Review Article

Diagnosis and Management of Endometrial Polyps: A CriticalReview of the Literature

S. Salim, H. Won, MBBS, MM,MRANZCOG, E. Nesbitt-Hawes, BMed, N. Campbell, MBChB,FRANZCOG, and J. Abbott*, B Med (Hons), MRCOG, FRANZCOG, PhDFrom the University of New South Wales (all authors), and Royal Hospital for Women (Drs. Won, Nesbitt-Hawes, and Abbott), Randwick,

New South Wales, Australia.

ABSTRACT This review article summarizes the salient literature on the diagnosis and management of endometrial polyps. Electronic re-

The authors have

products or comp

Corresponding au

PhD, Royal Hosp

Randwick, New S

E-mail: j.abbott@

Submitted March

Available at www

1553-4650/$ - se

doi:10.1016/j.jmi

sources includingMedline, PubMed, CINAHL, The Cochrane Library (including the Cochrane Database of Systematic Reviews),Current Contents, and EMBASE were searched with the MeSH terms including all subheadings and keywords endometrialpolyps, abnormal uterine bleeding, polypectomy, polyp management, polyp and diagnosis, and polyp and malignancy. Thereis a paucity of level I evidence in the literature on the diagnosis and management of this common gynecologic disease. Nonin-vasive investigations such as transvaginal ultrasonography, with or without the use of 3-dimensional ultrasonography and contrasttechniques remain the mainstay of first-line investigation. Hysteroscopic resection is the most effective management for endo-metrial polyps and allows histologic assessment, whereas blind biopsy or curettage has low diagnostic accuracy and shouldnot be performed. This article will review the cause, epidemiology, clinical presentation, diagnostic investigations, and manage-ment of endometrial polyps. Journal of Minimally Invasive Gynecology (2011) 18, 569–581 Crown Copyright� 2011 Publishedby Elsevier Inc. on behalf of AAGL. All rights reserved.

Keywords: Endometrial polyps; Abnormal uterine bleeding; Polypectomy; Hysteroscopic polypectomy; Infertility; Malignancy

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ital for Women, University of New SouthWales, Barker St,

outh Wales 2031, Australia.

unsw.edu.au

22, 2011. Accepted for publication May 26, 2011.

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Endometrial polyps are a common gynecologic conditionthat are associated with clinical symptoms such as abnormalvaginal bleeding and infertility, as well as premalignant andmalignant conditions. They may be found through specificinvestigation or as an incidental finding on imaging foranother reason. This review will critically appraise the liter-ature regarding diagnosis and management of endometrialpolyps and will review cause and epidemiology.

Methods

This review was produced by searching electronicresources including Medline (1950–2010), EMBASE(1980–2010), PubMed, CINAHL, The Cochrane Library(including the Cochrane Database of Systematic Reviews),Current Contents, as well as manual searching of bibliogra-phies of known primary research and review articles. Thesewere searched with the MeSH terms including all subhead-ings and keywords endometrial polyps, abnormal uterinebleeding, polypectomy, polyp management, polyp anddiagnosis and polyp and malignancy, as well as nonspecifickeywords such as uterine diseases, polyps, and intrauterinewere used to include a broad range of clinical studies andrelevant publications.

A total of 330 articles were identified, with 265 provision-ally included manuscripts retrieved, reviewed, and abstractedby teammembers, and with review and discussion of content

570 Journal of Minimally Invasive Gynecology, Vol 18, No 5, September/October 2011

and relevance to the review. Most were Canadian Task ForceClassification II uncontrolled case series, with a considerablysmaller number of Canadian Task Force Classification Irandomized controlled trials. Final decisions regarding inclu-sion or exclusion were made on the basis of the methodologicquality, which involved relevant features of population,intervention, and outcome.

Cause

Endometrial polyps are a localized endometrial intrauter-ine overgrowth that may be single or multiple, measuringfrom a few millimeters to centimeters, and may be sessileor pedunculated [1]. Endometrial polyps consist of endome-trial glands, stroma, and blood vessels [2], with most polypsarising from the fundal region and extending toward the in-ternal os. Occasionally they project through the external cer-vical os and can be seen in the vagina. Risk factors for thedevelopment of endometrial polyps include age, hyperten-sion, obesity, and tamoxifen use [3–5].

Microscopically, endometrial polyps are typically a mix-ture of dense fibrous tissue (stroma), large and thick walledvascular channels, and glandular spaces of varying shapesand size, covered by a surface epithelium. Recent workdescribes the parallel arrangement of the endometrial glandslong axis to the surface epithelium as a histologic feature ofendometrial polyps. This feature, found in 80% of premeno-pausal women, was significantly less common in postmeno-pausal women (42%) (p 5.001) and did not occur at allin any of the 56 normal control subjects, suggesting that,when present, this is an important additional histologicfeature for diagnosis [1].

