ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Endometrial polyps

Endometrial polyps
Literature review current through: Jan 2024.
This topic last updated: May 01, 2023.

INTRODUCTION — Endometrial polyps are one of the most common etiologies of abnormal genital tract bleeding in both premenopausal and postmenopausal patients (table 1). Unlike polyps of other etiologies (eg, colon), the vast majority of endometrial polyps are neither malignant nor premalignant. However, an increased risk of malignancy occurs in selected patients (eg, bleeding, postmenopausal, hereditary cancer syndrome, tamoxifen use).

The pathogenesis, diagnosis, and management of endometrial polyps are reviewed here. General principles of the evaluation of uterine bleeding are discussed separately. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis" and "Approach to the patient with postmenopausal uterine bleeding".)

HISTOPATHOLOGY — Endometrial polyps are localized hyperplastic overgrowths of endometrial glands and stroma around a vascular core that form a sessile or pedunculated projection from the surface of the endometrium (picture 1) [1,2]. Smooth muscle is sometimes present.

Single or multiple polyps may occur and range in diameter from a few millimeters to several centimeters [3]. Polyps can develop anywhere in the endometrial cavity.

PATHOGENESIS — Several molecular mechanisms have been proposed to play a role in the development of endometrial polyps. These include monoclonal endometrial hyperplasia [4], overexpression of endometrial aromatase [5,6], somatic gene mutations [7,8], and age-related accumulation of low-frequency single nucleotide variants in oncogenes, including mutations in KRAS, PTEN, and TP53 [9]. Like uterine leiomyomas, polyps have characteristic cytogenetic rearrangements. Rearrangements in the high-mobility group family of transcription factors appear to play a pathogenic role [7,10,11].

Endometrial polyps express both estrogen and progesterone receptors and these hormones (ie, estrogen, progesterone) may play a role in pathogenesis, especially in postmenopausal patients [12,13]. In a subset of patients with polyps (ie, those on tamoxifen therapy), progesterone may serve an antiproliferative function, as it does in normal endometrial tissue [14,15] (see 'Risk factors and prevention' below). While androgens have been found to cause endometrial atrophy, similar to progestins, data suggest that testosterone does not substitute for progestational activity for polyps [16].

PREVALENCE — The frequency of polyps is difficult to establish, since there are few data, and some polyps are asymptomatic.

In a study including Danish females ages 20 to 74 years, the prevalence of endometrial polyps in pre- and postmenopausal females was 7.6 and 13 percent, respectively [17]. This is consistent with other data which demonstrate an increasing prevalence when pre- versus postmenopausal patients are compared (6 versus 12 percent, respectively) [18]. Prevalence is higher in patients undergoing endometrial biopsy or hysterectomy (10 to 24 percent) [19,20], and those with infertility undergoing in vitro fertilization (IVF; 6 to 30 percent) [21].

Endometrial polyps are rare among adolescent patients [22].

RISK FACTORS AND PREVENTION

Risk factors for endometrial polyps include:

Tamoxifen – Endometrial polyps are diagnosed in 30 to 60 percent of patients on tamoxifen [21], and are the most common type of endometrial pathology associated with tamoxifen use.

Tamoxifen use is also associated with malignant transformation of endometrial polyps and an increase in the overall risk of endometrial cancer [23-25]. In one meta-analysis including pre- and postmenopausal patients with endometrial polyps, those with versus without tamoxifen use had an increased prevalence of premalignant and malignant lesions (prevalence ratio [PR] 1.53, 95% CI 1.06–2.21) [25].

Malignant transformation in such patients does not appear to be associated with polyp size or duration of tamoxifen use. This is discussed in detail separately. (See "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Tamoxifen' and "Abnormal uterine bleeding and uterine pathology in patients on tamoxifen therapy".)

Tamoxifen appears to increase the risk of endometrial polyp formation more than other selective estrogen receptor modulators, such as raloxifene. In a randomized trial including over 9400 postmenopausal patients with breast cancer treated with chemoprophylaxis, the incidence of polyps was lower in patients treated with raloxifene compared with tamoxifen (0.6 versus 2.1 percent, relative risk 0.3, 95% CI 0.25-0.35) over the 81-month study period [24].

Obesity – Endometrial polyps appear to be associated with obesity [25-29]. In a retrospective cohort study of 223 patients planning in vitro fertilization (IVF), those with a body mass index ≥30 kg/m2 compared with <30 kg/m2 had a higher rate of polyps (52 versus 15 percent, respectively) [27]. A subsequent cross-sectional study found that postmenopausal patients with polyps compared with postmenopausal patients without polyps had higher rates of obesity (odds ratio [OR] 4.66), elevated glucose levels (OR 2.83), dyslipidemia (OR 7.0), and a diagnosis of metabolic syndrome (OR 2.58) [30].

Hormone replacement therapy – Postmenopausal hormone therapy may be associated with endometrial polyps, particularly regimens with a high dose of estrogen and/or a progestin with low antiestrogenic activity [26,31]. In a case-control study including 243 postmenopausal patients, those with versus without endometrial polyps had higher rates of hormone therapy utilization (current use: OR 2.72, 95% CI 1.24-5.97; ever use: OR 1.83 95% CI 1.05-3.19) [29].

