Polyps, Endometrial

Published on 10/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Polyps, Endometrial

Synonyms/Description

None

Etiology

Endometrial polyps are relatively common intrauterine lesions that are typically benign and often asymptomatic. Hyperplastic/proliferative polyp is the most common type of polyp; it represents overgrowth of endometrial glands and stroma. Clinically they can be associated with postmenopausal and abnormal uterine bleeding as well as infertility.

Ultrasound Findings

The ultrasound appearance of endometrial polyps varies depending on whether the patient is premenopausal or postmenopausal. In premenopausal women, the endometrium (especially in the secretory/luteal phase) can be thick and heterogeneous, which often camouflages the polyps. In the proliferative/follicular phase or in postmenopausal women, when the endometrium is at its thinnest, the polyps may be more obvious because of their rounded contour and different echotexture from the surrounding endometrium. Polyps appear as hyperechoic or cystic lesions within the uterine cavity. In most cases, there is evidence of blood flow in the polyp, as seen by color flow Doppler. The stalk of the polyp can often be identified by Doppler, revealing a single-vessel pattern and thus highlighting the connection between the polyp and the underlying endometrium.
A sonohysterogram is very helpful when evaluating the endometrial cavity because polyps may not be discernible from the rest of the endometrium unless outlined by fluid.

Differential Diagnosis

When the endometrium is thickened and heterogeneous and the patient is either postmenopausal or in the proliferative/follicular phase of her cycle, a sonohysterogram may be necessary to further define the finding. If there is a small mass within the cavity, the differential diagnosis is either a polyp or a submucosal fibroid. A polyp is usually more hyperechoic than the surrounding endometrium, or it may be partly cystic. A fibroid is likely to have the same echotexture as the myometrium. Rarely, an adenomyoma can present as an intracavitary mass (see Adenomyosis). It may be difficult to differentiate a nonglobal endometrial cancer, which appears polypoid, from a true polyp.

Clinical Aspects and Recommendations

Postmenopausal patients with nonbleeding polyps are not automatic candidates for polypectomy. If it is removed, it should be done hysteroscopically, because blind D&C often misses such focal lesions. Patients with abnormal or postmenopausal bleeding are always candidates for removal of their polyps.
Increasingly, it appears that patients with asymptomatic polyps discovered incidentally need not have them automatically removed. Fernandez-Parra and colleagues reported that none of the 117 polyps removed in asymptomatic postmenopausal women were malignant. Ferrazzi and colleagues report that there was one endometrial cancer (less than 0.1%) in a polyp among 1152 asymptomatic postmenopausal women in a multicenter trial. Furthermore, Gerber and colleagues report that the detection of endometrial cancer in asymptomatic postmenopausal patients does not confer a better outcome compared with cancer patients presenting with abnormal uterine bleeding. Finally, operative hysteroscopy in such postmenopausal patients is associated with a small but significant incidence of complications (e.g., perforation, false channel, anesthesia problems).

Figures

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Figure P5-1 A, Patient with thickened endometrium. B shows that when saline is introduced into the endometrial cavity, the polyps become visible (calipers on largest one).

 

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Figure P5-2 A, Thickened heterogeneous endometrium with focal echogenic area within the cavity. B and C show the smooth-walled polyp outlined by fluid during the sonohysterogram. D shows the blood flow to the polyp using color Doppler.

 

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Figure P5-3 Two different patients with small 10-mm polyps seen in 2-D and 3-D at the fundus of the uterus. Note the characteristic smooth, round appearance of the polyps. A and B show the polyps with 2-D and 3-D transvaginal sonography. C and D show the polyp of a different patient using sonohysterography and color Doppler.

 

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Figure P5-4 A and B, Small polyp (calipers) identified on 2-D transvaginal sonography. The diagnosis is confirmed by the presence of blood flow with a single-vessel pattern. C shows blood flow to a polyp in a different patient, demonstrating the similar vascular pattern.

 

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Figure P5-5 A and B, Tiny cystic polyp seen using 2-D and 3-D ultrasound, mimicking an early pregnancy. The patient was postmenopausal.

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Figure P5-6 Sonohysterography with 3-D ultrasound is an excellent way to demonstrate polyps. A and B show two different patients with polyps.

 

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Figure P5-7 A to D, Very large polyp shown in standard 2-D (A), sonohysterography (B), and 3-D sonography with saline in the uterine cavity outlining the polyp (C and D).

 

Suggested Reading

Fang L., Su Y., Guo Y., Yingpu Sun Y. Value of 3-dimensional and power Doppler sonography for diagnosis of endometrial polyps. Ultrasound Med. 2013;32:247–255.

Fernandez-Parra J., Rodriguez Oliver A., Lopez Criado S., Parrilla Fernandez F., Montoya Ventoso F. Hysteroscopic evaluation of endometrial polyps. Int J Gynaecol Obstet. 2006;95:144–148.

Ferrazzi E., Zupi E., Leone F.P., Savelli L., Omodei U., Moscarini M., Barbieri M., Cammareri G., Capobianco G., Cicinelli E., Coccia M.E., Donarini G., Fiore S., Litta P., Sideri M., Solima E., Spazzini D., Testa A.C., Vignali M. How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study. Am J Obstet Gynecol. 2009;200:235.

Gerber B., Krause A., Müller H., Reimer T., Külz T., Kundt G., Friese K. Ultrasonographic detection of asymptomatic endometrial cancer in postmenopausal patients offers no prognostic advantage over symptomatic disease discovered by uterine bleeding. Eur J Cancer. 2001;37:64–71.

Goldstein S.R. Sonography in postmenopausal bleeding. J Ultrasound Med. 2012;31:333–336.

Lieng M., Istre O., Qvigstad E. Treatment of endometrial polyps: a systematic review. Acta Obstet Gynecol. 2010;89:992–1002.

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