Endometrial polyps are overgrowth of endometrium which is the inner lining of uterus. These are usually benign but a small proportion of atypical polyps may be cancerous. They usually occur at the age of 30-40 years and are fairly common. They are attached to the endometrium through either a long stalk or a broad base. One can have multiple polyps also inside her uterine cavity. When they get very large, they may protrude out of cervix as well. These polyps may cause problems with fertility and can cause irregular periods as well.
- Incidence: Endometrial polyps usually occur at 30-40 years of age but may happen before 20 years of age and even after menopause. Exact incidence is not known as they remain largely asymptomatic and thus remain undiagnosed but they account for approximately 50% cases of abnormal uterine bleeding and 35% of cases of infertility.
- Causes: Endometrial Polyps are caused due to overgrowth of endometrium and are usually non-cancerous. Exact reason of this overgrowth is not clear but may be increased estrogen levels in body. Hypertension and Obesity increases chances of polyp formation. Drug called tamoxifen also increases chances of polyp formation. Post- menopausal women taking hormone replacement therapy also have higher chances of polyp formation.
Symptoms- Following symptoms may occur:
- Heavy bleeding during periods
- Intermittent and irregular spotting in between periods
- Repeated vaginal infections if large polyp is protruding through cervix
- Pain during menses
- Infertility and miscarriages
- Vaginal bleeding after menopause
Diagnosis
- Trans-vaginal Ultrasound: Polyps can be visualized through transvaginal ultrasound in approximately 80-90% cases. Addition of power doppler increases its diagnostic accuracy.
- Ultrasound: Ultrasound is a very efficient tool for initial screening of polyps.
- 3-D Ultrasound: It is a better tool to diagnose uterine polyps.
- MRI: It is a very sensitive tool to diagnose endometrial polyps.
- Sonohysterogram: It is considered as the gold standard for diagnosing uterine polyps and can even pick up small polyps which can get missed by normal ultrasound. In this test, fluid is filled through a narrow catheter in uterine cavity and transvaginal ultrasound is done to localize the polyp.
- Hystero-salpingogram: X-ray of uterus can also show polyps but it is not very sensitive and can miss small polyps.
- Hysteroscopy: Visualising uterine cavity directly through camera is most accurate and the advantage is that it can be removed also in same sitting. Office hysteroscopy can also be done to localize the polyp alone.
- Histological diagnosis: Most definitive diagnosis occurs by biopsy examination of tissue after its removal. It is a procedure usually done under General anaesthesia.
Treatment
Only symptomatic polyps or those occurring after menopause need to be removed and if any polyp is not causing any symptom, it can be left as such with regular follow-ups. Medicines like progesterone or GnRh agonists can be given only for temporary relief of symptoms. They do not treat polyp unless it is very small. Surgery is otherwise the only way to remove these polyps.
Modalities of Surgery
- Hysteroscopic polyp removal: This is a small procedure done under general anaesthesia, in which a Hysteroscope or camera is inserted inside the uterine cavity and polyp is located. Afterwards, it is cut by hysteroscopic scissors (or resectoscope for big sessile polyps) under direct guidance of hysteroscope. It is the most accurate way of removing polyp and ensures its complete removal. Surgical expertise is required and it may be little costlier than other methods. Sometimes when polyp is too large, it may require multiple sittings as well.
- Dilatation and Curettage: It is also a procedure done under anaesthesia. Here, polyp is removed blindly by inserting an instrument called ovum forcep inside the uterus to grasp it and pull it out. Afterwards, the cavity is curetted thoroughly to ensure complete removal. As there is no way direct way to visualize cavity from inside, it may lead to incomplete removal.
- Hysterectomy: Sometimes in presence of very large polyps in older age groups, removal of uterus called Hysterectomy is recommended rather than just polyp removal. This can also be done laparoscopically and eliminates any chances of recurrence.
- Recurrence: Polyps may recur depending upon individuals’ own tendency to have thickened endometrium. Recurrence period may vary from few months to few years. Long term progesterone therapy either in the form of oral tablets or intra uterine device called Mirena can be inserted in those patients not desiring fertility. Those who desire fertility, it is advised to not to delay child bearing. Regular gynecological check-up and ultrasound should be done in either case to detect any reformation of polyp.
