Uterine Polyps

A uterine polyp, also known as an endometrial polyp, is an abnormal growth that arises from the endometrium, the lining of the uterus, and fills places as small as the uterine cavity or as large as it can. It has blood vessels, glands, and stroma. Both the reproductive and postmenopausal phases of life include them. The majority of polyps are found in the fundus, frequently in the corneal region, where curettage removal presents clear technical challenges. They can be detected in all age groups and range in size from about 5 mm to as large as occupying the entire uterine cavity, but they are most prevalent in people between the ages of 40 and 49.

Endometrial polyps are classified as pedunculated if they have a narrow, elongated pedicle connecting them to the uterine surface; sessile if they have a broad, flat base and no stalk. The color is tan to yellow, and the gross morphological appearance is smooth, spherical, or cylindrical in shape. When uterine polyps are present, the endometrium can range from a typical cycling endometrium to simple or complex hyperplasia, and endometrial cancer is occasionally discovered. The most common problematic finding in the uterus is uterine polyps, which are often benign lesions. Although the actual prevalence of uterine polyps is unknown, Dreisler et al. found that 82% of the women with polyps that had been histopathologically confirmed were asymptomatic. Nevertheless, 35% of infertility cases and 50% of irregular uterine bleeding have been linked to uterine polyps.

 

Uterine Polyps Epidemiology

Uterine polyps can develop at any age, but their prevalence is highest in women between the ages of 40 and 49. Between 20 and 40% of reproductive-aged women with abnormal uterine bleeding are thought to have uterine polyps. In about 10% of women, endometrial polyps are discovered after autopsy. Compared to postmenopausal women, premenopausal women had a lower risk of developing malignant uterine polyps.

 

Uterine Polyps Pathogenesis

Endometrial polyp formation has been linked to several different molecular processes. These include somatic gene mutations, monoclonal endometrial hyperplasia, and endometrial aromatase overexpression. Polyps have distinctive cytogenetic rearrangements, just like uterine leiomyomas. Transcriptional factor rearrangements in the high-mobility group family appear to be pathogenic.

Endometrial polyps exhibit progesterone and estrogen receptors, and these hormones may contribute to pathogenesis, particularly in postmenopausal women. Progesterone may have an antiproliferative effect in a subgroup of polyp patients (i.e., those receiving tamoxifen treatment), just like it does in healthy endometrial tissue. Data indicate that testosterone does not replace progestational activity for endometrial polyps, even though androgens and progestins both cause endometrial atrophy.

 

Uterine Polyps Histopathology

Uterine polyps are endometrial proliferation made up of connective, fibromuscular, glandular, and vascular components. Endometrial polyps have a predominantly vascular core and are superficially mainly covered by epithelial tissue. The three types of polyps are sessile, pedunculated, and prolapsing. Areas of squamous metaplasia, infection, or ulcers may be present in a prolapsed polyp. The endometrium that makes up the majority of polyps is distinct from the surrounding endometrium and does not react to cyclical hormonal changes. Other histological findings might be hyperplastic, atrophic, or carcinomatous.

 

What Causes Uterine Polyps?

Uterine polyps are small overgrowths of the stroma and glands that project from the endometrium. Endometrial polyps' precise pathogenesis is uncertain. Unopposed estrogen is thought to be a risk factor since endometrial polyps are connected to endometrial hyperplasia. Additional factors such as elevated endometrial aromatase activity, TGF-beta, VEGF, BCL-2, and genetics have also been linked to the development of polyps. Chronic tamoxifen medication is linked to endometrial abnormalities, including the growth of polyps, which affect 20% to 35% of females.

The bulk of polyps are benign, however, 0 to 12% of them can turn cancerous. The age and menopausal status of a patient are related to the malignancy of a uterine polyp. Malignant uterine polyps are more common in symptomatic postmenopausal women (4.5%), compared to asymptomatic postmenopausal women (1.5%). Age more than 60, big polyps, menopause phase, symptomatic bleeding, and polycystic ovarian syndrome (PCOS) are added risk factors for malignant uterine polyps.

