Management of Mildly Dysplastic Endometrial Polyp
Complete hysteroscopic polypectomy with histopathologic examination is the definitive treatment for a mildly dysplastic endometrial polyp, followed by surveillance rather than hysterectomy if the polyp is completely excised with clear margins. 1, 2
Immediate Management
Perform hysteroscopic polypectomy as the gold standard for complete removal and accurate histopathologic assessment, as blind dilation and curettage is inadequate for polyp removal and should be avoided. 3, 2, 4
Ensure complete excision with clear margins and submit the entire specimen for pathologic review by an expert gynecologic pathologist to confirm the degree of dysplasia and exclude concurrent endometrial hyperplasia or carcinoma. 5, 2
Obtain endometrial biopsies from the surrounding flat endometrium during the same procedure to rule out dysplasia or hyperplasia in the adjacent tissue, as this determines whether surveillance alone is adequate. 1
Risk Stratification Based on Final Pathology
If Mild Dysplasia (Hyperplasia Without Atypia) is Confirmed:
Surveillance with endometrial sampling every 3-6 months is recommended rather than immediate hysterectomy, as the risk of progression to cancer is low and most cases respond to conservative management. 5
Consider continuous progestin therapy (medroxyprogesterone acetate 400-600 mg/day or megestrol acetate 160-320 mg/day) if hyperplasia without atypia is present in the polyp or surrounding endometrium, with repeat endometrial sampling at 6 months. 5
If Atypical Hyperplasia/EIN is Found:
Hysterectomy with bilateral salpingo-oophorectomy is the standard treatment for postmenopausal women or those who have completed childbearing, as 42-67% of patients with high-grade dysplasia already harbor concurrent carcinoma. 1, 5
Fertility-sparing treatment with high-dose progestins (megestrol acetate 160-320 mg/day or medroxyprogesterone acetate 400-600 mg/day) may be considered only in premenopausal women desiring fertility, but this requires referral to specialized centers, comprehensive counseling that this is non-standard care, and close surveillance with endometrial sampling every 3-6 months. 5
If Carcinoma is Identified:
- Proceed to hysterectomy with bilateral salpingo-oophorectomy in all postmenopausal patients and premenopausal patients without desire for future fertility. 2
Surveillance Protocol After Complete Polypectomy
Repeat hysteroscopy at 3-6 months if the polyp required piecemeal resection or if margins were close, to ensure complete removal and assess for recurrence. 1
Annual surveillance is reasonable for completely resected polypoid dysplasia with clear margins and no flat dysplasia elsewhere, as the annualized cancer incidence after polypoid dysplasia resection is 0.5%. 1
Critical Considerations and Pitfalls
Never accept inadequate tissue sampling—if the initial biopsy is non-diagnostic or shows only fragments, proceed directly to hysteroscopic polypectomy with complete excision rather than repeat blind sampling. 6, 3
Postmenopausal status and abnormal uterine bleeding are the strongest risk factors for malignancy in endometrial polyps, with cancer risk reaching 3.8% in postmenopausal women with bleeding versus 0.9% in premenopausal women without bleeding. 7
Do not perform expectant management in symptomatic patients, especially postmenopausal women with bleeding, as the risk of missing concurrent malignancy is unacceptable. 2
Avoid progestin therapy in patients with contraindications including history of breast cancer, stroke, myocardial infarction, or active smoking. 5
If hyperplasia persists after 6-12 months of progestin therapy, proceed to hysterectomy as continued medical management is futile. 5
Special Populations
Women with Lynch syndrome require annual endometrial biopsy starting at age 30-35 and should be counseled about prophylactic hysterectomy with bilateral salpingo-oophorectomy at age 40 due to their 30-60% lifetime risk of endometrial cancer. 6, 5
Asymptomatic premenopausal women with small polyps (<2 cm) and no risk factors may be offered conservative management with surveillance, as up to 25% of polyps regress spontaneously. 8, 4