The exact cause of polyps is unknown, and their hetero-geneity makes identification of a single causative factorunlikely. Genetic factors may be contributory to the develop-ment of endometrial polyps, with reports identifying clustersof anomalies in chromosomes 6 and 12, which may alter theproliferative process, resulting in endometrial overgrowthand polyp formation [6]. Women with various intrauterinediseases (polyps, leiomyomata, adenomyosis) demonstratealterations in endometrial levels of matrix metalloprotei-nases and cytokines compared with control subjects [7]. Itis not yet known whether these changes produce the patho-logic processes or are a result of their development. Thesesame biochemical mediators are implicated in the role ofintrauterine disease causing fertility impairment. The pre-ponderance of polyps in the postmenopausal group maybe partly explained by an increase in a proliferation-regulating protein, p63, in this group. This protein is alsoa marker of reserve cells of the basalis layer, from whichpolyps are believed to arise [8].

Estrogen and progesterone regulate the balance of prolif-eration and apoptosis in normal endometrium, althoughconflict exists over the roles of hormonal receptors in thepathophysiology of endometrial polyps. It appears that bothestrogen and progesterone contribute to the elongation of en-

dometrial glands, stromal tissues, and spiral arteries that givethe characteristic polypoid appearance to these growths [9].In postmenopausal women, estrogen receptors are moreprevalent in polyps than in normal endometrium [10], withmore limited evidence showing progesterone receptors maycontribute to polyp development in some women [11].

There are conflicting reports of increased estrogen andprogesterone receptor concentration in the glandular epithe-lium of polyps but not in the stroma when compared withnormal endometrium [12] and other work showing no differ-ence in the concentration of receptors in any area [13]. It ispossible that the timing in the cycle may be contributory,with endometrial staining demonstrating that estrogenreceptors are more prevalent during the secretory than theproliferative phase [14]. Regardless of the hormonal recep-tor status, functional similarities between endometrialpolyps and normal endometrium occur, with polyps under-going similar cyclic surface changes to those seen in normalendometrium [15].

Epidemiology and Clinical Presentation

The reported prevalence of endometrial polyps varieswidely and ranges from 7.8% to 34.9%, depending on thedefinition of a polyp, diagnostic method used, and thepopulation studied [16–19]. The prevalence of polypsappears to increase with age, and it is reported that morepostmenopausal (11.8%) than premenopausal women (5.8%)are affected (p ,.01). The association with menopause maybe a selection bias, given that postmenopausal women withany vaginal bleeding are more likely to be investigated[17]. There are conflicting reports of menopause being animportant etiologic factor, and this is an area for future re-search [17,19–23]. The incidence of endometrial polyps isunknown with several prospective studies demonstratingendometrial polyps in symptom-free women [24–27].

For both premenopausal and postmenopausal womenwith an endometrial polyp, abnormal vaginal bleeding oc-curs in approximately 68% of cases and is the most commonpresenting symptom for women with this disease [28]. Over-all, 64% to 88% of premenopausal women with endometrialpolyps have symptoms [28], most commonly presentingwith menorrhagia, irregular menses, postcoital bleeding, orintermenstrual bleeding. Endometrial polyps account for39% of all abnormal vaginal bleeding in premenopausalwomen [29], with this bleeding believed to be due to stromalcongestion within the polyp leading to venous stasis andapical necrosis [9].

Although bleeding is a common presentation, womenwith a polyp may remain symptom free and present withthis incidental finding on imaging for other indications[30]. It is important to note that symptoms do not correlatewith polyp number, diameter, and site [31]. In the postmen-opausal period, 56% of women with an endometrial polyppresent with symptoms such as postmenopausal bleeding[28,31]. Polyps account for only 21% to 28% of all causes

Salim et al. Diagnosis and Management of Endometrial Polyps: A Critical Review of the Literature 571

of postmenopausal bleeding [21,28,29]. The presence ofa polyp does not always cause symptoms, with a class IIstudy of 686 women aged 20 to 74 years reporting thatabnormal uterine bleeding is significantly less frequent(p 5.015) among women with polyps compared withthose without [17]. Such data indicate that most postmeno-pausal women with polyps are symptom free, and abnormalbleeding is not commonly associated with polyps in premen-opausal women.

In premenopausal women, endometrial polyps are associ-ated with infertility, although the causal relationship remainsuncertain [32]. Hypotheses include mechanical obstructionhindering ostium function and affecting sperm migration[33], or biochemical effects of polyps on implantation orembryo development. The latter reflects the finding of in-creased levels of metalloproteinases and cytokines such asinterferon-gamma found in polyps when compared with nor-mal uterine tissue [7]. Women treated with gonadotropinsfor infertility are exposed to a higher level of estrogen, whichpredisposes them to development of endometrial polyps[34]. The incidence of polyps occurring in infertile womenis widely variable, ranging between 3.8% to 38.5% of womenwith primary infertility, 1.8% to 17% of women with second-ary infertility, and 1.9% to 24% of infertile women whencombined [32,35–37]. The specific subpopulation and thediagnostic voracity are factors that may lead to this widevariation.

Women using tamoxifen are at specific risk fordevelopment of polyps, with class II studies reporting upto 30% to 60% prevalence in this particular group[22,38–40]. Premenopausal women using the combinedoral contraceptives may be at reduced risk for developmentof polyps, with a large population study showing theoverall prevalence of polyps in premenopausal women tobe 5.8%, whereas users of combined oral contraceptiveshad a prevalence of 2.1% [17]. Other risk factors that maypredispose to endometrial polyps include hypertension andobesity [22]. Increased levels of estrone is the likely mecha-nism in obese women, although the link with hypertensionmay be a confounder of obesity, rather than a direct correla-tion to the causation of polyps.