Lynch and Cowden syndrome – Patients with Lynch and Cowden syndrome may have an increased incidence of endometrial polyps compared with the general population; these patients are also at an increased risk of endometrial hyperplasia and endometrial carcinoma [32-34]. (See "Lynch syndrome (hereditary nonpolyposis colorectal cancer): Clinical manifestations and diagnosis" and "PTEN hamartoma tumor syndromes, including Cowden syndrome", section on 'Genitourinary'.)

Other – The presence of more than one polyp and endometriosis may be independent risk factors of recurrent polyps, as suggested by at least one study [35].

Preventative factors include:

Oral contraception – Oral contraception use (current or ever use) is associated with decreased rates of endometrial polyps [29].

Levonorgestrel IUD – The levonorgestrel intrauterine device (LNG 52 mg IUD, Mirena or Liletta) may also be associated with decreased rates of endometrial polyps. This can be extrapolated from data including patients receiving tamoxifen treatment which show a decreased incidence of endometrial polyps among those using an LNG 52 [15,36,37].

Further study is needed, however, to determine whether such treatment results in a decrease of malignant transformation in polyps (and endometrial carcinoma in general) and whether the LNG 52 can be used safely in patients with progesterone receptor-positive breast cancer [38,39]. This is discussed in more detail separately. (See "Abnormal uterine bleeding and uterine pathology in patients on tamoxifen therapy".)

NATURAL HISTORY

Continued growth or regression — If left untreated, endometrial polyps may persist, progress, or resolve. In a prospective study including 64 asymptomatic premenopausal patients (mean age 44 years), two saline infusion sonograms (SISs) were performed 2.5 years apart [40]. Of the seven patients (11 percent) diagnosed with polyps on the first examination, four (57 percent) had spontaneous resolution of their polyps at the second scan; seven additional patients developed new polyps over the 2.5-year interval. Polyps larger than 1 cm compared with smaller polyps were less likely to resolve. Hormone use did not appear to affect the natural history of the polyps, but the study sample was small. By contrast, a retrospective study including 112 patients managed expectantly for a mean of 22.5 months found that only 6.3 percent of polyps spontaneously resolved and that no factors were reliably associated with polyp growth and regression [41].

Risk of malignancy — The vast majority of endometrial polyps are benign. In systematic reviews and meta-analyses including large numbers of patients (ie, >10,000 and >21,000 patients), the incidence of malignant polyps was between 3.4 and 3.57 percent [25,42].

The risk of malignancy is higher in selected patients, including postmenopausal patients, patients with bleeding, patients using tamoxifen, and those with a hereditary cancer syndrome (eg, Lynch and Cowden syndrome). These characteristics are also associated with an increased risk of endometrial malignancy without polyps:

Postmenopausal patients – The risk of malignancy is higher in postmenopausal compared with premenopausal patients. In one meta-analysis, the incidence of malignant or hyperplastic polyps was over threefold higher in postmenopausal compared with premenopausal patients (5.4 versus 1.7 percent, relative risk [RR] 3.86, 95% CI 2.9-5.1) [42].

Patients with bleeding – The risk of malignancy is also higher in patients with versus without bleeding. In the meta-analysis discussed above, the incidence of malignant or hyperplastic polyps was higher in patients with versus without bleeding (premenopausal patients: 4.2 versus 2.2 percent, RR 2, 95% CI 1.2-3.1; postmenopausal patients: 4.5 versus 1.5 percent, RR 3.4, 95%CI 1.5-7.8) [42]. In the largest study included in this meta-analysis which evaluated 1922 postmenopausal patients with polyps, endometrioid adenocarcinoma on a polyp was found in one patient without bleeding (0.1 percent) and eight patients with bleeding (1 percent) [43]. Other polypoid cancers were found in 0.3 and 2.7 percent of patients, respectively.

Tamoxifen use (see 'Risk factors and prevention' above).

Hereditary cancer syndromes (see 'Risk factors and prevention' above).

Large polyp size – Data regarding polyp size and risk of malignancy are less clear. In the meta-analysis review described above, data were inconsistent regarding whether increased polyp size was associated with malignancy [42]. In a subsequent meta-analysis (see 'Risk factors and prevention' above), polyp size (ie, ≥2 and <2 cm) was not associated with malignancy [25]. However, other studies have reported that premalignant or malignant histology is associated with polyps greater than 1.3 cm [44] or 1.5 cm in greatest dimension [45].

Treatment of malignant endometrial polyps is the same as for endometrial carcinoma. (See "Overview of resectable endometrial carcinoma".)

Coexisting hyperplasia — Patients with endometrial polyps may also be at increased risk of a coexisting endometrial hyperplasia. In one prospective study including 694 pre- and postmenopausal patients with endometrial polyps, coexisting endometrial hyperplasia with or without atypia was found in 7 and 18 percent of patients, respectively [46]. Rates were higher in postmenopausal patients and patients with larger polyps [46].  

Endometrial hyperplasia is discussed in detail separately. (See "Endometrial hyperplasia: Clinical features, diagnosis, and differential diagnosis" and "Endometrial hyperplasia: Management and prognosis".)

CLINICAL PRESENTATION — The most common clinical presentation is bleeding. Endometrial polyps may also be asymptomatic and diagnosed incidentally on pelvic imaging performed for another indication, reported on cervical cytology or endometrial biopsy results, or visualized on physical examination.

