【Hysteroscopy】Endometrial polyps

Endometrial polyps are a common gynecological disease. Many women are concerned about whether endometrial polyps will affect pregnancy. What exactly are endometrial polyps?

We can imagine the endometrium as land, the fertilized egg as seeds, and the polyps as weeds! Weeds growing on the land may interfere with the growth and development of seeds, so of course we should be anxious! As we age, the incidence of endometrial polyps will gradually increase, but we should not worry too much!

Guidelines for identifying the presence of polyps

1. Ageing is the most common risk factor for the development of endometrial polyps (grade B). 2. For women with endometrial polyps, abnormal uterine bleeding is the most common symptom (grade B). 3. Infertile women are more likely to have endometrial polyps (grade B). 4. The spontaneous regression rate of endometrial polyps is as high as 25%, and small polyps are more likely to spontaneously regress (grade A). 5. Drugs such as tamoxifen may induce the formation of endometrial polyps (grade B). It is rare for polyps to become malignant due to ageing; however, symptoms of abnormal uterine bleeding and the use of tamoxifen increase the possibility of malignant transformation of polyps (grade B).

Polyp Diagnosis Guide

1. Vaginal ultrasound provides reliable information for the detection of endometrial polyps, and the appropriate one should be selected (Grade B). 2. Color or power Doppler improves the ability of vaginal ultrasound to diagnose endometrial polyps (Grade B). 3. The use of intrauterine contrast ultrasound (with or without 3D imaging) improves the diagnosis of endometrial polyps (Grade B). 4. Guidelines for identifying the presence of polyps 1 Increasing age is the most common risk factor for the development of endometrial polyps (Grade B).For women with endometrial polyps, abnormal uterine bleeding is the most common symptom (grade B). Infertile women are more likely to have endometrial polyps (grade B). The spontaneous regression rate of endometrial polyps is as high as 25%, and small polyps are more likely to spontaneously regress (grade). Drugs such as tamoxifen may induce the formation of endometrial polyps (grade B). It is rare for polyps to become malignant with aging; however, symptoms of abnormal uterine bleeding and the use of tamoxifen increase the possibility of malignant transformation of polyps (grade B).

Guidelines for the diagnosis of polyps 1. Vaginal ultrasound provides reliable information for the detection of endometrial polyps, and the appropriate one should be selected (Grade B). 2. Color or power Doppler improves the ability of vaginal ultrasound to diagnose endometrial polyps (Grade B). 3. The use of intrauterine contrast ultrasound (with or without 3D imaging) improves the ability to diagnose endometrial polyps (Grade B). 4. Blind dilation, curettage, or biopsy should not be used for the diagnosis of endometrial polyps (Grade B).

Guidelines for the treatment of polyps

1. Conservative treatment is reasonable, especially for small, asymptomatic polyps (Grade A). 2. Drug treatment of polyps is not currently recommended (Grade B). 3. Hysteroscopic polypectomy remains the gold standard for treatment (Grade B). 4. There is no significant difference in clinical prognosis between different hysteroscopic polypectomies (Grade C). 5. Postmenopausal women with symptoms should have polyps removed and undergo histological evaluation (Grade B).

1. Why do so many people around me seem to have polyps? Is it related to genetics?

Endometrial polyps, in simple terms, are a common gynecological disease caused by the overgrowth of the local endometrium of the uterus. The number can be single or multiple, the diameter can be large or small, and it can be pedunculated or pedunculated. The incidence rate is about 7.8% to 34.9%. The 2015 AAGL guidelines point out that the high-risk factors for endometrial polyps include age, hypertension, obesity and the use of tamoxifen.

Well, it has nothing to do with genetics. The situation that all the aunts and uncles have may just be a coincidence.

2. Is there a relationship between endometrial polyps and estrogen?

Yes! Some people even go for a B-ultrasound when they are about to have their period and find small "polyps". In fact, they may be thickened endometrium. When they go for a B-ultrasound again when their period is over, they find that they are gone. Because the endometrium is affected by estrogen and progesterone, it sheds regularly every month, which causes menstruation every month.

The endometrial polyp tissue and the endometrial tissue around the polyp of 53 premenopausal women were studied. The results showed that the expression of estrogen receptors in endometrial polyp tissue was higher than that in normal endometrial tissue. In addition, Gul et al. studied and compared 25 premenopausal endometrial polyp patients and 25 postmenopausal endometrial polyp patients and found that the expression of estrogen and progesterone receptors in the polyp glands of postmenopausal women was much higher than that in the matrix.

