What is the recommended treatment for an endometrial polyp?

Management of Endometrial Polyps

Hysteroscopic polypectomy is the recommended treatment for endometrial polyps, particularly in symptomatic patients or those with risk factors for malignancy. 1, 2

Diagnosis of Endometrial Polyps

• First-line diagnostic tool: Transvaginal ultrasonography (TVUS) is the primary imaging modality for detection of endometrial polyps 3

  • Accuracy increases with color-Doppler, 3D investigation, and contrast enhancement
  • Sonohysterography has similar accuracy to hysteroscopy for diagnostic confirmation

• Gold standard for diagnosis: Hysteroscopy provides direct visualization and allows for concurrent treatment 2

  • Office hysteroscopy shows highest diagnostic accuracy in patients with suspected endometrial polyps 3
  • Blind dilation and curettage (D&C) should be avoided due to inaccuracy for focal endometrial pathology 3

Treatment Recommendations Based on Clinical Presentation

1. Symptomatic Patients (with abnormal uterine bleeding)

• Polypectomy is strongly recommended for all women with abnormal uterine bleeding 1
  • Hysteroscopic removal is the standard approach with a low complication rate 2
  • Can be performed in office setting using small-diameter hysteroscopic equipment without anesthesia in most women 2

2. Asymptomatic Premenopausal Women

• Selective polypectomy is recommended based on risk factors:
  • Remove polyps in patients with risk factors for endometrial cancer 3
  • Risk factors include: obesity, diabetes mellitus, hypertension, and tamoxifen use 1

3. Asymptomatic Postmenopausal Women

• Polypectomy is recommended if:
  • Polyp diameter >2 cm 3
  • Patient has risk factors for endometrial carcinoma 3
• Conservative management is reasonable for:
  • Polyps <2 cm without risk factors (excision has no impact on cost-effectiveness or survival) 3

4. Postmenopausal Women with Vaginal Bleeding

• Immediate polypectomy is recommended due to higher risk of malignancy 3
  • Diagnostic hysteroscopy with concurrent polypectomy is the preferred approach 3
  • Histopathological analysis is mandatory due to risk of malignancy 3

Risk of Malignancy in Endometrial Polyps

• Overall risk of malignancy in endometrial polyps is approximately 3% 1
• Main risk factors for malignancy:
  • Postmenopausal status
  • Abnormal uterine bleeding
  • Secondary risk factors: hypertension, obesity, diabetes mellitus, and tamoxifen use 1

Surgical Approach

• Recommended technique: Hysteroscopic polypectomy 2, 3

  • Allows for complete polyp removal under direct visualization
  • Office-based procedure is feasible and safe with negligible risk of intrauterine adhesion formation 3
  • Technological tools include: laser, resectoscopes, morcellators, and scissors/graspers 4

• Not recommended: Blind dilation and curettage (D&C) 3, 4

  • Inaccurate for diagnosis and removal of focal endometrial pathology

Special Considerations

• Infertility: Polyps may alter endometrial receptivity and embryo implantation 3

  • Cost-effectiveness analysis suggests performing office polypectomy in women desiring to conceive 3
  • However, routine removal in sub-fertile women is not currently supported by strong evidence 3

• Malignancy: If atypical hyperplasia or carcinoma is found on a polyp, hysterectomy is recommended in all postmenopausal patients and in premenopausal patients without desire for future fertility 3

Remember that about 25% of polyps resolve spontaneously if managed conservatively 1, but the potential risk of malignancy and symptom relief generally favor removal in most clinical scenarios.