Bleeding – Bleeding is the most common presenting symptom and occurs in 64 to 88 percent of patients with polyps [18,47,48].

Bleeding due to polyps is referred to as "Abnormal uterine bleeding – Polyp (AUB-P)" in the nomenclature recommended by the International Federation of Gynecology and Obstetrics system, also known as the Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial dysfunction, Iatrogenic, and Not otherwise classified (PALM-COEIN) system [49]. (See "Causes of female genital tract bleeding", section on 'Polyps (AUB-P)'.)

Intermenstrual bleeding is the most frequent bleeding pattern in premenopausal patients with endometrial polyps [50]. The volume of bleeding is usually small and may be just spotting. Some patients experience heavier bleeding between menstrual cycles. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis", section on 'Intermenstrual bleeding'.)

Postmenopausal bleeding (PMB) is another common presentation; some postmenopausal patients with polyps have breakthrough bleeding during hormonal therapy. (See "Approach to the patient with postmenopausal uterine bleeding".)

Incidental finding

On imaging – Endometrial polyps are often identified incidentally on a pelvic ultrasound or hysteroscopy performed for another indication (see 'Pelvic imaging' below). For example, endometrial polyps may be detected during the evaluation of female infertility; the reported prevalence of endometrial polyps on ultrasound or hysteroscopy in those undergoing in vitro fertilization (IVF) is 6 to 8 percent [51,52].

On cervical cytology – While cervical cytology is not a useful method for diagnosing endometrial polyps, studies have shown an association between the finding of benign endometrial cells on liquid cervical cytology testing and both benign and malignant endometrial neoplasms. In a retrospective chart review including 440 patients (age 40 years or older) with a cervical cytology report that included the presence of endometrial cells and follow-up endometrial sampling, 12 percent of patients had endometrial polyps alone and 2 percent had polyps with a coexistent diagnosis (ie, hyperplasia, endometritis) [53]. Among patients with polyps alone, 72 percent were asymptomatic.

The evaluation of endometrial cells on cervical cytology is discussed separately. (See "Cervical cancer screening: The cytology and human papillomavirus report", section on 'Benign-appearing endometrial cells'.)

On endometrial biopsy – In some patients, an endometrial biopsy may show evidence of an endometrial polyp. In such cases, hysteroscopy is typically performed, as the entire polyp may not have been removed with the endometrial biopsy. (See 'Hysteroscopic polypectomy' below and 'Management' below.)

Prolapsed polyp – An endometrial polyp may prolapse and be visible on speculum examination as a globular, friable, pedunculated lesion protruding from the external cervical os.

Prolapsed polyps may be symptomatic or asymptomatic.

DIAGNOSTIC EVALUATION

History and physical examination — The medical history should include a detailed menstrual history and asses for risk factors associated with endometrial polyps. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis", section on 'Gynecologic and obstetric history' and 'Risk factors and prevention' above.)

A complete pelvic examination should be performed. However, in the absence of a prolapsed polyp, there are no physical examination findings associated with an endometrial polyp. (See 'Clinical presentation' above.)

Pelvic imaging

Transvaginal ultrasound – Transvaginal ultrasound (TVUS) is the first-line imaging study of choice for evaluation of patients with abnormal bleeding or a suspected uterine polyp. This modality is effective at characterizing uterine and adnexal lesions and is less expensive than other modalities. However, in patients with structural alterations of the uterus (eg, endometrial polyps, uterine leiomyomas), complete visualization of the endometrium may be impaired [54].

Sonohysteroscopy or diagnostic hysteroscopy – Sonohysterography, also referred to as saline infusion sonogram (SIS (image 1)), or diagnostic hysteroscopy (picture 2) may be used for further evaluation of patients with any of the following:

An uncertain finding on TVUS alone or incomplete visualization of the endometrium.

Postmenopausal patients with a thickened endometrium on TVUS.

In a randomized trial including 200 postmenopausal patients with bleeding, a thickened endometrium (>4 mm), and a negative endometrial biopsy, two patients had undiagnosed endometrial cancer and one patient had endometrial hyperplasia with atypia in polyps [55]. The authors concluded that either hysteroscopy or SIS is warranted to evaluate for structural lesions in postmenopausal patients with thickened endometrium.

In our practice, we also use sonohysteroscopy or diagnostic hysteroscopy for patients with an endometrial polyp in whom expectant management is planned.

Three-dimensional SIS does not appear to confer significant benefit over two-dimensional SIS [56].

A systematic review including over 5000 patients reported a similar performance for the diagnosis of polyps with TVUS, SIS, and hysteroscopy (sensitivity: 91, 95, and 90 percent; specificity: 90, 92, and 93 percent, respectively) [18]. In a subsequent meta-analysis, the pooled sensitivity and specificity of sonohysteroscopy for the diagnosis of endometrial polyp was 93 and 81 percent, respectively [57]. The shape of the lesion is often better visualized with either SIS or hysteroscopy compared with TVUS alone. While SIS compared with hysteroscopy allows for visualization of the adnexa and is thus useful in patients with suspected adnexal pathology, diagnostic hysteroscopy allows direct visualization of the lesion and in many cases simultaneous removal. (See "Saline infusion sonohysterography" and "Overview of hysteroscopy", section on 'Procedure'.)

