What are the management options for endometrial polyps?

Management of Endometrial Polyps

Hysteroscopic polypectomy is the gold standard treatment for endometrial polyps, with management decisions guided by symptoms, malignancy risk, and reproductive goals. 1, 2

Diagnostic Approach

• Initial evaluation:

  • Transvaginal ultrasound (TVS) is the first-line diagnostic tool 3
  • Sonohysterography or hysteroscopy provides confirmatory diagnosis with similar accuracy 3
  • Blind dilation and curettage (D&C) is NOT recommended for polyp diagnosis or removal 3, 4

• Risk assessment factors:

  • Menopausal status (higher risk in postmenopausal women)
  • Presence of abnormal uterine bleeding
  • Size of polyp
  • Comorbidities (hypertension, obesity, diabetes mellitus)
  • Tamoxifen use 2, 5

Management Algorithm

1. Symptomatic Polyps

• Abnormal uterine bleeding:

  • Hysteroscopic polypectomy is recommended for all women 2
  • Complete removal under hysteroscopic guidance is the standard approach 2
  • Office-based hysteroscopy can be performed without anesthesia in most women 3

• Infertility:

  • Hysteroscopic polypectomy is indicated, though benefits for reproductive outcomes remain uncertain 3
  • Should be considered before assisted reproductive technology 3

2. Asymptomatic Polyps

• Premenopausal women:

  • Conservative management is a reasonable option 2
  • Approximately 25% of polyps resolve spontaneously 2

• Postmenopausal women:

  • Without bleeding: Conservative management is acceptable (malignancy risk ~1.9%) 5
  • With bleeding: Polypectomy strongly recommended (malignancy risk ~3.8%) 5

3. High-Risk Patients

• Mandatory polypectomy for:
  • Postmenopausal women with bleeding 2, 5
  • Large polyps (>1.5 cm)
  • Tamoxifen users
  • Multiple risk factors for endometrial cancer 2

Surgical Techniques

• Preferred approach: Hysteroscopic polypectomy 1, 2

  • Small-diameter hysteroscopic equipment allows office-based procedures 3
  • Technological options include: laser, resectoscopes, morcellators, MyoSure, Truclear, and scissors/graspers 4

• Contraindications to office-based procedures:

  • Very large polyps
  • Patient intolerance
  • Technical difficulties 3

Follow-up Recommendations

• Histopathological examination:

  • All removed polyps should undergo histopathological examination 1
  • Overall malignancy risk is approximately 3% 2

• Surveillance:

  • No specific follow-up needed if benign polyp completely removed
  • Consider follow-up ultrasound in 3-6 months if incomplete removal suspected

Special Considerations

• Recurrence:

  • Recurrence rates and prevention strategies are not well established 3
  • Consider hormonal therapy in cases of multiple or recurrent polyps

• Malignancy risk:

  • Overall risk of malignancy in endometrial polyps: 1.3% 5
  • Risk of cancer confined to polyp: 0.3% 5
  • Highest risk in postmenopausal women with bleeding (3.8%) 5

Hysteroscopic polypectomy remains the most effective approach for symptomatic polyps and those with high-risk features, while conservative management can be considered for low-risk asymptomatic polyps, particularly in premenopausal women.