Treatment for Endometrial Polyp
Hysteroscopic polypectomy is the recommended treatment for endometrial polyps, particularly in women with abnormal uterine bleeding, postmenopausal status, or infertility, while conservative management with surveillance is acceptable for asymptomatic premenopausal women without risk factors for malignancy. 1, 2
Indications for Surgical Removal
Polypectomy is mandatory in the following situations:
- All women with abnormal uterine bleeding – This is the primary indication, as polyps are a common cause of bleeding and surgical removal both treats symptoms and excludes malignancy 1, 2
- All postmenopausal women – The risk of malignancy increases significantly after menopause (approximately 3% overall, higher in symptomatic cases), making histologic examination essential 1, 2
- Women with infertility – Hysteroscopic polypectomy is the standard of care for fertility preservation or enhancement, though care must be taken to avoid collateral endometrial damage 3
- Presence of risk factors for malignancy – Including tamoxifen use, obesity, diabetes, or hypertension 1
Surgical Technique
Hysteroscopic polypectomy is the gold standard approach:
- Office-based "see-and-treat" hysteroscopy using small-diameter hysteroscopes (often no larger than a saline infusion sonography catheter) allows single-stage diagnosis and treatment without anesthesia in most women 3, 2
- Complete polyp removal under hysteroscopic guidance is essential, as blind dilatation and curettage is not recommended due to inadequate visualization and incomplete removal 2
- Attention to the polyp base is critical, as many premalignant and malignant lesions are found at this location 3
- Multiple surgical techniques provide adequate tissue for histological diagnosis, including mechanical instruments, bipolar electrodes, hysteroscopic morcellators, and dual wavelengths laser systems 4, 5
Conservative Management
Observation is acceptable only in highly selected cases:
- Asymptomatic premenopausal women without risk factors for malignancy can be offered conservative management, as approximately 25% of polyps resolve spontaneously 1
- Asymptomatic postmenopausal women have low malignancy risk, but there are no known benefits of polyp removal in preventing malignant transformation in this group 2
- Surveillance with transvaginal ultrasound is the primary monitoring tool if conservative management is chosen 1
Important Clinical Caveats
Several factors complicate polyp management:
- Significant recurrence risk exists following simple polypectomy, especially in tamoxifen-treated women, which may necessitate consideration of partial or total endomyometrial resection in select cases 3
- Polypectomy alone may be insufficient for satisfactory management of abnormal uterine bleeding, as other endometrial pathology may coexist 3
- Minimally invasive hysteroscopy is preferred over traditional operating room approaches when technically feasible, as it can be performed safely in an office setting with lower costs and no anesthesia requirement 3, 2
Diagnostic Workup Before Treatment
Transvaginal ultrasound is the first-line diagnostic tool for detecting endometrial polyps, though hysteroscopy remains the gold standard for visualization and definitive diagnosis 1, 2