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Practice Guidelines for the Diagnosis and Management of Endometrial Polyps

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Practice Guidelines for the Diagnosis and Management of Endometrial Polyps Special Article AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Endometrial Polyps AAGL ADVANCING MINIMALLY INVASIVE GYNECOLOGY WORLDWIDE ABSTRACT Endometrial polyps are a common gynecologic disease that may be symptomatic, with abnormal vaginal bleeding being the most common presentation. They may be found incidentally in symptom-free women investigated for other indications. Increasing age is the most important risk factor, with medications such as tamixifen also implicated. Specific populations at risk include women with infertility. Malignancy arising in polyps is uncommon, and specific risks for malignancy include increasing age and postmenopausal bleeding. Management may be conservative, with up to 25% of polyps regressing, particularly if less than 10 mm in size. Hysteroscopic polypectomy remains the mainstay of management, and there are no differences for outcomes in the modality of hysteroscopic removal. Symptomatic postmenopausal polyps should be excised for histologic assessment, and removal of polyps in infertile women improves fertility outcomes. Blind removal is not indi- cated where instrumentation for guided removal is available. Surgical risks associated with hysteroscopic polypectomy are low. Journal of Minimally Invasive Gynecology (2012) 19, 3–10 Ó 2012 AAGL. All rights reserved. Keywords: Endometrial polyp; Hysteroscopic management; Diagnosis of endometrial polyp; Malignancy in endometrial polyp; Diagnosis of endometrial polyp Use your Smartphone to scan this QR code DISCUSS You can discuss this article with its authors and with other AAGL members at http:// and connect to the www.AAGL.org/jmig-19-1-1768 discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace. Endometrial polyps are a localized endometrial intrauter- uterine bleeding [5,6] and less commonly infertility [7]. ine overgrowth that may be single or multiple, may measure Malignancy is uncommon and occurs in 0% to 12.9% of en- from a few millimeters to centimeters, and may be sessile or dometrial polyps, depending on the population studied [6]. pedunculated [1]. Endometrial polyps consist of endometrial glands, stroma, and blood vessels [2]. Risk factors for the de- Identification and Assessment of Evidence velopment of endometrial polyps include age, hypertension, obesity, and tamoxifen use [3,4]. Endometrial polyps may be This AAGL practice guideline was produced with the fol- asymptomatic [5], and when symptoms occur they most lowing search methodology; electronic resources including commonly include abnormal (including postmenopausal) Medline, PubMed, CINAHL, the Cochrane Library (includ- ing the Cochrane Database of Systematic Reviews), Current Contents and EMBASE were searched for all publications in The purpose of this guideline is to provide clinicians with evidence-based relation to Endometrial polyps (1951 to week 30 2010). The information about the management of endometrial polyps to guide the clinical management of this condition. MeSH terms included all subheadings and keywords Single reprints of AAGL Practice Report are available for $30.00 per Report. included ‘‘endometrial polyps,’’ ‘‘intrauterine pathology,’’ For quantity orders, please directly contact the publisher of The Journal of ‘‘endometrial polyp and malignancy,’’ ‘‘diagnosis of endo- Minimally Invasive Gynecology, Elsevier, at [email protected]. metrial polyps,’’ ‘‘management of endometrial polyps,’’ ‘‘in- Ó 1553-4650/$ -see front matter 2012 by the AAGL Advancing Minimally trauterine surgery,’’ ‘‘intrauterine pathology and infertility.’’ Invasive Gynecology Worldwide. All rights reserved. No part of this publica- tion may be reproduced, stored in a retrieval system, posted on the Internet, The search was not restricted to English language, with or transmitted, in any form or by any means, electronic, mechanical, photo- committee members fluent in languages other than English copying, recording, or otherwise, without prior written permission from the reviewing relevant publications and providing related infor- publisher. doi:10.1016/j.jmig.2011.09.003. mation to the committee, translated into English. The full Submitted August 18, 2011. Accepted for publication September 3, 2011. text of all publications was retrieved, abstracted, and tabu- Available at www.sciencedirect.com and www.jmig.org lated. Relevant publications were then reviewed and 1553-4650/$ - see front