Cervical polyps are associated with endometrial polypsin 24% to 27% of cases [23,41,42]. The frequency ofthe association increases with the presence of abnormalbleeding and advancing age (p ,.001), with up to 56.8% ofpostmenopausal women presenting with vaginal bleedinghaving both diseases [42]. Women who have atypical glandu-lar cells demonstrated on Pap smear may be diagnosed withan endometrial polyp in 3.4% to 5% of cases [30,43].

Tendency to Malignancy

Most endometrial polyps are benign; however they maybecome hyperplastic, with malignant transformation devel-oping in 0% to 12.9% of polyps in case series reported todate [3,19,44–48]. A recent meta-analysis has reviewed

malignant risk in detail, and the reader is directed to thisfor further information, with important findings in this areaincluded here [49]. The most salient fact from this reviewis that the risk of malignancy found in endometrial polypsis highest in postmenopausal women with symptoms. Thereported incidence of carcinoma confined to endometrialpolyps varies between 0% to 4.8%, depending on thepopulation studied and the diagnostic methods used [16].Although the risk of malignancy is low in premenopausalwomen [50], it has been significantly correlated with in-creasing age and menopausal status (p 5.03); polyps witha size greater than 1.5 cm (p ,.001) [45]; and hypertensionand tamoxifen use [4]. In a class II-3 study, the incidence ofendometrial hyperplasia and malignancy was similar andclinically relevant in patients with symptoms (3.2%) andsymptom-free patients (3.9%), suggesting that polyps shouldbe removed whenever identified [47]. The use of ultrasonog-raphy may aid in the diagnosis of neoplastic change withinendometrial polyps, with sensitivity of 67% to 100% andspecificity of 71% to 89% [51,52]. The variation in rangeis dependent on the endometrial thickness used as therequirement for further investigation by more invasivemethods. The data are limited in this area, and thedifferentiation of endometrium from endometrial polypssonographically with regard to possible neoplastic changeis a confounding factor.

Natural History

The spontaneous regression rates of incidentally detectedendometrial polyps at 1 year is estimated in one study to be27% [27]. In this class II-1 study, the size of polyps atdiagnosis correlated with their likelihood of persistence at12 months follow-up. Polyps with a mean length of 15.1 mmwere significantly less likely to have spontaneously re-gressed at follow-up compared with polyps that hada mean length of 10.7 mm (mean difference 4.4, 95% confi-dence interval [CI] 0.2-8.6, p 5.04) [27], suggesting thatsmaller polyps are more likely to regress spontaneously. Aseparate prospective study also demonstrated that smallerpolyps ,1 cm were more likely to regress spontaneously,whereas those .1 cm were more likely to persist and causeabnormal uterine bleeding, although the difference was notsignificant (p 5.16) [53]. Polyp regression may be associ-ated with isolated episodes of menorrhagia associated withcramping followed by resumption of normal menstruationpossibly related to the passage of endometrial polyps [53].

Diagnosis

Imaging

Transvaginal UltrasonographyOn transvaginal ultrasonography (TVUS), an endome-

trial polyp typically appears as a hyperechoic lesion withregular contours within the uterine lumen, outlining the

572 Journal of Minimally Invasive Gynecology, Vol 18, No 5, September/October 2011

endometrial walls on which it rests, surrounded by a thinhyperechoic halo [26]. Cystic spaces corresponding todilated glands filled with proteinaceous fluid may be seenwithin the polyp [54] or the polyp may appear as a nonspe-cific endometrial thickening or focal mass within the endo-metrial cavity [55]. Such sonographic findings are notspecific to polyps, and other endometrial abnormalitiessuch as submucosal fibroids may have the same features[56]. To aid in the diagnosis of an endometrial polyp,TVUS is best performed in premenopausal women beforeday 10 of the cycle when the endometrium is at its thinnestto minimize the risk of false-positive and -negativefindings [57].

Table 1 compares the diagnostic accuracy of various im-aging techniques for endometrial polyps. TVUS has reportedsensitivity of 19% to 96%, specificity of 53% to 100%, pos-itive predictive value (PPV) of 75% to 100%, and negativepredictive value (NPV) of 87% to 97%, when comparedwith hysteroscopy with guided biopsy. A paucity of level Ievidence may explain this wide range of data, as well asstudies describing a small number of patients. Withinsome of these studies the pathologic condition is heteroge-neous, with some combining both endometrial polyps andsubmucous fibroids as a diagnostic group, making exact fig-ures difficult to extract. In a single large prospective studyevaluating the causes of menorrhagia, the reported sensitiv-ity, specificity, PPV, and NPVof TVUS for the diagnosis ofendometrial polyps were 86%, 94%, 91%, and 90%, respec-tively [61].