Magnetic resonance imaging does not appear to be a sensitive diagnostic test for polyps [58].

Role of endometrial sampling — Endometrial sampling (eg, endometrial biopsy, dilation and curettage [D&C]) may be used in addition to pelvic imaging, especially in patients undergoing expectant management (see 'Patients without bleeding or other indications for removal' below).

While endometrial sampling can assess the endometrium for the presence of coexisting hyperplasia or carcinoma, endometrial sampling cannot be used to reliably assess the histology of the polyp, which may or may not be sampled using a "blind" technique. This is discussed in detail separately. (See "Overview of the evaluation of the endometrium for malignant or premalignant disease", section on 'Methods of evaluation'.)

DIAGNOSIS — A definitive diagnosis of an endometrial polyp is made based on histologic diagnosis of a specimen, usually collected at time of polypectomy. Histologic evaluation can also exclude malignancy.

A presumptive diagnosis of endometrial polyp can be made with a fair degree of confidence based on classic findings on imaging; however, malignancy cannot be excluded based on imaging alone.

The typical sonographic appearance of an endometrial polyp is a well-defined, homogeneous, polypoid lesion isoechoic to the endometrium with preservation of the endometrial-myometrial interface [59]; use of color flow or power Doppler to identify the central feeder vessel pathognomonic of an endometrial polyp may also be used (image 1 and image 2). (See "Saline infusion sonohysterography", section on 'Polyp'.)

On hysteroscopy, polyps often have a beefy red appearance, and are soft and friable when touched with an instrument (picture 2); a dilated gland can sometimes be visualized.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of an endometrial polyp includes other structural lesions of the uterine cavity.

Intracavitary leiomyomas – Intracavitary leiomyomas can often be differentiated from an endometrial polyp based on their appearance on ultrasound; in contrast to an endometrial polyp, leiomyomas often appear hypoechoic with shadowing and demonstrate peripheral flow on Doppler. In addition, polyps and fibroids typically have different appearances when visualized with hysteroscopy; myomas often appear firm, sessile, and are mainly white in color with surface blood vessels. Final determination is made with histology. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Diagnostic evaluation'.)

Endometrial hyperplasia or carcinoma – In contrast to endometrial hyperplasia or neoplasia, polyps are generally well demarcated at hysteroscopy; however, only histology can exclude malignancy. (See "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening", section on 'Ultrasound'.)

Cervical polyp or prolapsed leiomyoma – The differential diagnosis of a prolapsed endometrial polyp includes a cervical polyp (picture 3) and a prolapsed leiomyoma. In general, a cervical polyp is identified by visualizing or palpating a stalk originating from the endocervical canal, while the stalk of an endometrial polyp originates from the uterine cavity. Prolapsed leiomyomas typically have a firm consistency, while polyps are soft and friable. (See "Benign cervical lesions and congenital anomalies of the cervix", section on 'Polyps' and "Uterine fibroids (leiomyomas): Prolapsed fibroids", section on 'Incidental finding on pelvic examination'.)

MANAGEMENT — Our preferred approach to management is summarized below and described in the table (table 2).

Patients with bleeding — For pre- and postmenopausal patients with an endometrial polyp and bleeding (ie, abnormal uterine bleeding [AUB], postmenopausal bleeding [PMB]), we suggest removal of the endometrial polyp. The goal of polypectomy is both relief of symptoms and detection of malignancy, since symptomatic compared with asymptomatic polyps are more likely to be malignant. (See 'Risk of malignancy' above.)

Patients with risk factors for cancer, large or multiple polyps, or infertility — We also suggest removal for pre- and postmenopausal patients with an endometrial polyp and any of the following:

Multiple polyps – In our experience, multiple polyps are unlikely to regress and are likely to become symptomatic.

Prolapsed polyps – Prolapsed polyps are unlikely to regress, are likely to become symptomatic, and can typically be removed easily in an outpatient setting.

Risk factors for endometrial hyperplasia or carcinoma (table 3). (See "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Risk factors'.)

Large polyp size – Data are inconsistent regarding whether large polyp size is associated with malignancy. Some studies report that polyps >1.5 cm in diameter are associated with an increased risk of malignancy or hyperplasia, although lower thresholds have been reported. (See 'Risk of malignancy' above.)

Infertility – Most clinicians perform polypectomy in patients with infertility, although data regarding the impact of polyp removal on fertility are limited. (See "Female infertility: Treatments", section on 'Endometrial polyps'.)

Systematic reviews conclude that removing polyps may be beneficial in infertile patients undergoing intrauterine insemination (IUI) [60,61]. In one such review, patients with polyps undergoing IUI after hysteroscopic polypectomy had higher pregnancy rates compared with hysteroscopy alone (odd ratio [OR] 3.24, 95% CI 2.2-4.79) [61]. Rates of pregnancy were similar for those undergoing in vitro fertilization (IVF).

Endometrial polyps do not appear to be associated with an increased risk of spontaneous abortion or adverse obstetric outcomes and do not need to be removed in such patients.

