Guideline No. 447: Diagnosis and Management of Endometrial Polyps

Abstract

Objective

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps.

Target population

All patients with symptomatic or asymptomatic endometrial polyps.

Options

Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice.

Outcomes

Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp.

Benefits, harms, and costs

The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps.

Evidence

The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

Validation methods

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

Intended audience

Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows.

Tweetable Abstract

Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary.

SUMMARY STATEMENTS

• 1.Endometrial polyps are a common diagnosis in both pre- and postmenopausal patients (high).
• 2.Patients with endometrial polyps may present with abnormal uterine bleeding, postmenopausal bleeding, infertility, or may be asymptomatic (high).
• 3.Transvaginal ultrasound is associated with a wide range of accuracy in diagnosing endometrial polyps; however, it remains a good first-line investigation because of safety, availability, and patient acceptance (high).
• 4.In situations where the diagnosis of polyp on transvaginal ultrasound remains in question, consideration of saline-infused sonohysterography or 3D ultrasound, if available, can be considered as alternative diagnostic imaging techniques (moderate).
• 5.Hysterosalpingography, CT scanning, and MRI are not useful in the diagnosis of endometrial polyps (high).
• 6.Hysteroscopy with guided biopsy remains the gold standard for diagnosis of endometrial polyps (high).
• 7.Patients at highest risk for premalignant or malignant endometrial polyps are older (≥60y), postmenopausal, symptomatic with postmenopausal bleeding, and take tamoxifen (high).
• 8.Patients at intermediate risk of premalignant or malignant endometrial polyps are postmenopausal with no symptoms or premenopausal with abnormal uterine bleeding (moderate).
• 9.Polyp size alone has not consistently been associated with an increased risk of malignancy (low).
• 10.There are limited data to guide the management of patients with atypical or malignant pathology diagnosed within an endometrial polyp and normal or atrophic endometrium (low).
• 11.Hysteroscopic polypectomy is the most effective option for both diagnosis and treatment. The goals of hysteroscopy are three-fold: 1) complete resection, 2) minimize recurrence, and 3) obtain a pathology specimen (high).
• 12.Hysteroscopic polypectomy can be achieved using a variety of techniques and instruments, and it can be performed in different settings. Choice of polypectomy technique should consider the following: patient factors, local access to instruments and operating room time, setting, fluid management, cost, and surgeon preference (low).
• 13.Risks related to hysteroscopic polypectomy are estimated to occur in less than 3% of cases and should be discussed with the patient (high).
• 14.Endometrial polyps of any size treated with hysteroscopic polypectomy appear to improve pregnancy outcomes among those who conceive naturally or with intrauterine insemination (high).
• 15.Management of a newly diagnosed polyp during in vitro fertilization stimulation is influenced by patient prognosis, number of freezable embryos, laboratory-specific frozen embryo success rates, and accessibility of hysteroscopy (moderate).
• 16.There appears to be an association between endometrial polyps and recurrent pregnancy loss, but to date, data supporting polypectomy to reduce the risk of subsequent pregnancy loss is lacking (low).

RECOMMENDATIONS

• 1.Transvaginal ultrasound should be used as initial investigation in patients suspected to have endometrial polyps (strong, high).
• 2.Patients who present with features suspicious for endometrial polyps and who would benefit from subsequent polypectomy should be directed toward hysteroscopy, with a plan for operative management should a polyp be diagnosed (strong, moderate).
• 3.Blind sampling to diagnose endometrial polyps via endometrial biopsy or dilation and curettage should not be performed (strong, high).
• 4.Patients with endometrial polyps who are older (≥60 y), menopausal, have symptoms of postmenopausal bleeding, or are taking tamoxifen should be referred to a gynaecologist for further investigation and consideration of polyp resection (strong, high).
• 5.Referral to a gynaecologist can be considered in premenopausal patients who are symptomatic or attempting to conceive. (conditional, moderate).
• 6.A gynaecologic oncologist should be involved in managing the care of patients with premalignant or malignant lesions confined to an endometrial polyp, particularly in cases of uterine preservation (strong, low).
• 7.Expectant management can be considered for asymptomatic patients and those with a low risk of malignancy (conditional, moderate).
• 8.Polypectomy should be performed via direct hysteroscopic visualization, as this approach decreases the risk of complications, incomplete removal, and recurrence (strong, high).
• 9.Bipolar energy should be used preferentially over monopolar energy, as it reduces the risk of electrosurgical burns and fluid overload. Tissue removal systems also reduce the risk of fluid overload and avoid the risk of electrosurgical burns altogether but have functional and cost limitations (strong, high).
• 10.Patients diagnosed with an endometrial polyp should be offered hysteroscopic resection to improve their fertility potential if they are experiencing infertility, regardless of polyp size (strong, high).
• 11.When a new endometrial polyp is diagnosed during in vitro fertilization stimulation, the following options should be discussed with the patient: 1) cycle cancellation, 2) freeze-all, and 3) transfer. There is no evidence to support need to cancel the cycle (conditional, low).