This issue of eMedRef provides information to clinicians on the pathophysiology, diagnosis, and therapeutics of endometrial polyps

Siems, Courtney

University of Missouri: MOspace

Endometrial Polyps Page 1 of 4    6.12.09 Endometrial Polyps Background 1. Localized outgrowth of endometrial glands and stroma that projects into the endometrial cavity  o Most arise from fundus o Polypoid hyperplasia:   Multiple small polyps found throughout endometrial cavity o Rarely contain foci of neoplastic growth  Pathophysiology 1. Pathology of disease  o Several proposed mechanisms of development   Monoclonal endometrial hyperplasia  Overexpression of endometrial aromatase  Gene mutations o 2/3 of polyps have immature endometrial tissue that does not respond to hormonal changes (non-functional polyps) o 1/3 have normal endometrium that changes with cyclic hormonal fluctuations (functional polyps)   Secretory or proliferative depending on the phase of the remaining endometrium o Malignant transformation   Estimated at up to 0.5% o Size   Range from millimeters to several centimeters  2. Incidence, prevalence  o Increasing identification   Due to widespread use of transvaginal ultrasonography and sonohysterography o 20-25% of reproductive-aged women   Peak incidence 40-49 yo o 10% incidence in autopsy studies o 23.8% incidence in symptomatic patients o 10-24% prevalence in women undergoing endometrial biopsy or hysterectomy 3. Risk Factors  o Increasing age o HTN o Menopausal status o Tamoxifen use   20-35% incidence of polyps in women on long-term tamoxifen 4. Morbidity/ Mortality  o Abnormal uterine bleeding   Metrorrhagia most common  Intermenstrual bleeding and menorrhagia also often seen  Polyps cause 25% of all abnormal vaginal bleeding o Extrusion from cervical os  Endometrial Polyps Page 2 of 4    6.12.09  Causing pain  Spotting with intercourse o Malignant transformation o Endometrial hyperplasia o Infertility o Recurrent miscarriage  Diagnostics 1. History  o Most are asymptomatic o Abnormal vaginal bleeding o Found incidentally   Vaginal ultrasound performed for other reasons 2. Physical exam  o May see tip of polyp extruding from cervical os o Most pts have normal exam 3. Diagnostic testing  o Laboratory evaluation   Negative evaluation for other causes of abnormal vaginal bleeding  Microscopic examination of tissue obtained from biopsy can distinguish between benign and malignant polyp o Diagnostic imaging   Transvaginal ultrasound may be negative  Sonohysterography is gold standard   US w/infusion of sterile saline into endometrial cavity to delineate structures  More accurate than transvaginal ultrasound in determining if polyps present  Most useful, non -invasive and cost -effective  Doppler flow studies do not appear to help distinguish between benign and malignant polyps  Combining ultrasound and sonohysterography does not significantly improve dx accuracy o Other studies   Hysteroscopy   Useful for diagnosis and resection  Resection and microscopic exam  o Only reliable method to distinguish b/t benign and malignant polyps  Cervical cytology is not useful  Differential Diagnosis 1. Abnormal vaginal bleeding  o Dysfunctional uterine bleeding o Uterine leiomyomata o Uterine adenomyosis o Endocrine abnormality (thyroid disease) o Endometrial hyperplasia or carcinoma Endometrial Polyps Page 3 of 4    6.12.09 2. Direct visualization  o Polypoid endometrial adenocarcinoma o Malignant polyp o Hyperplastic polyp o Leiomyoma o Adenomyosis  Therapeutics 1. Acute treatment  o Surgical removal with hysterographic visualization is the mainstay of therapy o Improvement of symptoms in 75-100% of pts 2. Recommendations  o No data from randomized trials to guide therapy of asymptomatic polyps o Removal of symptomatic polyps (bleeding, infertility) [Grade 1C]9  o Removal of asymptomatic polyps of any size in women with risk factors for endometrial hyperplasia / cancer [Grade 2C]9  o Removal of asymptomatic polyps in women without risk factors if there are multiple polyps or   In premenopausal women, a single polyp exceeds 2 cm  In postmenopausal women, a single polyp exceeds 1 cm [Grade 2C]9  o Expectant management of asymptomatic polyps 2 cm or less in premenopausal women or 1 cm or less in postmenopausal women without risk factors for endometrial hyperplasia / cancer since these polyps are more likely to regress [Grade 2C]9  3. Surgical removal, w/hysterographic visualization  o Mainstay of therapy  Prognosis 1. Increased risk of developing endometrial cancer in the future 2. May cause infertility  References 1. Beal, HN, Stone, J, Beckmann, MJ, McAsey, ME. Endometrial cells identified in cervical cytology in women > or = 40 years of age: criteria for appropriate endometrial evaluation. Am J Obstet Gynecol 2007; 196:568.  2. Dal Cin, P, Vanni, R, Marras, S, et al. Four cytogenetic subgroups can be identified in endometrial polyps. Cancer Res 1995; 55:1565. 3. Goldstein SR, et al. Evaluation of endometrial polyps. Am J of Obstet and Gynecol 2002;186(4):669-74. 4. Jovanovic, AS, Boynton, KA, Mutter, GL. Uteri of women with endometrial carcinoma contain a histopathological spectrum of monoclonal putative precancers, some with microsatellite instability. Cancer Res 1996; 56:1917. 5. Maia, H Jr, Pimentel, K, Silva, TM, et al. Aromatase and cyclooxygenase-2 expression in endometrial polyps during the menstrual cycle. Gynecol Endocrinol 2006; 22:219. 6. Stenchever. Comprehensive Gynecology, 4th Ed. Mosby, Inc., 2001, pp. 496-7. Endometrial Polyps Page 4 of 4    6.12.09 7. Savelli, L., et al. Histopathologic features and risk factors for benignity, hyperplasia, and cancer in endometrial polyps. Am J of Obstet and Gynecol 2003;188(4):927-31. 8. Stewart, EA. Adenomyosis and endometrial polyps. UpToDate, 4/27/05. available at https://store.utdol.com 9. Stewart, EA. Endometrial polyps. UpToDate, 5/10/2009. Available at http://www.uptodate.com/home/store/index.do 10. Van Bogaert, LJ. Clinicopathologic findings in endometrial polyps. Obstet Gynecol 1988; 71:771.   Author:  Courtney Siems, MD, Baylor COM, TX  Editor:  Chandrika Iyer, MD, St. John FMRP, Detroit, MI 

Endometrial polyps

Abstract

Similar works

Full text

Available Versions

University of Missouri: MOspace