Patients without bleeding or other indications for removal — The management of pre- and postmenopausal patients with an endometrial polyp but without bleeding, spotting, or other indications for removal is less clear. While many of these patients can be managed expectantly, counseling must be individualized, and patients who remain concerned about the risk of malignancy may reasonably choose to undergo removal [60]. While endometrial biopsy may be used to evaluate for concomitant endometrial hyperplasia or carcinoma, sampling devices perform better when pathology is global rather than focal; thus, endometrial sampling may not be reliable in patients with endometrial polyps. (See 'Risk of malignancy' above and 'Coexisting hyperplasia' above and "Overview of the evaluation of the endometrium for malignant or premalignant disease", section on 'Endometrial biopsy'.)

For patients choosing expectant management, there are no studies regarding the need for continued surveillance. In our practice, we do not perform further surveillance in these patients. Rather, further evaluation is based on new symptoms (eg, bleeding) or new risk factors for endometrial cancer (table 3). As such, patients are strongly encouraged to report any bleeding (eg, spotting, brown discharge) to their health care provider promptly. (See "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening", section on 'General recommendations'.)

HYSTEROSCOPIC POLYPECTOMY

Procedure — Polypectomy under hysteroscopic guidance is the treatment of choice for most endometrial polyps [62]. Hysteroscopic instruments that may be used to remove a polyp include grasping forceps, microscissors, electrosurgical loop (ie, resectoscope), morcellator, or a bipolar electrosurgical probe [63-65]. Rigid or flexible hysteroscopes may be used, and the procedure may be performed in either an ambulatory or operating room setting. (See "Overview of hysteroscopy", section on 'Instrumentation' and "Overview of hysteroscopy", section on 'Choosing an operative setting'.)

Hysteroscopic visualization of the polyp is preferred over blind curettage as the latter may miss small polyps and other structural abnormalities [63,66,67].

Occasionally, an endometrial polyp prolapses through the cervix and can be removed vaginally (see 'Clinical presentation' above). The procedure for removal of a prolapsed endometrial polyp is the same as for a prolapsed leiomyoma. (See "Uterine fibroids (leiomyomas): Prolapsed fibroids", section on 'Vaginal myomectomy'.)

Efficacy — For patients with symptomatic polyps, polypectomy results in improvement of symptoms in 75 to 100 percent of patients, based on studies with follow-up intervals of 2 to 52 months [68].

Complications — Complications of hysteroscopic polypectomy are infrequent, and the risks are the same as for other hysteroscopic procedures. (See "Overview of hysteroscopy", section on 'Complications'.)

In one retrospective study including 82 asymptomatic postmenopausal patients with an incidental endometrial polyp diagnosed on imaging, complications from hysteroscopy occurred in 3.6 percent of patients [69]. Two patients experienced uterine perforation; no patients experienced fluid overload.

RECURRENCE — In rare cases, endometrial polyps recur after removal. Patients who undergo removal of a prolapsed polyp without dilation of the cervix and visualization of complete removal may also experience polyp recurrence. The risk of recurrence in this situation is not known.

In such cases, care should be taken to completely remove the polyp(s) in a repeat polypectomy procedure; however, there are no data regarding the management of recurrent endometrial polyps.

The formation of recurrent polyps may be prevented by use of the levonorgestrel-releasing intrauterine device (LNG 52 mg IUD, Mirena or Liletta) [14,70]. Endometrial ablation/resection may also be an option for patients who have completed childbearing [71]; however, it is less preferred as it does not provide contraception. Moreover, if ablation is not complete, recurrent polyps can form. (See 'Risk factors and prevention' above and "Overview of endometrial ablation".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Abnormal uterine bleeding".)

SUMMARY AND RECOMMENDATIONS

Histopathology – Endometrial polyps are hyperplastic overgrowths of endometrial glands and stroma that form a projection from the surface of the endometrium (lining of the uterus); they are one of the most common causes of abnormal genital tract bleeding in both premenopausal and postmenopausal patients (table 1). (See 'Introduction' above and 'Histopathology' above.)

Prevalence – Among clinically recognized polyps, the prevalence is higher in postmenopausal compared with premenopausal patients. Prevalence of endometrial polyps is also higher in patients undergoing endometrial biopsy or hysterectomy, and those with infertility undergoing in vitro fertilization (IVF). (See 'Prevalence' above.)

Risk of malignancy – The vast majority of endometrial polyps are benign, but malignancy occurs in some patients. Endometrial polyps are more likely to be malignant in patients who are postmenopausal and those who present with bleeding. Treatment of malignant endometrial polyps is the same as for endometrial carcinoma. (See 'Risk of malignancy' above and "Overview of resectable endometrial carcinoma".)

Presentation – While most endometrial polyps cause bleeding, polyps may also be asymptomatic or present incidentally (eg, on pelvic imaging performed for another indication, reported on cervical cytology results, visualized on physical examination). (See 'Clinical presentation' above.)

Diagnostic evaluation

Transvaginal ultrasound (TVUS) is the first-line imaging study of choice for evaluation of patients with a suspected polyp. (See 'Pelvic imaging' above.)

Sonohysteroscopy (saline infusion sonogram [SIS]) or diagnostic hysteroscopy may be used for additional imaging in selected patients with an uncertain finding on TVUS, incomplete visualization of the endometrium, or in whom expectant management is planned. (See 'Pelvic imaging' above.)

Endometrial sampling (eg, endometrial biopsy, dilation and curettage [D&C]) may be used in addition to pelvic imaging and has the potential to diagnosis a coexisting hyperplasia or malignancy. However, because such procedures may not sample the entire lesion, they should not be used alone in patients with an endometrial polyp. (See 'Role of endometrial sampling' above and 'Coexisting hyperplasia' above.)