There are limited data to support color-flow or powerDoppler aiding in the differentiation of hyperplasia and ma-lignancy in polyps [51,79,80]. A class II-2 study demon-strated specificity and NPV of 95% and 94% respectivelyin the diagnosis of endometrial polyps with the addition ofcolor-flow Doppler scanning to TVUS to identify a singlefeeding vessel [81], whereas others demonstrated addingcolor-flow Doppler scanning to have low specificity for en-dometrial cancer [51], with no difference in the histologiccondition of polyps on the basis of their resistive index, pul-satility index, or size [82].

The use of power Doppler sonography seems more prom-ising [79,83,84]. This technique offers some advantages overconventional color-flow Doppler sonography that makes ita better technique for depicting vascular networks. Thereis level II evidence demonstrating that the addition of powerDoppler sonography with identification of a single vesselpattern improves diagnostic sensitivity to 89% and specific-ity to 87% for an endometrial polyp [83], in comparison tothe multivessel or scattered vessel pattern seen in malignantlesions or endometrial hyperplasia [79]. This benefit wasseen in the diagnosis of endometrial polyps in symptom-free patients, whereas sensitivity in women with symptomsremained largely unchanged from gray-scale TVUS alone[83]. At this time, sonographic examination either with orwithout color-flow or power Doppler sonography is nota substitute for pathologic evaluation after surgical removal.

Saline Infusion SonographyThe use of saline infusion sonography (SIS) or sonohys-

terography (SHG) increases sonographic contrast of the en-dometrial cavity, enabling delineation of the size, locationand other features of an endometrial polyp. With SIS, polypsappear as echogenic, smooth, intracavitary masses with ei-ther broad bases or thin stalks outlined by fluid [55]. Thistechnique may outline small endometrial polyps missed ongray-scale TVUS and is likely improve diagnostic accuracy[60,85–89]. In a prospective comparative study, the use ofsaline solution as a contrast agent significantly enhancedthe sensitivity and specificity compared with TVUS alone,because it detected small lesions that were missed bynoncontrast sonography [60]. Differentiating endometrialpolyps from submucosal fibroids can be difficult, but exam-ination of lesion echotexture and identification of overlyingechogenic endometrium are useful features to distinguish thetwo [90].

When compared with hysteroscopy by use of guided bi-opsy for the identification of different endometrial diseases,SIS has sensitivity of 58% to 100%, specificity of 35% to100%, PPV of 70% to 100%, and NPV of 83% to 100%[37,56,59,60,62]. A number of prospective comparativestudies have reported no significant difference betweenSIS and diagnostic hysteroscopy in diagnosing endometrialpolyps [60,86,91].

When compared with hysteroscopy, SIS has the advan-tage of assessing both the uterine cavity and other uterineand pelvic structures and visualizing potential myometrialand adnexal abnormalities [91]. Previous work reports SISto be less painful than diagnostic hysteroscopy in the outpa-tient setting [92], although these studies were not performedwith the smaller-diameter hysteroscope in common use to-day, with both techniques requiring the cervix to be traversedand uterine distension to occur [93]. Disadvantages of SISinclude an inability to determine final endometrial disease[56], a longer learning curve compared with noncontrastTVUS [87], and patient discomfort caused by fluid leakageor pain with the use of a balloon catheter [94]. Gel instilla-tion sonohysterography may be an alternative solution tothis issue, although limited data are currently available onthis technique [94].

Three-dimensional TVUS and Three-dimensional SISThree-dimensional ultrasonography (3-D US) is a nonin-

vasive imaging technique with the ability to generate multi-planar reconstructed images through the uterus and itsexternal contours. One of the most useful scan planes ob-tained with the 3-D US is the coronal view which is usuallynot obtained by two-dimensional (2-D) ultrasound becauseof the limited mobility of the transvaginal transducer [95].Coronal views allow more accurate visualization betweenthe endometrium and myometrium at the fundus and cornualangles [96], providing superior diagnostic accuracy in de-tecting endometrial polyps compared to 2-D TVUS. A class

Table 1

Diagnostic modalities for endometrial polyps

Reliability

Method [references]

Total number

of patients

included

in studies

Sensitivity

Median (range)

Specificity

Median (range)

PPV

Median (range)

NPV

Median (range) Advantages Disadvantages Future development

TVUS [18,58–64] 1807 91% (19%–100%) 90% (53%–100%) 86% (70%–100%) 90% (87%–97%) Readily available

Safe

Noninvasive

Reproducible

Not specific for

endometrial polyp

Complementary use of

power and color-flow

Doppler may aid in

diagnosis

3-Dimensional TVUS

[35,64]

3873 100% (100%) 85% (71%–99%) 94% (89%–99%) 100% (100%) Noninvasive and safe

Evaluates all surfaces

of uterus and adnexae

Expensive and may not

be readily available

Requires further evaluation

in methodologically

sound studies

SIS

[37,56,58,59,62,

64–70]

1354 95% (58%–100%) 92% (35%–100%) 95% (70%–100%) 94% (83%–100%) Accuracy comparable

to hysteroscopy

Easier to learn than

hysteroscopy

Does not allow

histologic diagnosis

Higher skill requirement

than TVUS

Patient discomfort from

fluid leakage and pain

from balloon catheter

Gel instillation may

lessen patient discomfort

3 Dimensional SIS

[71,72]

