The management of endometrial polyps in the 21st century

Abstract

Key contentr Hysteroscopic endometrial polyp removal appears to be superior to the current practice of blind avulsion. r Outpatient treatment is safe, cost effective and well tolerated, even in older or nulliparous women. r New technologies facilitate office hysteroscopy. r Benign endometrial polyps can regress and rarely progress to malignancy. Learning objectivesr To learn how to diagnose and treat endometrial polyps in pre and postmenopausal women.r To be able to compare the performance of diagnostic modalities. r To understand the role of outpatient vaginoscopy and hysteroscopy. Ethical issuesr Given the cost effectiveness and acceptability of office ambulatory diagnostic and interventional hysteroscopy, is it ethical not to offer such a service?

Risk Factors Associated with the Malignant Changes of Symptomatic and Asymptomatic Endometrial Polyps in Premenopausal Women

“…These differences in the prevalence rates observed may be due to different study designs, sample sizes, inclusion and exclusion criteria, and different methods used for removal of polyps, such as uterine curettage this blind method fails to extract the whole polyp and obtains only a mixed specimen of polyp and the adjacent endometrial mucosa. Hysteroscopic endometrial polyp removal appears to be superior to the current practice [23]. In addition, it gives the possibility of removing the entire polyp with its stalk, and the histological examination proved the presence of an endometrial carcinoma hidden in either stalk or center [24], so that the risk of malignancy of endometrial polyps can be estimated confidently.…”

The role of hysteroscopy in diagnosis of menstrual disorders

“…Therefore, hysteroscopic polypectomy is advised for symptom relief and to rule out malignancy, especially in the post-menopausal age group. The traditional approach to polypectomy was blind avulsion, but this led to issues with the recurrence of symptoms and missed histological diagnosis of endometrial cancer [31]. Increasingly, polypectomy is now performed under direct vision in the outpatient setting without general anaesthesia [8].…”

Asymptomatic endometrial thickening in postmenopausal women

“…Two recent articles in TOG have addressed the problem of how to manage incidental abnormal endometrial findings in asymptomatic postmenopausal women but have failed to clarify this issue. In their useful review of management of women with postmenopausal bleeding, Bakour et al .…”

“…cite evidence that follow up and/or treatment of endometrial polyps incidentally diagnosed in asymptomatic postmenopausal patients could safely be restricted to a few select cases based on polyp diameter. However, Annan et al . recommend removal of all such polyps.…”

“…Of the control group, 4878 women (13.3%) had endometrial thickness between 5 and 10 mm and 1116 (3%) between 10 and 20 mm but did not go on to develop cancer. Asymptomatic postmenopausal thickening is most commonly due to presence of a polyp and the overwhelming majority of such polyps are entirely benign . Surely the current recommendation should be that asymptomatic endometrial thickening in postmenopausal women should normally be ignored unless there are other features of concern and women reassured that the appearance is due to the presence of a small polyp which is most unlikely to do them any harm in the absence of any warning sign of bleeding?…”