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Endometrial Polyp

Endometrium Polyp

Endometrial polyps are a localized mass in the uterine cavity consisting of endometrial glands, blood vessels and stroma. They may enlarge extensively in the cavity and undergo secondary changes. Most endometrial polyps are benign tumors and are common findings usually discovered during cervical assessment for the management of infertility


Presentation

Most polyps are asymptomatic, however, they are one of the causes of pre- and post-menopausal vaginal bleeding. They account for approximately 30% of cases of vaginal bleeding in post-menopausal women and are also associated with infertility, and menorrhagia [2] among pre-menopausal women. Cervical dilation following protrusion of large polyps through the external cervix may cause severe pain accompanied with profuse bleeding.

Metrorrhagia
  • A 69-year-old woman presented with metrorrhagia. The patient had been diagnosed 4 years before with infiltrating lobular breast carcinoma. Follow-up was uneventful. She underwent hysteroscopy with biopsy. An endometrial polyp was seen.[ncbi.nlm.nih.gov]
  • Metrorrhagia was assessed by average days of bleeding per month.[journals.lww.com]
  • CONCLUSION: Our results showed that simple polypectomy and more invasive surgical procedures led to subjective improvement in symptoms of menorrhagia and metrorrhagia and a high satisfaction rate in women with endometrial polyps.[ncbi.nlm.nih.gov]
  • In pre-menopausal women, they may cause intermenstrual bleeding, metrorrhagia, and infertility. Polyps can be histologically characterised as localised hyperplastic overgrowths of glands and stroma.[radiopaedia.org]
  • Endometrial polyps cause menorrhagias – heavy periods, sanioserous premenstrual discharge, bloody smearings outside of the mensese and after a sexual intercourse, metrorrhagias, bleeding after the menopause.[pinkycloud.com]

Workup

There are various invasive and non-invasive techniques that are useful in the diagnosis of EMPs. Hysteroscopy, sonohysterography and transvaginal ultrasound with Doppler flowmetry are commonly used for proper examination of the tissue mass and effective biopsy [16]. High sensitivity (97%) and specificity (90%) of hysteroscopy for EMP diagnosis is observed when the technique is combined with biopsy. In contrast, ultrasound evaluation has low sensitivity (41%) and specificity (83%) [17]. Hysteroscopy is an invasive procedure, and is considered as the gold standard for the management of endometrial polyps. With this technique, the histological features of the polyp (size, thickness, width, appearance etc.) are examined [18]. As previously stated, the definitive management of EMPs is achieved by biopsy. Suspected cases can also be diagnosed using a non-invasive technique such as transvaginal Doppler ultrasound. This may also help in detecting twisted vascular pedicle, which is commonly seen in ovarian torsion. The endometrial polyp thickness measured using transvaginal ultrasonography is not sufficient in predicting malignant changes in endometrial polyps seen in postmenopausal women presenting with vaginal bleeding or fibrotic endometrium [19] [16] [20].

Treatment

Although there is no specific protocol for the management of EMPs, hysteroscopical removal of polyps is the most commonly applied method. Anesthesia may be required during this procedure  [21].

Conservative management can be carried out in asymptomatic patients or those with normal histological findings on biopsy, particularly in menacme or post menopausal women [22]. It may also be used in a gradually atrophied polyp of ≤0.7 cm [23]. Symptomatic polyps in all pre- and post-menopausal patients require surgical resection and histological examination is important to determine their pathogenicity.

Prognosis

Postmenopausal women above 60 years with vaginal bleeding were found to have a notable increase in the incidence of precancerous and cancerous polyps [5] [14]. Endometrial polyps can reoccur in some women, although the actual recurrence rate is unknown. Some studies have reported a rate of 15% [15]. Recurrence following polypectomy depends upon various factors including the surgeon's technique, experience and the characteristics of the polyps. Endometrial resection following polypectomy is applies as a prophylactic method to prevent recurrence, though long term effects are still unclear.

Etiology

EMPs appear as a multiple, fibrotic enlarged mass and may result from prolonged exposure to tamoxifen. Factors that influence the progression of polyps to malignant tumors include obesity, old age, hypertension, postmenopausal hormonal changes, and tamoxifen drug use [2]. Increased frequencies of abnormal endometrial changes are observed in postmenopausal women on tamoxifen with the risk of progression into endometrial neoplasms.

