What is the management for a patient with focal adenomatous hyperplasia without atypia on an endometrial polyp and mildly elevated coagulation parameters?

Management of Focal Adenomatous Hyperplasia Without Atypia on Endometrial Polyp with Elevated Coagulation Parameters

For a patient with focal adenomatous hyperplasia without atypia on endometrial polyp and mildly elevated coagulation parameters (INR 1.23 and PT 15.5), the recommended management is complete surgical resection of the polyp with careful follow-up, but without the need for additional endometrial surveillance beyond routine gynecologic care.

Understanding the Pathology and Risk Assessment

• Focal adenomatous hyperplasia without atypia on an endometrial polyp represents a benign condition with low risk of progression to endometrial cancer (<5%) 1
• Hyperplastic polyps constitute a significant percentage of all endometrial polyps, with complex hyperplasia without atypia being recognized as a potential precursor lesion to endometrial cancer in certain contexts 2
• The World Health Organization classifies endometrial hyperplasia according to architectural abnormality and presence of atypia - the absence of atypia in this case indicates lower risk 2

Surgical Management Considerations

• Complete polypectomy is indicated for endometrial polyps with hyperplastic features, even in the absence of atypia 2
• The mildly elevated coagulation parameters (INR 1.23, PT 15.5) should be noted but do not contraindicate surgical removal of the polyp 2
• Hysteroscopic resection is the preferred approach for complete removal and histological evaluation 2

Rationale for Complete Resection

• Although the hyperplasia lacks atypia, studies have shown that hyperplasia within polyps may be associated with hyperplasia in the surrounding endometrium in approximately 52% of cases 3
• Complete removal allows for:
  • Definitive diagnosis and exclusion of concurrent malignancy
  • Relief of any abnormal uterine bleeding symptoms
  • Prevention of potential progression 2, 3

Follow-up Recommendations

• After complete resection of a polyp with focal adenomatous hyperplasia without atypia, routine gynecological follow-up is sufficient 2
• Routine surveillance in asymptomatic women after treatment is not recommended 2
• Any recurrence of abnormal uterine bleeding should prompt re-evaluation 2

Special Considerations for Elevated Coagulation Parameters

• The mildly elevated INR (1.23) and PT (15.5) should be evaluated prior to any surgical intervention 2
• Consider consultation with hematology if there are concerns about bleeding risk
• Minimally invasive approaches may help minimize bleeding complications 2

Important Caveats

• If the patient has additional risk factors for endometrial cancer (obesity, diabetes, tamoxifen use, Lynch syndrome), more careful surveillance may be warranted 2
• If complete resection cannot be achieved, closer follow-up with endometrial sampling may be necessary 2
• The diagnosis should be confirmed by an expert gynecologic pathologist to ensure accurate classification of the hyperplasia 2