173 94% (92%–95%) 94% (88%–99%) 99% (97%–100%) 97% (97%) Reported accuracy

comparable to

hysteroscopy

Evaluates all

surfaces of uterus

Expensive and may not

be readily available

Further studies with

larger number of

patients are required

Blind biopsy [62,73,74] 1411 10% (8%–46%) 100% (100%) 66% (31%–100%) 33% (7%–58%) Allows a histologic

diagnosis if tissue

actually sampled

Nontargeted biopsy

frequently miss

polyps

Has no role in diagnosis

of polyps when used

alone

Diagnostic

hysteroscopy

[18,60,62,72,75–77]

5261 90% (58%–99%) 93% (87%–100%) 96% (21%–100%) 93% (66%–99%) Higher accuracy than

other imaging

modalities

Allows potential

endometrial

sampling and

removal of polyp

Invasive

Higher complication

rate than other

imaging modalities

High skills by operator

required

May require anesthesia

and hospitalization

Newer instruments allow

outpatient operative

hysteroscopy with

reduced cost and same

clinical outcomes

Flexible hysteroscopy

[78]

661 74% 91% d d Better tolerated than

rigid hysteroscopy

Maneuverable tip

allows visualization

of disease

Inferior images to

rigid hysteroscopy

Expensive

Delicate instrument

Newer instruments with

video chips allow

better quality images

Hysterosalpingography

[37]

286 98% 35% 70% 92% Provides information

on tubal patency

Exposure to radiation

and contrast

material

Has no role as primary

imaging for endometrial

polyps

Salim

etal.

Diagnosis

andManagem

entofEndometria

lPolyp

s:ACritica

lReview

oftheLitera

ture

573

574 Journal of Minimally Invasive Gynecology, Vol 18, No 5, September/October 2011

II-2 study of 3850 consecutive 3-D US cases reported sensi-tivity of 100%, specificity of 99%, PPVof 99% and NPVof100% in diagnosing endometrial polyps when compared tohysteroscopy with biopsy [35]. These figures need to be in-terpreted with caution because only those with a suspectedpolyp on 3-D US subsequently underwent hysteroscopyand therefore do not include those women with endometrialpolyps who had negative 3-D US result. On reviewing thesedata, there is no capacity to provide NPV in this study.Smaller studies with this technique have reported more mod-est figures of 100% for sensitivity, 71% for specificity, 89%for PPV, and 100% for NPV [64].

Adding saline solution contrast into the endometrial cav-ity to perform 3-D SIS may provide additional informationin the diagnosis of endometrial polyps, because it combinesthe advantages of TVUS and SIS. However, studies reportonly slightly higher specificity (88% to 99%) and PPV(97% to 100%) for endometrial polyps than those of 3-DUS, with sensitivity of 92% to 95% and NPV of 97%[64,97]. Given these data, the greater expense of 3-Dsonography and its less-frequent availability, 2-D US withintrauterine contrast should be preferred as an effectiveand reliable noninvasive method to diagnose polyps.

Histologic Diagnosis

Blind BiopsyBlind dilation and curettage is inaccurate in diagnosing

endometrial polyps and should not be used as a diagnosticmethod [98]. Despite specificity and PPV of 100%, its useis limited by its low sensitivity of 8% to 46% and NPV of7% to 58% when compared with hysteroscopy and guidedbiopsy [62,73,74]. Use of an endometrial sampler ora curette can miss pedunculated polyps and fragmentationof sessile polyps may make histologic diagnosis difficult[99]. In postmenopausal women, this is particularly thecase for polyps, which tend to be broader based with an un-even surface caused by small translucent cysts covered byatrophic endometrium [99].

Hysteroscopy with Guided BiopsyHysteroscopy with guided biopsy is the gold standard in

the diagnosis of endometrial polyps [72]. The main advan-tage of hysteroscopy is the ability to visualize and removepolyps concurrently. Diagnostic hysteroscopy alone allowsonly subjective assessment of the size, location, andphysical properties of the lesion, with reported sensitivityof 58% to 99%, specificity of 87% to 100%, PPV of 21%to 100%, and NPVof 66% to 99% when compared with hys-teroscopy with guided biopsy [18,60,62,75,76,97]. Despitethe increasing popularity of office hysteroscopy, mostroutine diagnostic hysteroscopies are still performed in anoperating theater and require anesthesia and hospitalization[56,100]. This may be explained by the requirement ofa high level of expertise to perform hysteroscopy in an

ambulatory or office setting, especially if operativehysteroscopy is required concurrently. The evidence favorsoutpatient hysteroscopy for diagnosis, with 2 large-scalestudies reporting success rates of 92% to 96% in this setting,with no difference between premenopausal and postmeno-pausal women [21,76], and a class I study reporting lessexpense and greater patient preference for an outpatientprocedure [101]. The addition of polypectomy for smallpolyps is possible, and technological improvements andgreater surgeon skill should see increased uptake of outpa-tient procedures in the future.

