Are Endometrial Polyps Overtreated?

This article offers a good overview of endometrial polyps and treatment options.

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A "watch and wait" course of action for patients diagnosed with endometrial polyps may be the best course of action, recent studies show:
 
Endometrial polyp
From Wikipedia, the free encyclopedia
 
An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus.[1] They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle(pedunculated).[1][2] Pedunculated polyps are more common than sessile ones.[3] They range in size from a few millimeters to several centimeters.[2] If pedunculated, they can protrude through the cervix into the vagina.[1][4] Small blood vessels may be present, particularly in large polyps.[1]
 
No definitive cause of endometrial polyps is known, but they appear to be affected by hormone levels and grow in response to circulating estrogen.[2] They often cause no symptoms.[3] Where they occur, symptoms include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual bleeding (menorrhagia), and vaginal bleeding after menopause.[2][5] Bleeding from the blood vessels of the polyp contributes to an increase of blood loss during menstruation and blood "spotting" between menstrual periods, or after menopause.[6] If the polyp protrudes through the cervix into the vagina, pain (dysmenorrhea) may result.[4][edit]Cause and symptoms
 
Diagnosis
Endometrial polyps can be detected by vaginal ultrasound(sonohysterography), hysteroscopy and dilation and curettage.[2]Detection by ultrasonography can be difficult, particularly when there is endometrial hyperplasia (excessive thickening of the endometrium).[1] Larger polyps may be missed by curettage.[7]
 
Treatment
Polyps can be surgically removed using curettage with or without hysteroscopy.[8] When curettage is performed without hysteroscopy, polyps may be missed. To reduce this risk, the uterus can be first explored using grasping forceps at the beginning of the curettage procedure.[6] Hysteroscopy involves visualising the endometrium (inner lining of the uterus) and polyp with a camera inserted through the cervix. If it is a large polyp, it can be cut into sections before each section is removed.[6] If cancerous cells are discovered, a hysterectomy (surgical removal of the uterus) may be performed.[2] A hysterectomy would usually not be considered if cancer has been ruled out.[6] Whichever method is used, polyps are usually treated under general anesthetic.[7]
 
Prognosis and complications
Endometrial polyps are usually benign although some may be precancerous or cancerous.[2] About 0.5% of endometrial polyps contain adenocarcinoma cells.[9] Polyps can increase the risk of miscarriage in women undergoing IVF treatment.[2] If they develop near the fallopian tubes, they may lead to difficulty in becoming pregnant.[2] Although treatments such as hysteroscopy usually cure the polyp concerned, recurrence of endometrial polyps is frequent.[6] Untreated, small polyps may regress on their own.[10]
 
Risk factors and epidemiology
Endometrial polyps usually occur in women in their 40s and 50s.[2] Risk factors include obesity, high blood pressure and a history of cervical polyps.[2] Taking tamoxifen or hormone replacement therapy can also increase the risk of uterine polyps.[2][11] The use of an IntraUterine System containing levonorgestrel in women taking Tamoxifen may reduce the incidence of polyps.[12] Endometrial polyps occur in up to 10% of women.[1] It is estimated that they are present in 25% of women with abnormal vaginal bleeding.[11]
 
 
"A metaanalysis of women who have had polypectomies suggests that postmenopausal status and abnormal bleeding are negatively associated with endometrial neoplasia. However, a second prospective analysis of patients diagnosed with polyps who were referred for follow-up rather than immediate intervention suggests that "watch and wait" might be the most prudent course in a majority of cases. Both studies were reported here at the American Institute of Ultrasound in Medicine (AIUM) 2011 Annual Convention.
 
"Everyone in this room knows that with the advent of high-resolution, unenhanced transvaginal sonography, as well as saline infusion sonography and hysteroscopy, we're diagnosing a lot more polyps then we have in the past," said Andrew Kaunitz, MD, from the Department of Pathology, University of Florida College of Medicine, Jacksonville.
 
The majority of these polyps are benign. However, the small number of polyps that are malignant might be influencing how the majority of diagnosed polyps are being treated. "We are often asked by a patient or referring colleague: What's the chance this given polyp is cancerous? And the related question: Is removal necessary?"
 
In an attempt to answer these questions by determining a stratified risk profile for this patient population, Dr. Kaunitz and lead investigator Stephanie Lee, MD, performed a metaanalysis of reports published from 1980 to 2010. Articles for this analysis were selected on the basis of the inclusion of women who had undergone polypectomy and who had tissue analysis. The primary end point of the metaanalysis was to compare the prevalence of endometrial neoplasia among pre- and postmenopausal women; the secondary end point compared the prevalence of neoplasias in women who had abnormal bleeding with the prevalence in women who were asymptomatic at the time of their procedure.
 
A total of 17 articles were selected for review, representing a patient population of 10,572 women. Metaanalysis revealed that 377 women were identified as having endometrial neoplasia. Of these, 5.4% were postmenopausal and 1.7% were premenopausal; 4.2% of these women had experienced symptoms of bleeding, whereas 2.2% were asymptomatic. "Women who were menopausal with polyps had an almost 4-fold higher likelihood of that polyp being malignant than when polyps were diagnosed in reproductive-aged women," said Dr. Kaunitz. Correspondingly, a polyp was 2-fold more likely to be malignant in women with bleeding than in those who were asymptomatic.
 
The authors hope that there is now a bit more clarity about which polyps can wait and which might require immediate attention.
 
What Happens When You Watch and Wait?
 
