Management of Premenopausal Woman with Endometrial Polyp and Fibroids
Proceed directly to hysteroscopy with directed biopsy to remove and histologically evaluate the vascularized endometrial polyp, while the asymptomatic fibroids require no intervention unless they become symptomatic. 1, 2
Endometrial Polyp Management
Why Hysteroscopy is Essential
The 6 × 4 mm vascularized echogenic lesion requires tissue diagnosis through hysteroscopic removal rather than blind endometrial sampling, as focal lesions can be missed by blind sampling techniques like Pipelle, which are designed for diffuse pathology. 1, 2
Hysteroscopy provides 100% sensitivity for detecting endometrial pathology and allows direct visualization to distinguish between polyps, submucosal fibroids, and other focal lesions. 1, 2
The presence of vascularity within the lesion, detected by Doppler ultrasound, improves specificity for detecting pathology and warrants definitive evaluation. 3
Endometrial Thickness Context
The 7.6 mm endometrial thickness falls within the normal range for premenopausal women and does not independently indicate pathology, as optimal cutoffs for premenopausal women have not been established. 4
In premenopausal women with abnormal uterine bleeding, an endometrial thickness >5 mm combined with a visualized intracavitary abnormality has 85% sensitivity for detecting pathology. 2
Alternative Diagnostic Approach (If Hysteroscopy Unavailable)
Saline infusion sonohysterography (SIS) can be performed as an intermediate step if immediate hysteroscopy is not available, with 88% sensitivity and 95% specificity for detecting intracavitary abnormalities in premenopausal women. 2
SIS involves transcervical injection of sterile saline combined with transvaginal ultrasound to distinguish between focal and diffuse pathology with 96-100% sensitivity. 3, 1
However, SIS is diagnostic only—tissue diagnosis through hysteroscopy remains mandatory for any confirmed focal lesion. 1, 2
Uterine Fibroid Management
Conservative Approach for Asymptomatic Fibroids
Asymptomatic uterine fibroids in premenopausal women require no intervention, as fibroids are present in 20-30% of reproductive age women and are benign. 5
The presence of bridging vessels on ultrasound helps confirm uterine origin of the fibroids and distinguish them from adnexal masses. 5
When to Intervene
Intervention is only warranted if fibroids become symptomatic (heavy menstrual bleeding, bulk symptoms, pain) or if they are submucosal and contributing to abnormal bleeding. 1
If submucosal fibroids are identified during hysteroscopy, the percentage projecting into the endometrial cavity should be documented, as this determines surgical approach. 1
Critical Pitfalls to Avoid
Do not perform blind endometrial sampling (Pipelle) as the sole diagnostic test for focal lesions, as it may miss the polyp entirely—blind sampling is designed for diffuse endometrial pathology, not focal lesions. 1, 2
Do not assume the polyp is benign based on size alone—while most endometrial polyps are benign, tissue diagnosis is mandatory to exclude atypical hyperplasia or malignancy. 1, 4
Do not treat the fibroids without first addressing the polyp, as the polyp may be the source of any bleeding symptoms and requires definitive diagnosis. 1
Do not delay evaluation—while the malignancy risk is low in premenopausal women, establishing a tissue diagnosis allows for appropriate management and symptom relief if the patient develops abnormal bleeding. 4
Follow-Up Strategy
After hysteroscopic polypectomy, routine follow-up ultrasound is not necessary unless symptoms develop. 2
The fibroids should be monitored clinically—repeat imaging is only indicated if new symptoms emerge (increased bleeding, pain, or bulk symptoms). 5
If the patient remains asymptomatic after polyp removal, annual gynecologic examination is sufficient for fibroid surveillance. 5