What is the recommended treatment for a patient with an endometrial polyp?

Treatment of Endometrial Polyps

Hysteroscopic polypectomy is the recommended treatment for symptomatic endometrial polyps, particularly in patients with abnormal uterine bleeding or postmenopausal bleeding, while asymptomatic polyps in premenopausal women can be managed conservatively with surveillance. 1, 2, 3

Symptomatic Patients

Patients with Abnormal Uterine Bleeding

• Hysteroscopic polypectomy is the standard of care for all patients presenting with abnormal uterine bleeding and documented endometrial polyps 1, 4, 3
• Office hysteroscopy with polypectomy can be performed without anesthesia in most women using small-diameter hysteroscopic equipment, offering a cost-effective approach 1, 3
• Blind dilatation and curettage (D&C) should be avoided for polyp removal due to its inaccuracy—it is not recommended as a diagnostic or therapeutic modality 1, 4, 3

Postmenopausal Women with Bleeding

• All postmenopausal women with vaginal bleeding and suspected endometrial polyps should undergo diagnostic hysteroscopy with polypectomy due to the elevated risk of malignancy in this population 3
• Histopathological examination of the removed polyp is mandatory to exclude premalignant or malignant pathology 3
• The risk of malignancy justifies the necessity of polypectomy with tissue examination in this group 1

Asymptomatic Patients

Premenopausal Women

• Conservative management with surveillance is appropriate for asymptomatic premenopausal women without risk factors for endometrial cancer 2, 3
• Approximately 25% of polyps resolve spontaneously with conservative management 2
• Removal should be considered in patients with risk factors for endometrial cancer (obesity, diabetes, hypertension, tamoxifen use, unopposed estrogen exposure) 3

Postmenopausal Women

• Asymptomatic polyps >2 cm in diameter should be removed due to higher malignancy risk 3
• Polyps <2 cm in asymptomatic postmenopausal patients can be managed conservatively, as excision has no impact on cost-effectiveness or survival 3
• Remove asymptomatic polyps in patients with risk factors for endometrial cancer (tamoxifen use, obesity, diabetes, hypertension) 3

Infertility Patients

• The evidence does not currently support routine polypectomy in subfertile women as standard practice 3
• Polypectomy does not compromise reproductive outcomes from subsequent IVF procedures, and cost-effectiveness analysis suggests performing office polypectomy in women desiring to conceive 3
• Polyps may alter endometrial receptivity and embryo implantation, potentially reducing pregnancy rates 3

Surgical Technique

Preferred Approach

• Hysteroscopic polypectomy under direct visualization is the gold standard for both diagnosis and treatment 1, 4, 3
• Office hysteroscopy with "see and treat" approach is feasible, safe, and has the highest diagnostic accuracy with excellent cost-benefit ratio 4, 3
• Available effective tools include laser, resectoscopes, morcellators, MyoSure, Truclear, and scissors/graspers 4

Complications

• Hysteroscopic polypectomy has a low complication rate with negligible risk of intrauterine adhesion formation 3

Management of Malignancy

• If atypical hyperplasia or carcinoma is found on polyp histology, hysterectomy is recommended in all postmenopausal patients and in premenopausal patients without desire for future fertility 3
• This aligns with standard endometrial cancer management principles 5

Common Pitfalls to Avoid

• Never perform blind D&C for polyp diagnosis or treatment—it has unacceptable inaccuracy for focal endometrial pathology 1, 4, 3
• Do not accept conservative management in symptomatic patients, especially postmenopausal women with bleeding 3
• Always obtain histopathological examination of removed polyps—the overall malignancy risk is approximately 3%, with higher risk in postmenopausal women and those with abnormal bleeding 2, 3
• Do not assume asymptomatic polyps require removal in premenopausal women without risk factors—approximately 25% regress spontaneously 2