Flexible hysteroscopy causes less pain for patients andallows an easier passage through the cervical canal whencompared with rigid hysteroscopy [102,103], making itmore suited for outpatient procedures. It is reported to havelower sensitivity of 74% for the diagnosis of endometrialpolyps when compared with rigid hysteroscopy [77,78].This may be explained by the lower quality image obtainedthrough the fiberoptic bundle that carries both light and theimages, although newer flexible hysteroscopy with videochips rather than the old fiberoptic image bundle allows animproved image quality [103]. Expense, delicacy of the in-strument with easy breakage, and more limited operative in-strumentation are disadvantages of flexible hysteroscopescompared with rigid hysteroscopes.

With continuing technological improvements producingnarrow diameter hysteroscopes, operative hysteroscopycan be readily performed in an outpatient setting [104]. Alarge-scale class II study reported 4863 consecutive opera-tive outpatient hysteroscopies including 2306 for endome-trial polyps, in which most small endometrial polyps wereremoved with minimal discomfort [104]. Polyps largerthan the diameter of the internal cervical os may be best re-moved with the patient under general anesthesia given theincreased patient discomfort and longer operating time.

Choice of distension medium is important when consider-ing patient comfort and improveddiagnostic accuracy.Normalsaline solution causes significantly less shoulder tip andlower abdominal pain compared with carbon dioxide [105],allowing clear, reliable imaging for accurate diagnosis [106]and is widely used in the outpatient setting [21,34,104,107].Although some patients may not require analgesia oranesthesia for office hysteroscopy, the use of paracervicalblock or intrauterine anesthetics, particularly if operativehysteroscopy isperformed subsequently,maybehelpful [108].

Complication rates at hysteroscopy are low, with a large-scale class II-1 study reporting an overall complication rateof 0.28% in 13 600 hysteroscopic procedures; the rate foroperative removal of an endometrial polyp in this study is0.4% [109]. Approximately half of the complications wereentry related, whereas the remainder were related to the sur-geon’s experience and type of procedure. Overall, hystero-scopic polypectomy has half the risk of complication whencompared with hysteroscopic myomectomy or endometrialablation and 1/10th the risk for complication comparedwith hysteroscopic synechiolysis [109].

Salim et al. Diagnosis and Management of Endometrial Polyps: A Critical Review of the Literature 575

Other Diagnostic Tests

Hysterosalpingography may define endometrial polyps aspedunculated, nonspecific filling defects within the endome-trial cavity, with high sensitivity (98%) but low specificity(34.6%) compared with hysteroscopy [37]. It can be usedin infertile women to assess tubal patency, but, with disad-vantages including use of ionizing radiation, iodinated con-trast materials, and patient discomfort, routine use ofhysterosalpingography for diagnosis of an endometrialpolyp cannot be recommended.

Endometrial polyps can be identified on magnetic reso-nance imaging as low signal intensity intracavitary massessurrounded by high signal intensity fluid and endometriumby T2-weighted magnetic resonance imaging. Very highcost and limited availability, with limited advantages oversonography, preclude this technique from routine use. Com-puted tomography scanning has a limited role because of itscost, radiation exposure, and low sensitivity of 53% for en-dometrial thickness when compared with TVUS, even withcontrast enhancement [110]. Virtual hysterosalpingographywith 64-slice computed tomography scanning to assessthe uterine cavity has been described [111–113], althoughlimited data are currently available, and it should not beconsidered outside of a research protocol at this time.

ManagementFor women with endometrial polyps, management is

dependent on symptoms, risk of malignancy, fertility issues,and operator skills. Management options will be consideredunder the headings of conservative nonsurgical, conservativesurgical, and radical surgical approaches. Table 2 summa-rizes the management strategies for endometrial polyps.

Conservative Nonsurgical ManagementHaving diagnosed endometrial polyps, their removal ei-

ther in the office or with the patient under general anesthesiais considered a low-risk but not a no-risk procedure and therisk/benefit ratio must be discussed with the patient. In twoclass II-2 studies, it was found that polyps ,10 mm havea 27% chance of spontaneous regression over 12 monthsand a low chance of malignancy [27,53], indicating thatsymptom-free women with polyps ,10 mm in size couldbe managed conservatively.

Medical treatments may have some role in the manage-ment of endometrial polyps and GnRH agonists are reportedto give short-term symptomatic relief for endometrialpolyps, but symptom recurrence is common with treatmentcessation [125]. Although GnRH agonists could be used asan adjunctive treatment before hysteroscopic resection[125], this must be considered against the costs and side ef-fects of this medication and the comparative benefit fromsimple alternate extirpative treatments without the use ofthese medications.

In a class II study of 3 different hormone replacementtherapy types (2.5 mg with conjugated estrogen 0.625 mgand medroxyprogestorone 2.5 mg; estradiol 2 mg and nore-

thisterone 1 mg; tibolone 2.5 mg), the progestin with thehighest antiestrogenic activity (tibolone) is suggested to re-duce the development of endometrial polyps. Follow-up hys-teroscopic examination at 36 months after treatmentreported few polyps in any group (range 0–3), and theclinical superiority of any of these medications must beconsidered in a circumspect manner until class I studiesare undertaken. Importantly, the balance between diseasesuppression and other side effects of these medicationsmust be considered [126].