matter Ó 2012 AAGL. All rights reserved. doi:10.1016/j.jmig.2011.09.003 4 Journal of Minimally Invasive Gynecology, Vol 19, No 1, January/February 2012 Table 1 Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force I Evidence obtained from at least one properly designed randomized controlled trial. II-1 Evidence obtained from well-designed controlled trials without randomization. II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence. III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. On the basis of the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level AdRecommendations are based on good and consistent scientific evidence. Level BdRecommendations are based on limited or inconsistent scientific evidence. Level CdRecommendations are based primarily on consensus and expert opinion. additional references hand searched and added to the The prevalence of endometrial polyps appears to be Table 1. All studies were assessed for methodologic rigor increased in infertile women. In a large prospective trial and graded according to the classification system outlined including 1000 infertile women scheduled for invitro fertiliza- at the end of this document. tion, the prevalence of endometrial polyps was found to be 32% [7]. The high prevalence of endometrial polyps in Clinical Presentation infertile women suggests a causative relationship between Endometrial polyps are a common gynecologic disorder the presence of endometrial polyps and infertility. However, whose incidence is unknown because many polyps are asymp- a causal relationship between endometrial polyps and infertil- tomatic [8–11]. The prevalence is reported to be between 7.8% ity appears to have been confirmed in only one randomized to 34.9%, depending on the population studied [5,12–14]. trial [34]. Risk factors for the development of endometrial polyps Although uncommon, both atypical hyperplasia and include age, hypertension, obesity, and tamoxifen use [3,4]. endometrial cancer may originate from endometrial polyps. Increasing age appears to be the best-documented risk indica- The results of previous case series indicate that malignancy tor for endometrial polyps. The prevalence of endometrial occurs within 0% to 12.9% of endometrial polyps [14, polyps appears to increase by age during the reproductive 35–41]. Most authors agree that the risk of malignancy in years, but it is not clear whether it continues to rise or decreases endometrial polyps increases with age and that the risk of after menopause [5,14–18]. It is accepted that the evidence to malignancy in premenopausal women appears to be low. reliably arrive at this information is difficult to obtain. There The presence of symptoms (abnormal uterine bleeding) has appears to be an association between the finding of been identified as a possible risk indicator of malignancy endometrial polyps and other benign diseases including within endometrial polyps [37,39,42–44]. Polyp size also myomas, cervical polyps, and endometriosis [11,18–20]. appears to be a risk indicator for malignant endometrial Women using tamoxifen are at specific risk for develop- polyps [36,37]. Although the reports are not consistent, ment of polyps, with Class II studies reporting up to 30% other known risk factors for endometrial carcinoma, such to 60% prevalence [17,21–23]. Data regarding an eventual as obesity, diabetes mellitus, and hypertension have also relationship between hormone therapy and endometrial been reported to increase the risk of malignancy within polyps are contradictory, as some studies report higher endometrial polyps [14,40,45]. The use of tamoxifen prevalence of endometrial polyps in women using appears to increase the risk of atypical hyperplasia and hormone therapy [24,25], whereas others do not [26–30]. malignancy in endometrial polyps [3,45,46]. A progestogen with high antiestrogenic activity, as well as The knowledge regarding the natural history and clinical use of oral contraceptive pills may have a protective effect consequences of endometrial polyps without treatment is on the development of endometrial polyps [24,31]. The limited. In one class II study, 27% of the endometrial polyps use of the levonorgesterel-releasing intrauterine devices as regressed spontaneously during a 1-year follow-up [11]. a treatment for endometrial polyps or to prevent their devel- Polyps that regress tend to be smaller compared with polyps opment in a low-risk population has not yet been evaluated. that persist [11,47]. Most women with symptomatic endometrial polyps pres- ent with abnormal uterine bleeding, and this has
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