 

Uterine Polyps Symptoms

The most typical sign of uterine polyps in patients is dysfunctional uterine bleeding. Patients may sometimes be asymptomatic. Pelvic pain, infertility, and abdominal pain are among additional symptoms that may be present. Endometrial polyps will be present in the cavity in one in four reproductive-age women who experience abnormal bleeding. It's crucial to establish the underlying cause, the degree of the abnormal uterine bleeding, any accompanying symptoms, and any coexisting conditions for every patient who has it. To rule out additional causes of irregular uterine bleeding, it is essential to have a thorough medical and surgical history. Although uterine polyps do not have a specific diagnostic bleeding pattern, a thorough history of the patient's bleeding pattern should be collected. Menorrhagia and spotting during the intermenstrual period are the most often observed patterns.

Tamoxifen, a medication frequently used to treat breast cancer, can either agonistically or antagonistically affect the tissue that has estrogen receptors. On breast tissue, tamoxifen has anti-cancer properties; nevertheless, it causes cancer in endometrial tissue. Endometrial polyp development has been linked to chronic tamoxifen use, with a 20% to 35% incidence. In addition, uterine polyps may develop as a result of hormone replacement therapy for menopausal symptoms, with signs like irregular bleeding and thicker endometrium on ultrasonography.

During the clinic visits, a bimanual examination and sterile speculum examination should also be done. To rule out any structural causes for the patient's symptoms, the cervix and vaginal vault should be thoroughly examined. From the external os, a pedunculated uterine polyp may be seen.

 

Uterine Polyps Differential Diagnosis

Other structural abnormalities of the uterine cavity are included in the differential diagnosis of an endometrial polyp.

• Intracavitary leiomyomas. Based on their ultrasound morphology (leiomyomas seem hypoechoic with shadowing versus polyps, which appear hyperechoic and homogeneous) and pattern of Doppler flow (leiomyomas show peripheral flow versus the appearance of a single supplying vessel in polyps), intracavitary leiomyomas can frequently be distinguished from an endometrial polyp. Additionally, when viewed with hysteroscopy, polyps and fibroids typically have different appearances. Polyps frequently have a beefy red appearance, are typically thinner and less probable to be sessile, and are soft and brittle when touched with an instrument. In some cases, a dilated gland can also be seen. Myomas, on the other hand, are firm, primarily white in appearance, and have surface blood vessels. Histology is used to make the final decision.
• Endometrial hyperplasia or carcinoma. While polyps are typically defined with hysteroscopy, unlike endometrial hyperplasia or neoplasia, only histology can rule out cancer.

 

Uterine Polyps Diagnosis

 

The most popular and effective method for imaging pelvic tissues is transvaginal ultrasonography. Endometrial thickening that is widespread or localized and echogenic may make ultrasonography findings appear unspecific. An atrophic endometrium is related to an endometrial thickness of less than 4 mm in patients who have postmenopausal bleeding symptoms. However, endometrial disease, including polyps, is associated with an increased endometrial thickness higher than 4 mm. The number, size, and location of the polyps are not related to the symptoms that have been reported.

Saline-infusion sonography (SIS) is an additional technique for assessing the endometrial cavity. During the proliferative phase of the menstrual cycle, a thin catheter is used to inject 5 to 30 mL of warmed saline into the uterine cavity. Polyps are more easily seen when fluid is used to define the mass. Pregnancy and active uterine or cervical infection are contraindications. SIS offers a more accurate assessment of the adnexa and cornua than transvaginal ultrasonography does. Additionally, by seeing the position in relation to the endometrial layer, SIS improves the distinction between submucosal fibroids and uterine polyps. A submucosal fibroid will be visible beneath the endometrial layer, and a polyp will be visible emerging from it. Hysteroscopic examinations or hysterosalpingograms are additional methods of evaluation.

More crucially, these techniques cannot diagnose tissue. A tissue sample should be taken into consideration because uterine polyps carry a risk of cancer. Endometrial biopsy, dilation and curettage (D&C), or hysteroscopic polypectomy must be performed to acquire tissue diagnosis. Endometrial polyps cannot be accurately diagnosed via blind tissue sampling with endometrial biopsy or D&C; hence these procedures should only be utilized when hysteroscopic removal is not feasible.

