What are the treatment options for endometrial polyps?

Treatment of Endometrial Polyps

Hysteroscopic polypectomy is the standard treatment for endometrial polyps, particularly for symptomatic patients and those with risk factors for malignancy. 1

Diagnostic Approach

Before discussing treatment, proper diagnosis is essential:

• First-line diagnostic tool: Transvaginal ultrasonography (TVUS) 1

  • Accuracy increases with color-doppler, 3D investigation and contrast enhancement 1
  • Sonohysterography has similar accuracy as hysteroscopy for diagnostic confirmation 2

• Gold standard for diagnosis: Hysteroscopy 3

  • Office hysteroscopy shows highest diagnostic accuracy, especially in infertile patients 1

Treatment Algorithm

1. Symptomatic Patients

For patients with abnormal uterine bleeding:

• Primary treatment: Hysteroscopic polypectomy 3, 1

  • Avoid blind dilation and curettage (D&C) as it's not recommended for polyp removal 2, 1
  • Can be performed in office setting using small-diameter hysteroscopic equipment without anesthesia in most women 2
  • Histopathological analysis of the removed polyp is mandatory due to risk of malignancy 1

• Effectiveness: 70% of premenopausal women experience significant improvement in bleeding patterns after polypectomy 4

2. Asymptomatic Patients

Treatment depends on menopausal status and risk factors:

Postmenopausal Women:

• Polyps >2 cm: Remove due to higher risk of malignancy 1
• Polyps <2 cm: Can be managed conservatively if no risk factors for endometrial cancer are present 1
• With risk factors: Remove regardless of size 1

Premenopausal Women:

• With risk factors for endometrial cancer: Consider removal 1
• Without risk factors: Conservative management is an option as approximately 25% of polyps resolve spontaneously 3

3. Infertile Patients

• Polyps might alter endometrial receptivity and embryo implantation 1
• Hysteroscopic polypectomy is feasible with negligible risk of intrauterine adhesion formation 1
• Cost-effectiveness analysis suggests performing office polypectomy in women desiring to conceive 1
• However, routine removal in sub-fertile women is not currently supported by strong evidence 1

Risk Factors for Malignancy in Endometrial Polyps

• Menopause
• Abnormal uterine bleeding
• Age >40 years
• Large polyps (>2 cm)
• Hypertension
• Obesity
• Diabetes mellitus
• Tamoxifen use 3, 1

Special Considerations

• Malignancy risk: Overall risk is low (approximately 3%) 3
• Postmenopausal bleeding: Always warrants polypectomy with histologic examination due to higher risk of malignancy 2
• Atypical hyperplasia or carcinoma: If found on polyp histology, hysterectomy is recommended in all postmenopausal patients and premenopausal patients without desire for future fertility 1

Technological Options for Polypectomy

Several effective and safe technological tools are available:

• Resectoscopes
• Morcellators
• MyoSure
• Truclear
• Scissors/graspers
• Laser 5

Follow-up

• For symptomatic patients, assess bleeding pattern 6-12 months after procedure
• Younger patients may have less favorable outcomes and might require additional interventions like endometrial ablation 4

Remember that there is no proven preventative or medical treatment for endometrial polyps, with complete hysteroscopic removal being the recommended surgical approach 3.