Should uterine polyps be removed?

Should Uterine Polyps Be Removed?

Uterine polyps should be removed in symptomatic patients (abnormal uterine bleeding, infertility) and in postmenopausal women with bleeding, but asymptomatic polyps in premenopausal women can be managed conservatively unless risk factors for malignancy are present.

Symptomatic Patients: Remove the Polyps

Abnormal Uterine Bleeding

• Hysteroscopic polypectomy is the standard of care for symptomatic endometrial polyps causing abnormal uterine bleeding 1, 2, 3.
• Blind dilatation and curettage should be avoided—it is inaccurate for focal endometrial pathology and misses polyps 4, 5.
• Office hysteroscopy using small-diameter equipment can be performed without anesthesia in most women and is highly cost-effective 2, 4.
• Hysteroscopic polypectomy has a low complication rate with negligible risk of intrauterine adhesion formation 4.

Infertility

• Polypectomy improves fertility outcomes in infertile women 5.
• Polyps may impair fertility through mechanical interference with sperm transport, embryo implantation, intrauterine inflammation, or altered endometrial receptivity 6.
• Most clinicians recommend hysteroscopic polyp removal before IVF stimulation or frozen embryo transfer cycles 6.
• The evidence shows polypectomy does not compromise subsequent IVF outcomes, though routine removal in all subfertile women lacks definitive support 4.

Postmenopausal Women: High Priority for Removal

Postmenopausal Bleeding

• All postmenopausal women with vaginal bleeding and suspected endometrial polyps should undergo diagnostic hysteroscopy with polypectomy 4.
• The risk of malignancy justifies removal with histologic examination in this population 2.
• Transvaginal ultrasound should be the initial imaging modality, with endometrial thickness ≤3mm having high negative predictive value for cancer 1.
• If initial endometrial biopsy is negative but bleeding persists, hysteroscopy with directed biopsy is mandatory due to the 10% false-negative rate of office biopsy 7, 1.

Asymptomatic Postmenopausal Women

• Remove polyps >2cm in diameter or in patients with risk factors for endometrial cancer (obesity, hypertension, diabetes, tamoxifen use) 4.
• Excision of polyps <2cm in asymptomatic postmenopausal patients without risk factors has no impact on cost-effectiveness or survival 4.
• Saline infusion sonohysterography is highly accurate for detecting polyps in this population 4.

Premenopausal Asymptomatic Women: Conservative Management is Acceptable

Observation Strategy

• Approximately 25% of polyps resolve spontaneously, particularly those <10mm in size 3, 5.
• Conservative management is appropriate for asymptomatic premenopausal women without risk factors for malignancy 3.
• The overall risk of malignancy in endometrial polyps is low (approximately 3%) 3.

When to Remove Despite Lack of Symptoms

• Remove asymptomatic polyps in premenopausal women with risk factors for endometrial cancer (obesity, hypertension, diabetes, tamoxifen use, Lynch syndrome) 4.
• Consider removal in women planning pregnancy or undergoing fertility treatment 6.

Diagnostic Algorithm

Initial Evaluation

• Transvaginal ultrasound is the first-line diagnostic modality for detecting endometrial polyps 1, 4.
• Accuracy increases with color Doppler, 3D investigation, and saline contrast (sonohysterography) 4.
• Sonohysterography has similar accuracy to hysteroscopy for diagnostic confirmation and helps distinguish focal from diffuse pathology 1, 2.

Tissue Diagnosis

• Histopathological analysis is mandatory due to malignancy risk 4.
• Endometrial biopsy using Pipelle or Vabra devices has high sensitivity (99.6% and 97.1% respectively) for detecting carcinoma 1.
• In-office hysteroscopy has the highest diagnostic accuracy with excellent cost-benefit ratio for detecting premalignant and malignant pathologies 4.

Management of Malignancy

• If atypical hyperplasia or carcinoma is found within a polyp, hysterectomy is recommended in all postmenopausal patients and premenopausal patients without desire for future fertility 4.
• Further staging and treatment should follow endometrial cancer guidelines 1.
• Assess for Lynch syndrome in patients with endometrial cancer, particularly if diagnosed at younger age 1.

Common Pitfalls to Avoid

• Never rely solely on transvaginal ultrasound without histopathological confirmation—this can miss malignancy 1.
• Never accept a negative endometrial biopsy as definitive in a symptomatic patient—the 10% false-negative rate mandates escalation to hysteroscopy if bleeding persists 7, 1.
• Never perform blind D&C when hysteroscopic equipment is available—it is inaccurate and misses pathology 4, 5.
• Do not assume all asymptomatic polyps require removal—individualize based on menopausal status, size, and risk factors 3, 4.