Are Endometrial Polyps Significant?
Yes, endometrial polyps are clinically significant and warrant evaluation, particularly in postmenopausal women and those with abnormal uterine bleeding, due to their malignancy risk of approximately 2.7% overall, rising to 4.9-5.9% in postmenopausal women. 1, 2
Malignancy Risk Stratification
The significance of endometrial polyps depends critically on patient characteristics:
High-Risk Groups Requiring Intervention
- Postmenopausal women: Malignancy risk is 4.93-5.88%, approximately 4-5 times higher than premenopausal women 1, 2
- Symptomatic women with abnormal bleeding: Malignancy risk is 5.14% compared to 1.89% in asymptomatic women 1
- Polyps >15mm: Significantly associated with premalignant or malignant changes 2
- All malignant polyps in one series occurred exclusively in postmenopausal women 2
Lower-Risk Groups
- Premenopausal asymptomatic women: Malignancy risk only 1.12% 1
- Polyps <10mm: Higher spontaneous regression rate (up to 25%) 3, 4
- All asymptomatic polyps in one 300-patient series were benign 5
Clinical Presentation and Detection
Abnormal uterine bleeding is the hallmark presentation, occurring in 90% of endometrial cancer cases, making symptomatic polyps particularly concerning 6. However, most polyps (approximately 60-75%) are asymptomatic and discovered incidentally, with prevalence reaching 40% in some populations 3.
Transvaginal ultrasound serves as the primary diagnostic tool, though hysteroscopy with visualization remains the gold standard for diagnosis 3, 6.
Management Algorithm
Mandatory Polypectomy Indications
All symptomatic postmenopausal women with polyps should undergo hysteroscopic polypectomy for histologic assessment 4, 3. This recommendation is based on:
- The 4.9-5.9% malignancy risk in this population 1, 2
- The inability to distinguish malignant from benign polyps by hysteroscopic appearance alone 5
- Low surgical risk associated with hysteroscopic polypectomy 4
Conservative Management Acceptable For
Asymptomatic premenopausal women with polyps <15mm can be observed, given their malignancy risk of only 1.12% 1, 2. Up to 25% of these polyps regress spontaneously, particularly those <10mm 3, 4.
Special Populations
- Infertile women: Polypectomy improves fertility outcomes and is recommended 4
- Women on tamoxifen: Higher risk profile warrants removal 3
- Women with Lynch syndrome: Already require annual endometrial biopsy starting age 30-35 due to 30-60% lifetime endometrial cancer risk 6, 7
Critical Pitfalls to Avoid
Do not perform blind polypectomy where hysteroscopic guidance is available 4. Hysteroscopy provides superior diagnostic accuracy and ensures complete removal.
Do not assume asymptomatic status in postmenopausal women eliminates risk—while symptomatic polyps carry higher risk, postmenopausal status alone is the strongest predictor of malignancy regardless of symptoms 2.
Do not rely on polyp size or appearance alone to exclude malignancy—no distinct hysteroscopic features reliably predict malignancy 5.
Diagnostic Accuracy
The Pipelle and Vabra endometrial sampling devices demonstrate sensitivities of 99.6% and 97.1% respectively for detecting endometrial carcinoma 6, 7. However, these are for general endometrial sampling; hysteroscopic polypectomy with direct visualization and complete removal remains the definitive diagnostic and therapeutic approach 4.