Diagnosis – A definitive diagnosis of an endometrial polyp is made based on histologic diagnosis of a specimen, usually collected at time of polypectomy. Histologic evaluation can also exclude malignancy. A presumptive diagnosis of endometrial polyp can be made with a fair degree of confidence based on classic findings on imaging; however, malignancy cannot be excluded based on imaging alone. (See 'Diagnosis' above.)

Management (table 2)

Patients with bleeding – For pre- and postmenopausal patients with endometrial polyps that are associated with bleeding (ie, abnormal uterine bleeding [AUB], postmenopausal bleeding [PMB]), we suggest polypectomy (Grade 2C). The goal of polypectomy in this setting is both to relieve bleeding symptoms and to detect malignancy, since symptomatic compared with asymptomatic polyps are more likely to be malignant. (See 'Patients with bleeding' above.)

Patients with infertility, large or multiple polyps, or risk factors for cancer – We also suggest polypectomy for pre- and postmenopausal patients with any of the following (Grade 2C) (see 'Patients with risk factors for cancer, large or multiple polyps, or infertility' above):

-Multiple polyps

-Prolapsed polyps

-Risk factors for endometrial hyperplasia or carcinoma (table 3)

-Large polyp size (eg, >1.5 cm in diameter)

-Infertility

Other patients – The management of pre- and postmenopausal patients with endometrial polyps but without bleeding or other indications for removal is less clear. While many of these patients can be managed expectantly, counseling must be individualized, and patients who remain concerned about the risk of malignancy may reasonably choose to undergo removal. (See 'Patients without bleeding or other indications for removal' above.)

