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Endometrial polyps

What's new

Added 2024 SOGC, 2018 ESHRE, 2016 RCOG/BSGE, and 2012 AAGL guidelines for the diagnosis and management of endometrial polyps.

Background

Overview

Definition
Endometrial polyps are generally benign focal overgrowths of endometrial tissue projecting into the uterine cavity.
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Pathophysiology
The pathophysiology of endometrial polyps is not fully understood. However, hormonal imbalances and inflammation may play a role in the development. Genetic mutations, such as those in the RAS genes, have also been implicated in the formation of endometrial polyps.
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Epidemiology
The prevalence of endometrial polyps ranges from 7.8% to 47.8%, depending on the definition and population studied, with higher prevalence observed among older women and in patients with a history of tamoxifen use, infertility, or endometriosis.
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Risk factors
Risk factors for endometrial polyps include advanced age, postmenopausal state, and a history of tamoxifen use. Hypertension and obesity are also associated with an increased risk of endometrial polyps.
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Disease course
Clinically, endometrial polyps often present with abnormal uterine bleeding or postmenopausal bleeding, and in some cases, they may be associated with infertility. Endometrial polyps can also be asymptomatic, identified incidentally on imaging.
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Prognosis and risk of recurrence
Most endometrial polyps are benign. However, there is a small risk of malignancy, with estimates ranging from 0.5 to 4.8%. Advanced age (≥ 60 years), postmenopausal state, the presence of postmenopausal bleeding, and history of tamoxifen use increase the risk of malignancy. Histological features such as atypia within the polyp can also indicate a higher risk of malignancy.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of endometrial polyps are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2024), the American College of Obstetricians and Gynecologists (ACOG/AAGL 2020), the European Society of Human Reproduction and Embryology (ESHRE 2018), the British Society for Gynaecological Endoscopy (BSGE/RCOG 2016), and ...
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Classification and risk stratification

Risk of malignancy: as per SOGC 2024 guidelines, recognize that patients with the following are at highest risk for premalignant or malignant endometrial polyps:
age ≥ 60 years
postmenopausal state
postmenopausal bleeding
taking tamoxifen.
A
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Diagnostic investigations

Transvaginal ultrasound
As per SOGC 2024 guidelines:
Obtain transvaginal ultrasound as initial evaluation in patients with suspected endometrial polyps.
A
Consider obtaining saline-infused sonohysterography or 3D ultrasound, if available, as alternative imaging modalities in cases where the diagnosis of polyp on transvaginal ultrasound remains in question.
C

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  • Other imaging modalities

Diagnostic procedures

Hysteroscopy and biopsy: as per SOGC 2024 guidelines, offer hysteroscopy in patients presenting with suspected endometrial polyps who would benefit from subsequent polypectomy, with a plan for operative management if a polyp is diagnosed.
B
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  • Dilation and curettage

Medical management

Expectant management: as per SOGC 2024 guidelines, consider offering expectant management in asymptomatic patients and patients at low risk for malignancy.
C

Surgical interventions

Hysteroscopic polypectomy, indications
As per SOGC 2024 guidelines:
Offer hysteroscopic polypectomy to improve reproductive outcomes in patients attempting unassisted conception, ovulation induction, or mild ovarian stimulation.
B
Offer hysteroscopic polypectomy to improve fertility outcomes in patients planning intrauterine insemination.
B

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  • Hysteroscopic polypectomy (technical considerations)

Specific circumstances

Patients undergoing assisted reproduction technologies: as per SOGC 2024 guidelines, discuss the following options with the patient when a new endometrial polyp is diagnosed during IVF stimulation,
B
with the choice depending on patient prognosis, number of freezable embryos, laboratory-specific frozen embryo success rates, and accessibility of hysteroscopy:
B
cycle cancellation
freeze-all
transfer.
B

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  • Patients with endometrial hyperplasia

Follow-up and surveillance

Indications for referral: as per SOGC 2024 guidelines, refer patients with endometrial polyps and any of the following to a gynecologist for further evaluation and consideration of polyp resection:
age ≥ 60 years
postmenopausal state
postmenopausal bleeding
taking tamoxifen.
A
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