Epidemiology

EMPs are commonly diagnosed as pathological findings in the gynecological practice and show varying prevalence. The actual rate of prevalence is unknown since the condition may develop in women without any clinical presentation. The correct prevalence rate varies due to different factors. These include the type of population studied, sampling method and diagnostic technique [3]. Sampling method such as study design, population size or criteria of inclusion may influence the epidemiological value of EMP. Moreover, the diagnostic technique which comprises transvaginal scan (TVS), hysteronosonography (HSG) and hysteroscopy may determine the prevalence rate [6]. The estimated prevalence value of EMP among women with no observable symptoms ranges from 7.8-34.9% [7] [8]. These values rise with age and higher incidences are reported among postmenopausal women (11.8%) compared to the premenopausal group (5.8%) [9]. 25% of the female population develop this non malignant disease [4].

Sex distribution
Age distribution

Pathophysiology

Histologically EMPs consist of unevenly distributed glands with thick-walled blood vessels presenting in a fibrotic stroma [10] [11]. The stroma is composed of spindle cells with large thick-walled blood vessels. The morphological features of EMPs depend on the arrangement of the endometrium from where the polyps arise. Therefore, EMPs may either be atrophic, hyperplastic or carcinomatous in nature. The polyps may either be pedunculated or sessile, single or multiple, with varying sizes and are arranged on the vascular matrix along the uterine wall [12]. Hormones play a major role in the pathophysiology of endometrial polyps. For example, estrogen and progesterone regulate endometrial proliferation and differentiation through steroid receptors. Also, the development of polyps is related to increased receptor signalling of the glandular epithelium, which results in focal hyperplastic changes in the endometrium cells [13].

Prevention

Though there is no specific method to prevent the development of EMP, risk factors such as obesity, high blood pressure, or tamoxifen exposure for breast cancer treatment require regular monitoring. Also regular medical checkup is advised, particularly for post-menopausal women. As polyps may reoccur, further and prolonged treatment may be needed.

Summary

Endometrial polyps (EMPs) are usually benign with features of a nodular mass on the inner surface of the uterus. EMPs are also called uterine polyps. These polyps consist of unevenly distributed glands and fibrous stroma of the endometrium [1]. They are proliferative or hyperplastic lesions, which are often detected in routine surgical procedures in women particularly during infertility management.

Endometrial polyps are the major causes of vaginal bleeding in perimenopausal women. Moreover, EMPs are associated with postmenopausal bleeding, infertility, and heavy menstrual bleeding (menorrhagia). They may be enlarged and numerous and fibrotic in nature. Most often, EMPs are treated with hysteroscopic techniques which involve the removal of lesions either with or without anesthesia depending on the size or complexity of the nodular mass.

Patient Information

Endometrial polyps (EMPs) are abnormal enlarged growths attached to the uterine wall that can also extend outside the uterine cavity. These are caused by overgrowth of the cells lining the uterus. Most uterine or endometrial polyps are asymptomatic and non malignant (i.e. noncancerous), though some may be cancerous or change into a tumor mass (precancerous polyps). Endometrial polyps are a commonly diagnosed condition in gynecology practice, either accidentally or due to clinical presentation, which includes infertility and abnormal vaginal bleeding among pre- and post-menopausal women [7]. Most endometrial polyps are treated by a surgical procedure called hysteroscopy. In postmenopausal women, endometrial polyps must be adequately managed because of the risk (0.8-8%) of progressing into a malignant tumor [24]. Therefore, histopathological assessment involving guided biopsy using hysteroscopy is very important in managing the disease. Also, special clinical care must be designed to monitor any recurrence of endometrial polyps. EMPs are a common condition associated with breast cancer management resulting from prolonged use of tamoxifen. Although preventive measures to hinder the development of endometrial polyps are unknown, common risk factors can be avoided. These include obesity and high blood pressure. Post-menopausal women are also encouraged to regularly undergo medical check up so as to promptly identify any impending health challenges due to hormonal changes.