A randomized trial of LNG-IUS compared with observa-tion indicates that reduced endometrial thickness throughprogestogenic suppression may be a factor in reducing polypdevelopment. In the 4.5-year period of the study, 8 newpolyps were reported in the observation group comparedwith 3 in the LNG-IUS group (p 5.016). In this intentionto treat study, the 3 polyps in the LNG-IUS group occurredin 1 woman who did not have the LNG-IUS inserted and theremaining 2 in women who had it removed at 1 year becauseof side effects. Although these figures are encouraging, theuse of LNG-IUS for the treatment of polyps should becurrently limited to research protocols [127].

Conservative Surgical ManagementBlind dilation and curettage has been the standard man-

agement option for abnormal uterine bleeding and suspectedendometrial disease for many years and is still common prac-tice, with a survey from the United Kingdom in 2002reporting that 2% of gynecologists used blind dilation andcurettage for the management of endometrial polyps, and51% were performing blind curettage after hysteroscopyfor the removal of polyps [100]. Evidence suggests that thispractice is ineffective and has a significant complicationrate (1:100 perforation rate and 1:200 infection rate) associ-ated with its use. A class II study reports complete removal ofendometrial polyps by dilation and curettage alone in 8/51patients (4%), whereas the addition of polyp forceps in-creases complete extraction to 21/51 patients (41%). Theseclass II-2 and II-3 studies indicate that the endometrial dis-ease is removed less than 50% of the time, and in many casesremoval is incomplete [73,74,128–130]. Given the lowcomplication rate associated with hysteroscopic removal andits widespread availability, safety, and ability to be performedin an outpatient setting [76,105,109,131,132], blind dilationand curettage should be relegated to history and replacedby direct visualization and targeted disease removal.

TVUS-guided polypectomy has been suggested as a pos-sible improvement on the blind technique; however, after anearly feasibility study, there has been little further enthusi-asm for this technique [133]. The mean operating time forthe procedure was 8 minutes (95% CI, 5.9–10.4) and wassuccessful in 32/37 (86.5%) cases (95% CI, 75.5–97.5).In the failed cases, unsatisfactory imaging and failure tograsp the polyp were the causes. Two patients (5.4%) bledfrom the tenaculum insertion site, necessitating a suturefor hemostasis.

Table 2

Comparison of polyp management

Management Advantages Disadvantages Recurrence

Dilatation and curettage

or Hysteroscopy

followed by blind grasping

forceps/curettage [74,114]

Readily available

Low equipment costs

Minimal expertise required

Low sensitivity (8%-46%)

General anesthesia

Hospitalization required

Complication rates higher than

with targeted removal

Recurrence in 15%

Hysteroscopic polypectomy

[102,104,109,114–119]

Accurate, complete resection of polyp

Early recovery, return to normal

activities

Minimal hospitalization

Low risk of complication (0.38%)

Associated with good reproductive

outcome

Low risk of intrauterine adhesions with

operative hysteroscopy for polyps

Increased operating time for

operative hysteroscopy

Specialized equipment

Glycine absorption and associated

complications a potential issue

Higher skill requirement than

blind technique

Operative hysteroscope

use is associated with

a low recurrence rate

0% to 4.5%

Hysteroscopy and polyp

morcellation [120,121]

Easy to use

No glycine for distension

Time saving

Short learning curve

Expensive

Not widely available

Increased difficulty of pathological

examination

Increased risk of bleeding as

no electrosurgery

Not yet reported

Hysteroscopy and bipolar

removal of polyp [28,122]

Easy to use

No glycine for distension

Expensive

Not widely available

Not yet reported

Hysterectomy [123,124] Definitive treatment

No risk for future malignancy

Treatment of choice for polyp

associated malignancy

High risk of surgical morbidity

Compromises future childbearing

ability

No recurrence

Medical [125] Noninvasive Only for short-term treatment,

Limited evidence of effectiveness

Symptom recurrence on

treatment cessation

576 Journal of Minimally Invasive Gynecology, Vol 18, No 5, September/October 2011

Hysteroscopic ResectionHysteroscopy and polypectomy is an effective, safe

method of diagnosing and treating an endometrial polypthat allows expeditious recovery, return to normal activities,and short hospital or office stay [114,115,119]. A variety ofmethods are practiced to remove polyps at hysteroscopy,and Table 2 summarizes these techniques and their relativeadvantages and disadvantages.

The type of instruments used for polyp removal is depen-dent on availability, expense, and surgical experience, aswell as the size and location of the lesion. Large and sessilepolyps are best removed with a hysteroscope fitted with anelectrosurgical loop (resectoscopic), whereas small and pe-dunculated polyps may be removed with either scissors orsmall polyp forceps in an operating hysteroscope underdirect vision [114]. In a class II-2 study with 240 womenwith endometrial polyps, resectoscopic polypectomy tooksignificantly longer to perform (p,.05) and carried a higherrisk of complications than hysteroscopic polypectomy withother instruments, such as microscissors, grasping forceps,and electric probe. This was likely due to the larger polypsize and greater cervical dilation required for this technique.There was no recurrence of polyps in the resectoscopic

group, whereas the use of grasping forceps was associatedwith a 15% recurrence rate [114].