  1. Mutter GL, Nucci, MR, Robboy SJ. Endometritis, metaplasias, polyps, and miscellaneous changes. In: Robboy's Pathology of the Female Reproductie Tract, 2nd ed., Robboy SJ, Mutter GL, Prat J, et al (Eds), Churchill Livingston Elsevier, Oxford 2009. p.343.
  2. Kim KR, Peng R, Ro JY, Robboy SJ. A diagnostically useful histopathologic feature of endometrial polyp: the long axis of endometrial glands arranged parallel to surface epithelium. Am J Surg Pathol 2004; 28:1057.
  3. Gregoriou O, Konidaris S, Vrachnis N, et al. Clinical parameters linked with malignancy in endometrial polyps. Climacteric 2009; 12:454.
  4. Jovanovic AS, Boynton KA, Mutter GL. Uteri of women with endometrial carcinoma contain a histopathological spectrum of monoclonal putative precancers, some with microsatellite instability. Cancer Res 1996; 56:1917.
  5. Maia H Jr, Pimentel K, Silva TM, et al. Aromatase and cyclooxygenase-2 expression in endometrial polyps during the menstrual cycle. Gynecol Endocrinol 2006; 22:219.
  6. Pal L, Niklaus AL, Kim M, et al. Heterogeneity in endometrial expression of aromatase in polyp-bearing uteri. Hum Reprod 2008; 23:80.
  7. Dal Cin P, Vanni R, Marras S, et al. Four cytogenetic subgroups can be identified in endometrial polyps. Cancer Res 1995; 55:1565.
  8. Nogueira AA, Sant'Ana de Almeida EC, Poli Neto OB, et al. Immunohistochemical expression of p63 in endometrial polyps: evidence that a basal cell immunophenotype is maintained. Menopause 2006; 13:826.
  9. Sahoo SS, Aguilar M, Xu Y, et al. Endometrial polyps are non-neoplastic but harbor epithelial mutations in endometrial cancer drivers at low allelic frequencies. Mod Pathol 2022; 35:1702.
  10. Dal Cin P, Timmerman D, Van den Berghe I, et al. Genomic changes in endometrial polyps associated with tamoxifen show no evidence for its action as an external carcinogen. Cancer Res 1998; 58:2278.
  11. Tallini G, Vanni R, Manfioletti G, et al. HMGI-C and HMGI(Y) immunoreactivity correlates with cytogenetic abnormalities in lipomas, pulmonary chondroid hamartomas, endometrial polyps, and uterine leiomyomas and is compatible with rearrangement of the HMGI-C and HMGI(Y) genes. Lab Invest 2000; 80:359.
  12. Gul A, Ugur M, Iskender C, et al. Immunohistochemical expression of estrogen and progesterone receptors in endometrial polyps and its relationship to clinical parameters. Arch Gynecol Obstet 2010; 281:479.
  13. Liu Z, Kuokkanen S, Pal L. Steroid hormone receptor profile of premenopausal endometrial polyps. Reprod Sci 2010; 17:377.
  14. Chan SS, Tam WH, Yeo W, et al. A randomised controlled trial of prophylactic levonorgestrel intrauterine system in tamoxifen-treated women. BJOG 2007; 114:1510.
  15. Dominick S, Hickey M, Chin J, Su HI. Levonorgestrel intrauterine system for endometrial protection in women with breast cancer on adjuvant tamoxifen. Cochrane Database Syst Rev 2015; :CD007245.
  16. Filho AM, Barbosa IC, Maia H Jr, et al. Effects of subdermal implants of estradiol and testosterone on the endometrium of postmenopausal women. Gynecol Endocrinol 2007; 23:511.
  17. Dreisler E, Stampe Sorensen S, Ibsen PH, Lose G. Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20-74 years. Ultrasound Obstet Gynecol 2009; 33:102.
  18. Salim S, Won H, Nesbitt-Hawes E, et al. Diagnosis and management of endometrial polyps: a critical review of the literature. J Minim Invasive Gynecol 2011; 18:569.
  19. Van Bogaert LJ. Clinicopathologic findings in endometrial polyps. Obstet Gynecol 1988; 71:771.
  20. Epstein E, Ramirez A, Skoog L, Valentin L. Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. Acta Obstet Gynecol Scand 2001; 80:1131.
  21. Vitale SG, Haimovich S, Laganà AS, et al. Endometrial polyps. An evidence-based diagnosis and management guide. Eur J Obstet Gynecol Reprod Biol 2021; 260:70.
  22. Davis VJ, Dizon CD, Minuk CF. Rare cause of vaginal bleeding in early puberty. J Pediatr Adolesc Gynecol 2005; 18:113.
  23. Cohen I. Endometrial pathologies associated with postmenopausal tamoxifen treatment. Gynecol Oncol 2004; 94:256.
  24. Runowicz CD, Costantino JP, Wickerham DL, et al. Gynecologic conditions in participants in the NSABP breast cancer prevention study of tamoxifen and raloxifene (STAR). Am J Obstet Gynecol 2011; 205:535.e1.
  25. Sasaki LMP, Andrade KRC, Figueiredo ACMG, et al. Factors Associated with Malignancy in Hysteroscopically Resected Endometrial Polyps: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2018; 25:777.
  26. Oguz S, Sargin A, Kelekci S, et al. The role of hormone replacement therapy in endometrial polyp formation. Maturitas 2005; 50:231.
  27. Onalan R, Onalan G, Tonguc E, et al. Body mass index is an independent risk factor for the development of endometrial polyps in patients undergoing in vitro fertilization. Fertil Steril 2009; 91:1056.
  28. Reslová T, Tosner J, Resl M, et al. Endometrial polyps. A clinical study of 245 cases. Arch Gynecol Obstet 1999; 262:133.
  29. Dreisler E, Sorensen SS, Lose G. Endometrial polyps and associated factors in Danish women aged 36-74 years. Am J Obstet Gynecol 2009; 200:147.e1.
  30. Bueloni-Dias FN, Spadoto-Dias D, Delmanto LR, et al. Metabolic syndrome as a predictor of endometrial polyps in postmenopausal women. Menopause 2016; 23:759.
  31. Maia H Jr, Maltez A, Studard E, et al. Effect of previous hormone replacement therapy on endometrial polyps during menopause. Gynecol Endocrinol 2004; 18:299.
  32. Lécuru F, Metzger U, Scarabin C, et al. Hysteroscopic findings in women at risk of HNPCC. Results of a prospective observational study. Fam Cancer 2007; 6:295.
  33. Kalin A, Merideth MA, Regier DS, et al. Management of reproductive health in Cowden syndrome complicated by endometrial polyps and breast cancer. Obstet Gynecol 2013; 121:461.
  34. Baker WD, Soisson AP, Dodson MK. Endometrial cancer in a 14-year-old girl with Cowden syndrome: a case report. J Obstet Gynaecol Res 2013; 39:876.
  35. Gu F, Zhang H, Ruan S, et al. High number of endometrial polyps is a strong predictor of recurrence: findings of a prospective cohort study in reproductive-age women. Fertil Steril 2018; 109:493.
