How to manage an endometrial polyp causing menorrhagia (heavy menstrual bleeding) diagnosed by ultrasound?

From the Guidelines

Management of endometrial polyp causing menorrhagia should start with medical treatment, such as progestin-only contraception or combined hormonal contraception.

Medical Management

• Medical treatments, including progestin-only contraception and combined hormonal contraception, are recommended as the initial management for abnormal uterine bleeding associated with ovulatory dysfunction, which includes endometrial polyps 1.
• These medical treatments can help reduce heavy menstrual bleeding and manage symptoms.

Surgical Management

• If medical treatment fails, is contraindicated, or not tolerated, or if the patient has concomitant significant intracavitary lesions, surgery, including endometrial ablation and hysterectomy, may be considered as an option 1.
• Hysteroscopic resection can be used to remove endometrial polyps, especially if they are causing significant symptoms.
• Sonohysterography can be used to further characterize endometrial observations on transvaginal ultrasound (TVUS) and help distinguish between leiomyomas and endometrial polyps 1.

Diagnostic Evaluation

• Transvaginal ultrasound (TVUS) is the initial imaging study of choice for evaluating abnormal uterine bleeding, including endometrial polyps 1.
• Sonohysterography can be used to confirm the diagnosis of endometrial polyps and to assess the location and size of the polyp 1.
• MRI can be used to further evaluate the uterus and exclude other conditions, such as adenomyosis or leiomyosarcoma 1.

From the Research

Management of Endometrial Polyps Causing Menorrhagia

To manage an endometrial polyp causing menorrhagia (heavy menstrual bleeding) diagnosed by ultrasound, the following options are available:

• Expectant management: This approach is not recommended for symptomatic patients, especially in postmenopausal women 2.
• Medical management: Options include tranexamic acid, levonorgestrel intrauterine device, and oral progesterone 3, 4.
• Surgical management: Hysteroscopic polypectomy is a feasible and safe procedure with negligible risk of intrauterine adhesion formation 5, 2.

Diagnostic Approaches

The following diagnostic approaches can be used to evaluate endometrial polyps:

• Transvaginal ultrasonography (TVUS): This is the imaging modality of choice for detecting endometrial polyps in women of fertile age 2.
• Saline infused sonohysterography: This is highly accurate in detecting polyps in asymptomatic postmenopausal women 2.
• Hysteroscopy: This has the highest diagnostic accuracy in infertile patients with suspected endometrial polyps and is recommended for postmenopausal women with vaginal bleeding and suspected endometrial polyp 5, 2.

Treatment Considerations

When considering treatment, the following factors should be taken into account:

• Patient symptoms: Symptomatic patients, especially those with heavy menstrual bleeding, may require more aggressive management 6, 3.
• Risk of malignancy: Histopathological analysis of the polyp is mandatory due to the risk of malignancy 2.
• Patient desire for fertility: Hysteroscopic polypectomy is recommended for women wishing to preserve or enhance their fertility 5.
• Polyp size and location: Asymptomatic endometrial polyps in postmenopausal women should be removed if they are large (> 2 cm) or if the patient has risk factors for endometrial carcinoma 2.