Management of Uterine Polyp in a 70-Year-Old Patient
Hysteroscopic polypectomy with histopathological examination is the recommended management for a 70-year-old patient with a uterine polyp, given the elevated risk of malignancy in this age group. 1, 2
Risk Assessment for Malignancy
The primary concern in a 70-year-old patient with a uterine polyp is the risk of malignancy, which is approximately 3% overall but significantly higher in postmenopausal women, particularly those with abnormal uterine bleeding. 3, 1
Key risk factors that apply to this patient:
- Age ≥70 years - the most important risk factor for malignancy 3, 4
- Postmenopausal status - substantially increases cancer risk 1, 2
- Presence of abnormal uterine bleeding (if symptomatic) - further elevates malignancy risk 3, 1
Additional risk factors to assess include:
Diagnostic Approach
Transvaginal ultrasound (TVUS) should be the initial imaging modality to confirm the presence and characteristics of the polyp. 1, 2 The accuracy increases with color Doppler and 3D investigation. 1
Saline infusion sonohysterography is highly accurate in detecting polyps in postmenopausal women and can help characterize the lesion. 5, 1
In-office hysteroscopy has the highest diagnostic accuracy with excellent cost-benefit ratio for detecting premalignant and malignant pathologies. 1
Management Algorithm
For Symptomatic Polyps (Abnormal Bleeding):
Hysteroscopic polypectomy is mandatory in postmenopausal women with vaginal bleeding and suspected endometrial polyp. 1, 2 This approach allows:
- Direct visualization and complete removal 6
- Histopathological examination to exclude malignancy 1, 2
- Resolution of bleeding symptoms 4, 6
Blind dilatation and curettage (D&C) should be avoided as it is inaccurate for diagnosis of focal endometrial pathology and may miss polyps entirely. 1, 6
For Asymptomatic Polyps:
Even in asymptomatic postmenopausal women, removal is recommended if:
Conservative management (observation) is not recommended in symptomatic postmenopausal patients due to malignancy risk. 1 For asymptomatic polyps <2 cm without additional risk factors, the evidence is more equivocal, though excision of small polyps in asymptomatic postmenopausal patients has no impact on cost-effectiveness or survival. 1
However, given this patient's age of 70 years, polypectomy with histological examination is the prudent approach to definitively exclude malignancy. 1, 2
Surgical Technique
Office-based hysteroscopic polypectomy using small-diameter equipment is the standard approach and can be performed without anesthesia in most women. 6
Operating room hysteroscopy is an alternative if office-based procedure is not feasible. 6
Complete polyp removal under hysteroscopic guidance is essential, as partial removal may miss malignant foci. 3, 4
Histopathological analysis is mandatory due to the risk of malignancy in this age group. 1, 2
Management Based on Histology
If atypical hyperplasia or carcinoma is found on the polyp:
- Hysterectomy is recommended in all postmenopausal patients 1
- Further staging and oncologic management per endometrial cancer guidelines 5
If benign histology:
Important Caveats
Spontaneous regression is unlikely in postmenopausal women - while 25% of polyps may regress spontaneously, this occurs primarily in premenopausal women with polyps <10 mm. 3, 4 At age 70, expectant management carries unacceptable risk.
Hysteroscopic polypectomy has low complication rates with negligible risk of intrauterine adhesion formation, making it a safe procedure even in elderly patients. 1, 4
If the patient has abnormal bleeding and negative endometrial sampling, hysteroscopy should still be performed as office endometrial biopsies have a 10% false-negative rate and may miss focal lesions like polyps. 5