What is the treatment approach for a patient with an endometrial polyp?

Treatment Approach for Endometrial Polyps

Hysteroscopic polypectomy is the standard treatment for endometrial polyps, especially in symptomatic patients or those with risk factors for malignancy. 1, 2, 3

Diagnostic Evaluation

Before treatment, proper diagnosis is essential:

• Initial imaging: Transvaginal ultrasound (TVUS) is the first-line imaging modality 4
• Enhanced imaging:
  • Sonohysterography (saline infusion) can help distinguish between focal or diffuse pathology with high accuracy (97%) for differentiating polyps from other lesions 4
  • Color Doppler can help identify vessels within endometrial polyps 4, 5
• Definitive diagnosis: Hysteroscopy is the gold standard for visualization and diagnosis 1, 3
• Tissue sampling: Endometrial biopsy or dilation and curettage (D&C) for histopathological confirmation 4

Risk Stratification

Risk assessment for malignancy within polyps is critical:

Higher risk (prioritize treatment):

• Postmenopausal status
• Abnormal uterine bleeding
• Polyp size >1.5 cm
• Hypertension, obesity, diabetes mellitus
• Tamoxifen use

Lower risk (may consider observation):

• Premenopausal status
• Asymptomatic
• Small polyp size
• No other risk factors

Treatment Algorithm

1. Symptomatic patients (with abnormal uterine bleeding):

   • Hysteroscopic polypectomy is recommended regardless of menopausal status 1, 3

2. Asymptomatic patients:

   • Postmenopausal with risk factors: Hysteroscopic polypectomy recommended
   • Postmenopausal without risk factors: Polypectomy generally recommended but conservative management may be considered
   • Premenopausal: Conservative management is a reasonable option as approximately 25% of polyps resolve spontaneously 1

3. Patients with infertility:

   • Hysteroscopic polypectomy with care to avoid collateral endometrial damage 2

Surgical Approach

Hysteroscopic polypectomy is the standard surgical approach:

• "See-and-treat" hysteroscopy is preferred over blind D&C 2, 3
• Office-based procedures using small-diameter hysteroscopes can be performed without anesthesia in most women 3, 5
• Technique options:
  • Mechanical resection with scissors/graspers
  • Resectoscope
  • Morcellators (MyoSure, Truclear)
  • Laser techniques 5

Important Considerations

• Blind dilation and curettage alone is not recommended for polyp removal 3, 5
• Complete polyp removal including the base is important as premalignant and malignant lesions are often found at the polyp base 2
• Recurrence risk after simple polypectomy should be discussed, especially in tamoxifen-treated women 2
• Polypectomy alone may be insufficient for management of abnormal uterine bleeding in some cases 2

Follow-up

• Histopathological examination of all removed polyps is mandatory
• Follow-up TVUS may be considered to ensure complete removal and monitor for recurrence
• Patients with persistent symptoms despite polypectomy should be reevaluated for other causes of abnormal uterine bleeding

Caveats and Pitfalls

• Failure to obtain histopathology after removal can miss malignancy
• Incomplete removal may lead to recurrence
• Overtreatment of asymptomatic small polyps in low-risk premenopausal women may not be necessary
• Office procedures may have limitations for large polyps or difficult anatomical situations

By following this structured approach to endometrial polyps, clinicians can provide appropriate care while minimizing unnecessary procedures and optimizing outcomes related to morbidity, mortality, and quality of life.