Investigating irregular uterine bleeding also takes into account laboratory testing. To rule out anemia and coagulopathy, investigations should include a urine pregnancy test, a complete blood count (CBC), and a coagulation profile.

 

Uterine Polyps Treatment

Uterine polyps can be treated conservatively with observation in low-risk, asymptomatic patients. If untreated, incidental uterine polyps may naturally regress. In one study, 29% of premenopausal patients' uterine polyps spontaneously disappeared after a year. Ultrasound-based periodic polyp growth assessment is part of conservative management. Hormonal treatment medical management receives scant support in the literature and is not currently advised.

 

Uterine Polyps Removal

Uterine polyps are generally treated with hysteroscopic polypectomy. Both the polyp and the surrounding mucosa should be investigated histologically since polyps may be linked to underlying endometrial disease. 20% of cases with an endometrial cancer diagnosis also had benign polyps. For asymptomatic and low-risk patients, it is uncertain when hysteroscopic polypectomy should be performed. It is uncertain when to undertake routine polypectomy in asymptomatic females, according to the results of a retrospective study conducted to identify the proper timing of polypectomy, which found no incidence of cancer on histologic specimens. Larger polyps that are bigger than 1.5 cm are less likely to go away on their own, therefore polypectomy may be an option for symptomatic patients.

A radical surgical procedure called a hysterectomy removes the risk of cancer and reduces the likelihood of polyp recurrence. Hysterectomy should only be considered after comprehensive patient counseling because it has a much higher risk for the patient and a higher cost. If a patient has anemia brought on by unusual uterine bleeding, daily iron supplementation may be an option.

 

Uterine Polyps Complications

The obtained specimens should be sent to pathology for analysis after hysteroscopic polypectomy. When specimen pathology is followed up, polyps may show signs of cancer, and a referral to gynecologic oncology is advised for further therapy. Hysteroscopic polypectomy rarely results in complications, and there is little chance of intrauterine adhesion.

On the association between uterine polyps and the risk of infertility, conflicting information is available. Hysteroscopic polypectomy before intrauterine insemination is an effective measure that increased conception rates, according to a prospective, randomized controlled trial. Additionally, compared to patients with open Fallopian tubes, infertile patients with blockage have a much higher prevalence of uterine polyps. However, a retrospective study of individuals who underwent in vitro fertilization (IVF) during IVF cycles despite knowing polyps did not reveal any differences in pregnancy, miscarriage, or live birth rates. Currently, it is advised by experts that uterine polyps be removed before in vitro fertilization.

 

Uterine Polyps Prognosis

Intermenstrual hemorrhage has been observed to significantly improve following hysteroscopic polypectomy. Patients who initially had fewer polyps present can receive treatment after hysteroscopic polypectomy with little recurrence. The recurrence rate in polyps with histological confirmation ranges from 2.5% to 3.5%. If hysteroscopic polypectomy is paired with endometrial ablation or the implantation of a levonorgestrel-releasing intrauterine device, recurrence rates are considerably reduced. But there isn't much evidence to back up these suggestions, and right now they are only used in research protocols. A levonorgestrel intrauterine device (IUD) has been demonstrated to reduce polyp formation in patients with tamoxifen-associated polyps and may be taken into account as part of the therapeutic strategy.

According to several research, hysteroscopic polypectomy led to higher rates of spontaneous pregnancy and term deliveries. Between patients with polyps smaller than or equal to 1 cm and patients with polyps larger than 1 cm or many polyps, there was no statistically significant difference in reproductive rates. There was no statistically significant difference in the spontaneous abortion rate in the first trimester of pregnancy between patients with small and larger/multiple polyps.

 

Conclusion

Although uterine polyps are frequent growths that can appear at any age, your risk may be highest in your forties. The most typical sign is unusual bleeding, while some patients have no symptoms at all. Since many of the symptoms of uterine polyps are similar to those of other disorders, a self-diagnosis is not possible. This is why you should consult a physician if you have any unusual bleeding, such as heavier or longer periods or vaginal bleeding following menopause. Polyps in the uterus can be surgically removed. However, in some circumstances, particularly in the extremely unlikely event that malignant cells are found, additional treatments may be necessary. These polyps may come back, so you should consider ongoing detection, risk-reducing or preventative measures, and treatment with your doctor.