3. What are the symptoms of polyps?

Polyps smaller than 1 cm are basically not noticeable and are only discovered during physical examinations. As they grow larger, they start to cause trouble... such as menstrual disorders, prolonged menstruation, continuous menstruation, and periovulatory bleeding...

4. Will polyps affect pregnancy?

Endometrial polyps are pedunculated or pedunculated growths that protrude into the uterine cavity, changing the intrauterine environment and making it unfavorable for embryo implantation. Literature reports that the incidence of endometrial polyps in infertile patients is as high as 14.89%, and the risk of developing the disease increases with age. After endometrial polyp removal, the pregnancy rate of infertile patients can be increased to 35%~35%.

5. Will polyps become malignant?

It is not easy for endometrial polyps to become worse. The incidence rate is usually 0%~12.9%, depending on the study population. Most scholars believe that the risk of endometrial polyps becoming malignant increases with age, while the risk of polyps becoming malignant in premenopausal women seems to be very low. However, with age, vaginal bleeding after menopause often indicates the possibility of malignant transformation.

6. Will polyps heal on their own?

The spontaneous regression rate of endometrial polyps is as high as 25%, and smaller polyps are more likely to spontaneously resolve than polyps longer than 1 cm.

7. In what cases is surgery necessary?

If there are clinical symptoms, such as irregular vaginal bleeding;

If there is bleeding in postmenopausal polyps, it is necessary to be alert to the problem of malignant transformation and should be actively treated;

Removal of polyps in infertile women can improve the ability of natural conception;

Removal of polyps before IVF can help the success rate of IVF.

At present, hysteroscopic polypectomy is the main treatment method, which is highly safe, but blind curettage is not recommended. The operation is usually performed 3 to 7 days after the menstruation is over.

8. Can patients with endometrial polyps take progesterone?

There is currently no clear evidence to support the use of progesterone to cause hormone withdrawal endometrial exfoliation and the use of intrauterine progesterone sustained-release rings to treat endometrial polyps. The 2015 AAGL guidelines state that drug treatment has limited effect on polyps and is not recommended for drug treatment of polyps. For large and symptomatic polyps, hysteroscopic resection is still the gold standard.

9. Why do endometrial polyps recur after surgery?

The overall recurrence rate after surgery is about 2.5%~3.7%, mainly because the cause of the polyp is not removed, and secondly, the root of the polyp is not completely removed.

10. How to treat recurrence?

If it does not cause vaginal bleeding and does not affect pregnancy, it can be left untreated and there is no need for repeated surgery.

Hysteroscopy is currently the most widely used diagnostic method that can directly visualize the physiological and pathological changes of the endometrium and is regarded as the gold standard for diagnosing endometrial lesions. Its advantages are: ① Direct visualization of the uterine cavity can determine the size, number, and location of polyps; ② Low misdiagnosis rate, and the root of polyps and the endometrium around polyps can be explored at the same time; ③ The consistency rate between the hysteroscopy results and the final pathological tissue examination results is high. However, hysteroscopy is an invasive operation with risks such as uterine perforation and heavy bleeding. In addition, pain during the operation increases cardiovascular and cerebrovascular reactions, especially for patients who are older and have serious medical diseases, which limits the application of hysteroscopy to a certain extent.

How to treat

Expectant treatment

Functional endometrial polyps originate from the mature endometrium and may undergo periodic changes with the fluctuation of hormone levels in the body, especially polyps with a diameter of less than 1.0 cm, which may fall off partially or completely on their own during menstruation.

Curettage

Traditional curettage is performed under blind vision and is the main method for treating endometrial polyps in the past. However, it is difficult for the curette to scrape the uterine fundus and bilateral uterine horns, and 1/3 to 1/4 of the uterine cavity area may be missed, with a residual rate of up to 20% to 25%. Curettage can easily damage the endometrium and lead to postoperative infection, intrauterine adhesions, infertility, etc.

Hysteroscopic polypectomy

Polyps can be removed from the pedicle under direct vision, with minimal damage to the normal endometrium. For patients who want to have children, hysteroscopic operation will not have a negative impact on the physiological function of the ovaries.