  36. Gardner FJ, Konje JC, Bell SC, et al. Prevention of tamoxifen induced endometrial polyps using a levonorgestrel releasing intrauterine system long-term follow-up of a randomised control trial. Gynecol Oncol 2009; 114:452.
  37. Wong AW, Chan SS, Yeo W, et al. Prophylactic use of levonorgestrel-releasing intrauterine system in women with breast cancer treated with tamoxifen: a randomized controlled trial. Obstet Gynecol 2013; 121:943.
  38. Bakkum-Gamez JN, Laughlin SK, Jensen JR, et al. Challenges in the gynecologic care of premenopausal women with breast cancer. Mayo Clin Proc 2011; 86:229.
  39. Dinger J, Bardenheuer K, Minh TD. Levonorgestrel-releasing and copper intrauterine devices and the risk of breast cancer. Contraception 2011; 83:211.
  40. DeWaay DJ, Syrop CH, Nygaard IE, et al. Natural history of uterine polyps and leiomyomata. Obstet Gynecol 2002; 100:3.
  41. Wong M, Crnobrnja B, Liberale V, et al. The natural history of endometrial polyps. Hum Reprod 2017; 32:340.
  42. Lee SC, Kaunitz AM, Sanchez-Ramos L, Rhatigan RM. The oncogenic potential of endometrial polyps: a systematic review and meta-analysis. Obstet Gynecol 2010; 116:1197.
  43. Ferrazzi E, Zupi E, Leone FP, et al. How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study. Am J Obstet Gynecol 2009; 200:235.e1.
  44. Wong M, Thanatsis N, Nardelli F, et al. Risk of Pre-Malignancy or Malignancy in Postmenopausal Endometrial Polyps: A CHAID Decision Tree Analysis. Diagnostics (Basel) 2021; 11.
  45. Ben-Arie A, Goldchmit C, Laviv Y, et al. The malignant potential of endometrial polyps. Eur J Obstet Gynecol Reprod Biol 2004; 115:206.
  46. Rahimi S, Marani C, Renzi C, et al. Endometrial polyps and the risk of atypical hyperplasia on biopsies of unremarkable endometrium: a study on 694 patients with benign endometrial polyps. Int J Gynecol Pathol 2009; 28:522.
  47. Golan A, Sagiv R, Berar M, et al. Bipolar electrical energy in physiologic solution--a revolution in operative hysteroscopy. J Am Assoc Gynecol Laparosc 2001; 8:252.
  48. Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet 2018; 143:393.
  49. Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.
  50. Hassa H, Tekin B, Senses T, et al. Are the site, diameter, and number of endometrial polyps related with symptomatology? Am J Obstet Gynecol 2006; 194:718.
  51. Fatemi HM, Kasius JC, Timmermans A, et al. Prevalence of unsuspected uterine cavity abnormalities diagnosed by office hysteroscopy prior to in vitro fertilization. Hum Reprod 2010; 25:1959.
  52. Karayalcin R, Ozcan S, Moraloglu O, et al. Results of 2500 office-based diagnostic hysteroscopies before IVF. Reprod Biomed Online 2010; 20:689.
  53. Beal HN, Stone J, Beckmann MJ, McAsey ME. Endometrial cells identified in cervical cytology in women > or = 40 years of age: criteria for appropriate endometrial evaluation. Am J Obstet Gynecol 2007; 196:568.e1.
  54. Romano SS, Doll KM. The Impact of Fibroids and Histologic Subtype on the Performance of US Clinical Guidelines for the Diagnosis of Endometrial Cancer among Black Women. Ethn Dis 2020; 30:543.
  55. van Hanegem N, Breijer MC, Slockers SA, et al. Diagnostic workup for postmenopausal bleeding: a randomised controlled trial. BJOG 2017; 124:231.
  56. Nieuwenhuis LL, Hermans FJ, Bij de Vaate AJ, et al. Three-dimensional saline infusion sonography compared to two-dimensional saline infusion sonography for the diagnosis of focal intracavitary lesions. Cochrane Database Syst Rev 2017; 5:CD011126.
  57. Bittencourt CA, Dos Santos Simões R, Bernardo WM, et al. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017; 50:32.
  58. Balcacer P, Cooper KA, Huber S, et al. Magnetic Resonance Imaging Features of Endometrial Polyps: Frequency of Occurrence and Interobserver Reliability. J Comput Assist Tomogr 2018; 42:721.
  59. Heremans R, Van Den Bosch T, Valentin L, et al. Ultrasound features of endometrial pathology in women without abnormal uterine bleeding: results from the International Endometrial Tumor Analysis study (IETA3). Ultrasound Obstet Gynecol 2022; 60:243.
  60. Lieng M, Istre O, Qvigstad E. Treatment of endometrial polyps: a systematic review. Acta Obstet Gynecol Scand 2010; 89:992.
  61. Zhang H, He X, Tian W, et al. Hysteroscopic Resection of Endometrial Polyps and Assisted Reproductive Technology Pregnancy Outcomes Compared with No Treatment: A Systematic Review. J Minim Invasive Gynecol 2019; 26:618.
  62. The use of hysteroscopy for the diagnosis and treatment of intrauterine pathology. ACOG Committee Opinion No. 800. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;135:e138–48.
  63. Preutthipan S, Herabutya Y. Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women. Fertil Steril 2005; 83:705.
  64. Muzii L, Bellati F, Pernice M, et al. Resectoscopic versus bipolar electrode excision of endometrial polyps: a randomized study. Fertil Steril 2007; 87:909.
  65. Emanuel MH, Wamsteker K. The Intra Uterine Morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas. J Minim Invasive Gynecol 2005; 12:62.
  66. Brooks PG, Serden SP. Hysteroscopic findings after unsuccessful dilatation and curettage for abnormal uterine bleeding. Am J Obstet Gynecol 1988; 158:1354.
  67. Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. Am J Obstet Gynecol 1988; 158:489.
  68. Nathani F, Clark TJ. Uterine polypectomy in the management of abnormal uterine bleeding: A systematic review. J Minim Invasive Gynecol 2006; 13:260.
  69. Lev-Sagie A, Hamani Y, Imbar T, et al. The significance of intrauterine lesions detected by ultrasound in asymptomatic postmenopausal patients. BJOG 2005; 112:379.
  70. Shen Y, Feng W, Yang J, Yi J. Effect of Hysteroscopic Polypectomy Combined with Mirena Placement on Postoperative Adverse Reactions and Recurrence Rate of Endometrial Polyps: Based on a Large-Sample, Single-Center, Retrospective Cohort Study. Biomed Res Int 2022; 2022:1232495.
  71. Vahdat M, Mousavi AS, Kaveh M, et al. Hysteroscopic‎ polypectomy with ‎endometrial resection preventing the recurrence of endometrial polyps: A single-blinded randomized clinical ‎trial. Caspian J Intern Med 2022; 13:393.
Topic 5457 Version 34.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