How should irregular menstrual bleeding in a woman with an endometrial polyp identified on pelvic ultrasound be managed?

Management of Irregular Menses with Endometrial Polyps on Ultrasound

Proceed directly to hysteroscopic polypectomy with histopathologic examination, as this provides both definitive diagnosis and treatment while excluding malignancy—the primary concern in any woman with abnormal uterine bleeding and an endometrial polyp. 1, 2

Diagnostic Pathway

Initial Imaging Confirmation

• Transvaginal ultrasound combined with transabdominal imaging is the first-line diagnostic modality for confirming the presence of endometrial polyps and assessing endometrial thickness. 3
• Saline infusion sonohysterography (SIS) should be performed when focal lesions are suspected or when standard TVUS cannot adequately visualize the endometrium, offering 96–100% sensitivity and 94–100% negative predictive value for detecting endometrial pathology. 3, 1, 4
• Color Doppler imaging can identify a vascular pedicle within the polyp, with specificity of 62–98% for detecting endometrial polyps, though it cannot reliably distinguish benign from malignant lesions. 3

Why Tissue Diagnosis Is Mandatory

• Blind endometrial biopsy should be avoided because it frequently misses focal lesions such as polyps, with office endometrial sampling having a 10% false-negative rate for detecting pathology. 1, 4, 2
• Dilation and curettage (D&C) should be avoided for both diagnosis and management of polyps due to its inaccuracy for focal endometrial pathology. 2, 5
• Hysteroscopy with directed biopsy has the highest diagnostic accuracy and allows direct visualization of the polyp, targeted tissue sampling, and simultaneous therapeutic removal. 1, 2, 5

Risk Stratification for Malignancy

High-Risk Features Requiring Immediate Polypectomy

• Postmenopausal status with abnormal bleeding: 4% risk of malignancy or atypical hyperplasia in symptomatic postmenopausal women with polyps. 6
• Age ≥45 years with irregular bleeding: Endometrial sampling is mandatory regardless of ultrasound findings in this population. 1, 4
• Risk factors for endometrial cancer: obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, or Lynch syndrome. 1, 7
• Polyp size >2 cm in any woman: larger polyps carry higher malignancy risk. 2

Premenopausal Women

• Symptomatic premenopausal women with irregular bleeding and polyps should undergo polypectomy to exclude malignancy (overall risk ~3%) and resolve symptoms. 2, 7, 6
• Asymptomatic premenopausal women should have polyps removed if risk factors for endometrial cancer are present, as malignancy has been documented even in asymptomatic patients. 2, 6

Recommended Surgical Approach

Office Hysteroscopic Polypectomy

• Office hysteroscopy using small-diameter equipment is the standard approach, feasible without anesthesia in most women and offering the highest diagnostic accuracy with excellent cost-benefit ratio. 2, 5
• Hysteroscopic polypectomy is safe with negligible risk of intrauterine adhesion formation and allows complete polyp removal under direct visualization. 2, 5
• Histopathologic examination of the removed polyp is mandatory due to the risk of malignancy, even in asymptomatic patients. 2, 7

Management Based on Histology

• If benign pathology is confirmed, symptoms typically resolve and no further intervention is needed. 2, 8
• If atypical hyperplasia or carcinoma is found, hysterectomy is recommended in postmenopausal women and premenopausal women without desire for future fertility. 2

Common Pitfalls to Avoid

• Do not rely on blind endometrial biopsy alone when imaging shows a focal polyp—this misses up to 10% of pathology and cannot adequately sample focal lesions. 1, 4, 2
• Do not accept "expectant management" in symptomatic patients, especially postmenopausal women, as malignancy risk justifies removal. 2, 7
• Do not assume normal endometrial thickness excludes pathology—polyps can be present even with endometrial thickness <5 mm in premenopausal women. 3
• Do not initiate hormonal therapy before excluding malignancy in women ≥45 years or those with risk factors. 1, 4

Conservative Management (Limited Scenarios Only)

• Expectant management may be considered only in asymptomatic premenopausal women without risk factors and polyps <2 cm, as approximately 25% of polyps regress spontaneously. 7, 8
• Even in asymptomatic postmenopausal women, polyps >2 cm or presence of risk factors mandates removal due to malignancy risk. 2

Evidence Quality

The recommendation for hysteroscopic polypectomy is supported by high-quality guideline evidence from the American College of Radiology (2020) 3, National Comprehensive Cancer Network 1, and multiple systematic reviews published in high-impact journals 2, 7, 5. The diagnostic superiority of hysteroscopy over blind sampling represents Level A evidence 2, while the malignancy risk stratification is based on Level B evidence from large cohort studies 2, 7, 6.