Management of Suspected Uterine Polyp on MRI
The next step is to perform transvaginal ultrasound (TVUS) with Doppler to confirm the polyp, followed by hysteroscopy with directed biopsy to obtain tissue diagnosis and exclude malignancy. 1, 2
Diagnostic Algorithm
Step 1: Confirm with Transvaginal Ultrasound
- TVUS should be performed first to confirm the presence of the polyp and assess endometrial thickness, as MRI is not the standard initial imaging modality for suspected endometrial polyps 1
- Adding color Doppler imaging increases diagnostic accuracy by identifying the vascular pedicle of polyps (specificity 62-98%, negative predictive value 50-94%) 1
- Saline infusion sonohysterography (SIS) has very high sensitivity (96-100%) and negative predictive value (94-100%) for detecting endometrial polyps and can better characterize focal lesions 3, 4
Step 2: Obtain Tissue Diagnosis
- Hysteroscopy with directed biopsy is mandatory to exclude malignancy within the polyp, as the overall risk of malignancy in polyps is approximately 3% 5, 4
- Office endometrial biopsy alone is inadequate for polyps because blind sampling techniques miss focal lesions—the false-negative rate is approximately 10% 1, 2, 3
- Never perform blind dilation and curettage (D&C) for polyp diagnosis or removal, as it is inaccurate for focal endometrial pathology 6, 7, 4
Risk Stratification for Malignancy
High-Risk Features Requiring Immediate Polypectomy:
- Postmenopausal status with any bleeding (highest risk factor for malignancy) 5, 8, 4
- Polyp size >2 cm 4
- Tamoxifen use 1, 2, 5
- Obesity, hypertension, diabetes mellitus 5, 8
- Lynch syndrome (30-60% lifetime endometrial cancer risk) 1, 2, 3
Symptomatic Patients:
- All patients with abnormal uterine bleeding and confirmed polyp should undergo hysteroscopic polypectomy regardless of menopausal status 5, 6, 8
- Abnormal bleeding is present in 90% of endometrial cancer cases 1, 3
Management Based on Clinical Context
If Patient is Symptomatic (Bleeding):
- Proceed directly to hysteroscopy with polypectomy after TVUS confirmation 2, 8, 4
- Histopathological examination of the removed polyp is mandatory due to malignancy risk 6, 4
If Patient is Asymptomatic and Premenopausal:
- Consider polypectomy if risk factors for endometrial cancer are present (obesity, PCOS, unopposed estrogen, family history) 3, 4
- Conservative management is acceptable for small polyps (<2 cm) without risk factors, as approximately 25% resolve spontaneously 5, 8
- However, removal is recommended to definitively exclude malignancy 8, 4
If Patient is Asymptomatic and Postmenopausal:
- Polypectomy is strongly recommended for polyps >2 cm or in patients with any risk factors for endometrial cancer 4
- Even small polyps warrant removal in postmenopausal women due to higher baseline malignancy risk 8, 4
Critical Pitfalls to Avoid
- Never accept MRI findings alone without tissue diagnosis—imaging cannot reliably distinguish benign from malignant polyps 1, 4
- Never perform blind D&C instead of hysteroscopy, as it misses focal lesions and has poor diagnostic accuracy 6, 7, 4
- Never accept a negative office endometrial biopsy as reassuring if a polyp is visualized on imaging—blind biopsy techniques miss polyps 1, 2, 3
- Never proceed to hysterectomy without tissue diagnosis, as this exposes patients to unnecessary surgical risk if pathology is benign 2, 3
- In postmenopausal women with bleeding, never adopt expectant management—the risk of malignancy mandates tissue diagnosis 8, 4
Optimal Surgical Approach
- Office hysteroscopy with polypectomy is the preferred approach when feasible, as it is safe, effective, and can often be performed without anesthesia 6, 7, 8
- Hysteroscopic polypectomy has low complication rates and negligible risk of intrauterine adhesion formation 4
- Complete polyp removal under hysteroscopic guidance is the recommended surgical treatment 5, 7