References

Article

  1. Scott R. The elusive endometrial polyp. Obstet Gynecol. 1953; 1(2): 212-8.
  2. Pejić SA, Kasapović JD, Todorović AU, et al. Antioxidant enzymes in women with endometrial polyps: relation with sex hormones. Eur J Obstet Gynecol Reprod Biol. 2013; 170(1): 241-6.
  3. Rahimi S, Marani C, Renzi C, Natale ME, Giovannini P, Zeloni R. Endometrial polyps and the risk of atypical hyperplasia on biopsies of unremarkable endometrium: a study on 694 patients with benign endometrial polyps. Int J Gynecol Pathol. 2009; 28(6): 522-8.
  4. Lasmar B, Lasmar R. Endometrial polyp size and polyp hyperplasia. Int J Gynaecol Obstet. 2013; 123(3): 236-9.
  5. Antunes A Jr, Costa-Paiva L, Arthuso M, Costa JV, Pinto-Neto AM. Endometrial polyps in pre- and postmenopausal women: factors associated with malignancy. Maturitas 2007; 57: 415–421.
  6. Ávila I, Filogônio ID, Macedo RM. Pólipo endometrial: correlação da histeroscopia com achados clínicos, ultra-sonográficos e anátomo-patológicos. Rev Soc Bras Cir Laparosc. 1998;3:40-4.
  7. Haimov-Kochman R, Deri-Hasid R, Hamani Y, Voss E. The natural course of endometrial polyps: could they vanish when left untreated? Fertil Steril. 2009; 92(2):828.doi:10.1016/j.fertnstert.2009.04.054.
  8. Salim S, Won H, Nesbitt-Hawes E, Campbell N, Abbott J. Diagnosis and management of endometrial polyps: a critical review of the literature. J Minim Invasive Gynecol. 2011; 18(5): 569-81. doi: 10.1016/j.jmig.2011.05.018.
  9. Dreisler E, Stampe Sorensen S, Ibsen PH, Lose G. Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20-74 years. Ultrasound Obstet Gynecol. 2009; 33(1): 102-8.
  10. Reslová T, Tosner J, Resl M, Kugler R, Vávrová I. Endometrial polyps. Aclinical study of 245 cases. Arch Gynecol Obstet. 1999; 262(3-4): 133-9.
  11. Rosai J, Ackerman LV. Rosai, Ackerman S. Surgical Pathology. 9th ed. Rosai J, ed. St. Louis: Mosby, 2004: 3080.
  12. Pérez-Carbajo E, Martín-Arias A, Kazlauskas S. Patologia tumoral benigna del cuerpo uterino. Mioma uterino y patología endometrial. In: Bajo Arenas JM, Lailla Vicens JM, Xercanvins Montosa J, editors. Fundamentos de Ginecología. 1ª Madrid: Editorial Médica Panamericana; 2009. pp. 398–400.
  13. Lopes RG, Baracat EC, de Albuquerque Neto LC, et al. Analysis of estrogen- and progesterone-receptor expression in endometrial polyps. J Minim Invasive Gynecol. 2007; 14(3): 300-3.
  14. Schmidt T, Breidenbach M, Nawroth F, et al. Hysteroscopy for asymptomatic postmenopausal women with sonographically thickened endometrium. Maturitas 2009; 62: 176–178.
  15. Preutthipan S, Herabutya Y. Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women. Fertil Steril. 2005; 83(3): 705-9.
  16. Savelli L, De Iacco P, Santini D, et al. Histopathologic features and risk factors for benignity, hyperplasia, and cancer in endometrial polyps. Am J Obstet Gynecol 2003; 188: 927–931.
  17. Timmermans A, Gerritse M, Opmeer B, Jansen F, Mol B, Veersema S. Diagnostic accuracy of endometrial thickness to exclude polyps in women with postmenopausal bleeding. J Clin Ultrasound. 2008; 36(5): 286-90.
  18. Grimbizis G, Tsolakidis D, Themistoklis M, et al. A prospective comparison of transvaginal ultrasound, saline infusion, sonohysterography, and diagnostic hysteroscopy in the evaluation of endometrial pathology. Fertil Steril 2010; 94: 2720–2725.
  19. Orvieto R, Bar-Hava I, Dicker D, Bar J, Ben-Rafael Z, Neri A. Endometrial polyps during menopause: characterization and significance. Acta Obstet Gynecol Scand. 1999; 78(10): 883-6.
  20. Bakour SH, Khan KS, Gupta JK. The risk of premalignant and malignant pathology in endometrial polyps. Acta Obstet Gynecol Scand. 2000; 79(4): 317-20.
  21. Litta P, Cosmi E, Saccardi C, Esposito C, Rui R, Ambrosini G. Outpatient operative polypectomy using a 5 mm-hysteroscope without anaesthesia and/or analgesia: advantages and limits. Eur J Obstet Gynecol Reprod Biol. 2008;139(2): 210-4. doi: 10.1016/j.ejogrb.2007.11.008.
  22. Perez-Medina T, Bajo J, Huertas MA, Rubio A. Predicting atypia inside endometrial polyps. J Ultrasound Med. 2002; 21(2): 125-8.
  23. DeWaay D, Syrop C, Nygaard I, Davis W, Van Voorhis B. Natural history of uterine polyps and leiomyomata. Obstet Gynecol. 2002; 100(1) :3-7.
  24. Schwärzler P, Concin H, Bösch H, Berlinger A et al. An evaluation of sonohysterography and diagnostic hysteroscopy for the
    assessment of intrauterine pathology. Ultrasound Obstet Gynecol. 1998; 11(5): 337-42.

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Last updated: 2018-06-22 06:21