In a second presentation here, Alex Hartman, MD, from True North Imaging in Thornhill, Ontario, Canada, reported on a study that looked at women who had been diagnosed with endometrial polyps and who received no intervention at the time of diagnosis but who were referred for follow-up.
 
From January to July of 2010, Dr. Hartman examined 300 women who had been diagnosed with endometrial polyps in the previous 2 to 43 months. The women ranged in age from 22 to 78 years. Factors considered in this analysis were location of polyp, time interval between studies, menopausal status, abnormal bleeding, blood flow, endometrial thickness, and patient age.
 
Results of these examinations showed that in 41 (13.7%) of these women, the polyp had naturally resolved; in 125 (41.7%), there was no change in polyp size; in 61 (20.3%), there was a decrease of at least 1 mm; in 49 (16.3%), there was an increase of greater than 50% of the originally measured polyp diameter; and in 24 (8.0%), there was a greater than 50% increase in polyp diameter.
 
Change in polyp size was significantly associated with menopausal status and blood flow, but not with polyp location or abnormal bleeding. Further, there was no statistical association between polyp progression and patient age, time between scans, or endometrial thickness. Although Dr. Hartman acknowledged that his patient cohort was effectively chosen by the treatment preferences of his referring doctors, he concluded that "automatic treatment of benign-appearing endometrial polyps is a practice that at least should be reevaluated."
 

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4 comments on “Are Endometrial Polyps Overtreated?
  1. Margaret w Bailey taylor says:

    Question: I had a polyp two years ago. It was diagnosed w US using uterine fluid infusion for visualization. An endometrial bx was done. Though negative for ca, I received a hysteroscope/D&C. Path results were negative for ca though a polyp was seen and removed. Then a year ago ( nearly to the the same annual date ) another situation of a polyp occurred. I refused in office bx due to prior severe pain with that process, though an US showed thickening of the endometrium. I was treated again as the year before, with a negative path report though again a polyp via the hysteroscope was seen and removed. Now another year later, I am bleeding. I am scheduled for an US. The GYN feels another polyp or re growth has probably occurred. In reading up on articles, it appears high estrogen levels might contribute to the development of uterine polyps. I am overweight and am treated successfully for HTN. Recently, I started actively doing exercise and watching my fat and caloric intake. I have lost 7 lbs in just over three weeks. Are estrogen levels high because I am heavy or is this part of being post menopausal? I am 68, stopped menses around age 50. I am curious if I can help myself with polyp reoccurrence or not. Are high estrogen levels needing/or can they even be reduced, if the cause for polyps or does weight etc enhance increased estrogen in of itself. I was always small-some thought I looked too thin and I ate robustly. Once I got passed menopause I have struggled gaining more each year. I have yoyo’ed with dieting, so am hoping this time I can prevail.

  2. Hi Margaret-

    First of all, thanks for reaching out. Our exchange on PBC will educate others. Your example of regular check-ups and polyp removal will reduce the risk of future cancer.

    Research indicates that being 15 years past menses puts you in menopause and should reduce your body’s estrogen production not increase it.

    Further, your research/reading up on your situation seems to be on target all around. Yes, menopause causes weight gain as well as hypertension. You are correct to moderately exercise. Losing 7 lbs in three weeks is awesome. You are on the right track.

    WebMD’s discussion should be helpful-http://www.webmd.com/menopause/guide/menopause-weight-gain-and-exercise-tips

    The key to not yo-yo is to get into a habit of moderate exercise. Please read “The Power of Habit” by Charles Duhigg.

    Please confirm with your doctor but I think you can “help myself with polyp recurrence” by managing your weight and hypertension.

    Let me know if you have any questions- good luck!!!

    Thanks

    David Emerson

    “Causes of uterine polyps

    Uterine polyps are similar to uterine fibroids, most likely developing due to an imbalance of the hormone estrogen. Excess endometrial tissue develops in response to estrogen, causing soft uterine polyps to grow from the uterine lining. Polyps are more frequently seen in perimenopausal or postmenopausal women, but can occur in younger women as well.

    Uterine polyps are more common in women with high blood pressure (hypertension), who are overweight, or who are taking tamoxifen (a medication used for treating breast cancer).”

    Read more at http://trmbaby.com/for-patients/library/conditions/polyps/#jsyISc1ogRX6jYtQ.99

  3. Gee says:

    This is an eye opener for me. In 2011 I had a polyp removed and now i discovered it has recurred again. The doctor says he will carry out the same procedure as well as run more fertility tests to ensure everything is okay since I am also trying to conceive.
    However a previous check by a different doctor had shown my fallopian tubes were okay and had not blocked.

    I am however sceptical about all this tests and surgery (hysteroscopy) and I wanted to know if theres a need to also do the fertility tests or if removal of the polyp is all I need. I feel as if the doctor could be misguiding me since the surgery for polyp removal is really expensive for me right now and any additional tests for fertility may be even more expensive. Please give me your thoughts which I will highly appreciate.

    Gee

    • Hi Gee-
      I don’t mean to sound wishy-washy but everything has risks and benefits. I don’t believe that doctors purposely mislead. I think that recommendations are all based on percentage risks. The article outlines the risks so you have access to some basic information. Consider asking the doctor who wants to do fertility tests what the possible outcomes will be with and without the testing. I have always found drs to be hardworking clinicians but asking the right question helps both dr. and patient to understand the risks and benefits of any procedure. Let me know if you have any other questions. Thanks. David

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