound is the conventional method of ultrasound study.

Definition and risk factors

Endometrial polyps are focal intrauterine neoplasms, single or multiple, characterised by sessile or pedunculated morphology. They have three constituent elements: the glandular component, the stroma and the blood vessels. Malignant transformation occurs in between 0 and 12.9% of cases.
The main risk factors for endometrial polyp formation are age, hypertension, tamoxifen therapy and hyperestrogenism. The latter is typically linked to conditions such as obesity, polycystic ovary syndrome, late menopause, oestrogen-secreting stromal tumours and chronic liver failure. On the other hand, the role of hormone therapy in the pathogenesis of endometrial polyps is still debated, as some studies show an increased prevalence in these patients, while others find no differences compared to untreated women. Furthermore, it appears that progesterone has a protective role with respect to the development of polyps.

Diagnosis

Endometrial polyps may be totally asymptomatic, or they may manifest with abnormal uterine bleeding (AUB) pre- and postmenopausal or with infertility.
In symptomatic cases with abnormal uterine bleeding, the presence of an endometrial polyp should be suspected following the PALM-COEIN algorithm and should be investigated by transvaginal ultrasound, which is the non-invasive gold standard examination. It is preferable to perform the ultrasound examination during the proliferative phase of the menstrual cycle, as the endometrium is thinner, also making use of the colour Doppler study, which allows visualisation of the vascular pedicle. The lesion appears hyperechogenic, with well-defined margins, surrounded by a hyperechogenic halo.

Sonohysterography can also be used, which, through the injection of physiological solution, allows visualisation of the distended endometrial cavity and thus easier recognition of the lesion. To directly observe an endometrial polyp, however, it is necessary to perform a diagnostic hysteroscopy.

Treatment

The removal of an endometrial polyp is routinely performed by operative office hysteroscopy or videoresectoscopy in the operating theatre. The risk of intrauterine adhesion formation after the procedure is negligible and the complication rate is extremely low.
Currently, there are insufficient data to justify the routine removal of endometrial polyps in all sub-fertile patients, however, this intervention is considered safe and a pregnancy rate advantage has been demonstrated in infertile women who undergo polypectomy prior to performing intrauterine insemination (IUI) or a level II medically assisted procreation technique (IVF/ICSI).
In the case of an occasional finding of an asymptomatic endometrial polyp in pre- or postmenopausal women, removal is recommended if there are anamnestic risk factors for the development of endometrial carcinoma and/or if the lesion is more than 2 cm in diameter.
After menopause, a suspected symptomatic endometrial polyp should always be investigated by diagnostic hysteroscopy and, if confirmed, should be removed for histological examination. The risk of diagnosing an atypical hyperplasia or carcinoma is greater in the presence of AUB and does not increase with increasing polyp size. If these histological findings are found in the lesion, bilateral hysteroannessiectomy is recommended, as the risk of endometrial carcinoma in the surrounding tissue is 30%.

Bibliography

1. Ludwin A, Lindheim SR, Booth R, Ludwin I. Removal of uterine polyps: clinical management and surgical approach. Climacteric J Int Menopause Soc. 2020 Aug;23(4):388-96.
2. Raz N, Feinmesser L, Moore O, Haimovich S. Endometrial polyps: diagnosis and treatment options - a review of literature. Minim Invasive Ther Allied Technol MITAT Off J Soc Minim Invasive Ther. 2021 Oct;30(5):278-87.
3. Vitale SG, Haimovich S, Laganà AS, Alonso L, Di Spiezio Sardo A, Carugno J, et al. Endometrial polyps. An evidence-based diagnosis and management guide. Eur J Obstet Gynecol Reprod Biol. 2021 May;260:70-7.