Other instruments include the bipolar Versapoint(Gynecare, Sommerville, NJ) system with less cervicaldilation compared with the operating hysteroscope and theuse of saline solution rather than glycine, potentiating adecreased risk of hyponatraemia and its sequelae [28,122].The hysteroscopic morcellator removes polyp chips as itresects, allowing continuous vision, a short operating time,and less movement of instruments through the cervix withdecreased potential for cervical laceration and fluidloss [120,121]. These techniques may be limited byavailability and cost, and there is no evidence that theysignificantly alter clinical outcome at this time. Randomized,comparative studies with standard electrosurgical resectionare recommended.

Radical Surgical OptionsHysterectomy is the definitive treatment for endometrial

polyps. Although this guarantees no recurrence and no po-tential for malignancy, its invasive nature, risk of surgicalmorbidity, cost, and implication for future fertility are fac-tors that require careful consideration and discussion with

Salim et al. Diagnosis and Management of Endometrial Polyps: A Critical Review of the Literature 577

the patient [124]. There are no class I studies comparing hys-terectomy with conservative treatments for polyps; however,a pragmatic approach with the less-invasive treatment seemsappropriate in the absence of such evidence.

Clinical OutcomesClinical outcomesafter treatment of endometrial polyps are

generally good. In a randomized clinical trial of 150 womenwith an endometrial polyp allocated to hysteroscopic removalor observation, therewas nodifference identified in thevolumeofmenstrual loss between the groups, although the symptoms,such as intermenstrual bleeding, were significantly improvedby removal at follow-up (residual symptoms following polypremoval 7/75 vs conservative 28/75; p 5.001) [134]. Otherstudies report the symptomatic improvement to be verygood, with abnormal uterine bleeding resolved after hystero-scopic polypectomy in 75% to 100% of cases [135,136].

Adhesion risk is low after polypectomy, because themyometrium is not incised and the endometrium has anexcellent regenerative capacity [137]. A class I study with90 women reports no adhesions after hysteroscopic polypec-tomy, and routine antiadhesion treatments are unlikely tobe of benefit in this group of patients [116].

In a class II-3 retrospective study, recurrence of polypsafter 9 years of follow-up after hysteroscopic polypectomywas reported in 5 of 240 patients (3.7%), requiring repeathysteroscopic removal in 3 (1.7%) and subsequent hysterec-tomy in 2 (0.8%) [114]. This is in contrast to a class II-3study that reports recurrence of symptoms after polypec-tomy of 60% by survival curve analysis; however, only2/78 (2.5%) women were identified to have recurrent polyps,with many other diseases present in the remaining patientsincluding abnormal uterine bleeding [138]. This indicatesthat although recurrence of polyps is low, the presentingsymptoms leading to surgical removal are not always relatedto the presence of the polyp. It is therefore important to dif-ferentiate recurrence of disease with recurrence of symp-toms, and discussion of this fact with the patient beforeintervention is required.

Most of the data for polypectomy in subfertile patientssuggests that removal improves fertility, with reported preg-nancy rates varying between 43% to 80% [114,139,140].Both spontaneous pregnancy rates and those associatedwith assisted reproductive technology are reported to beincreased after polypectomy. In a class I study, polypectomybefore intrauterine insemination significantly increasedsubsequent pregnancy success (relative risk 2.1, 95% CI1.5-2.9, p ,.001). The rate of pregnancy in the study groupwas 51%, and of these, 65% had a spontaneous conceptionbefore the first intrauterine insemination, whereas allpregnancies in the control group were obtained during thefertility treatment [141].

There is conflict surrounding the size of polyp needed tobe removed to achieve an improvement in assisted reproduc-tive technology, with data suggesting that removal of polyps,2 cm has no impact on the outcome of fertility treatment

[142–144]. In contrast, a class II-2 study suggested that res-toration of fertility was not dependent on the size of lesionremoved (139) and a class II-3 study reported no significantdifference in the reproductive outcome for patients withpolyps %2.5 cm or .2.5cm [114].

Conclusion

Endometrial polyps are a common gynecologic diseasethat increases with age and are rarely associated with malig-nancy. Polyps may not be responsible for abnormal uterinebleeding symptoms in premenopausal women when theyare found, although, when diagnosed, removal seems pru-dent to exclude this as a simple causative factor. Noninvasivetechniques such as gray-scale TVUS are a reliable modalityfor diagnosis, with diagnostic improvement by use of con-trast techniques. In clinical practice, the choice of diagnosticmethod for endometrial polyps is dependent on the conditionof the patient, the facilities available, comparative costs, andthe physician’s experience with these modalities.

For management, hysteroscopic resection is safe and ef-fective and allows histologic assessment. Blind techniquesshould be avoided when visual techniques are available forexcision. Conservative treatment is a viable option pendingpatient preference and risk factors. For patients with infertil-ity and the presence of polyps, removal of disease is likely tobe helpful to subsequent pregnancy. Conservative treatmentsfor benign lesions should be favored over radical options.

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