EEndometrial polyps (EPs) are a common cause of abnormal uterine bleeding (AUB) in perimenopausal and

postmenopausal women and are typically suggested by a screening transvaginal ultrasound. In addition,

the increasing use of pelvic imaging often discloses asymptomatic EPs. In the past, saline infusion sonogra-

phy (SIS) has been advocated in order to triage patients to undergo a blind curettage or a diagnostic or opera-

tive hysteroscopy.

The introduction of small diameter hysteroscopes and resectoscopes—often no larger than a SIS catheter—now

allows most women with abnormal ultrasound findings to undergo a single-stage “see-and-treat” hysteroscopy

for the management of endometrial polyps. In order to provide optimal management of endometrial polyps,

however, a variety of known and unknown factors must be considered prior to “see-and-treat” hysteroscopy.

For a woman wishing to preserve or enhance her fertility, hysteroscopic polypectomy—with care to avoid

collateral endometrial damage—remains the standard of care.

However, the literature reveals three issues that are important to address. First, that many premalignant and

malignant lesions are found at the polyp base. Second, that there is a significant recurrence risk following

simple polypectomy; this is especially true in tamoxifen-treated women. Third, that polypectomy alone is often

insufficient for the satisfactory management of AUB.

By offering a variety of options to women undergoing hysteroscopic polypectomy—including partial or total

endomyometrial resection—the author addresses many of the limitations of traditional polypectomy.

Moreover, the use of small diameter hysteroscopes and resectoscopes allow these procedures to be performed

as a single stage “see-and-treat” hysteroscopy in the comfort and safety of an office-based setting.

“See-and-Treat” Hysteroscopy in theManagement of Endometrial Polyps

MORRIS WORTMAN, MDCLINICAL ASSOCIATE PROFESSOR

GYNECOLOGY AND OBSTETRICS DEPARTMENTUNIVERSITY OF ROCHESTER MEDICAL CENTER

ROCHESTER, NY

DIRECTORCENTER FOR MENSTRUAL DISORDERS

ROCHESTER, NY

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ABSTRACT

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Endometrial Polyps (EP) are com-monly associated with abnormal pre-and post-menopausal bleeding, infertili-ty, as well as pre-malignant and malig-nant intrauter ine lesions. Manyasymptomatic polyps are discovered asincidental findings during imaging stud-ies. Histologically speaking, an EP is ahyperplastic overgrowth of endometrialglands and stroma around a vascularcore. Hysteroscopically, polyps appearas nodular or fingerlike projections ofvarying dimensions that occur in anyportion of the endometrial cavity. EPscan be single or multiple, sessile, orpedunculated and are generally coveredwith a smooth endometrial layer (Fig.1), though they are sometimes sur-rounded by a delicate vascular lattice-

work (Fig. 2). Polyps vary from severalmillimeters to several centimeters,occasionally prolapsing through thecervix becoming grossly indistinguish-able from those of endocervical origin.While the cause and pathogenesis ofendometrial polyps is incompletelyunderstood, they are believed to be arisk factor for the development ofhyperplastic changes of the endometri-um as well as endometrial cancer.1The evaluation and management of

endometrial polyps is the subject of anevolving debate as knowledge and tech-nology advance. The advent of smalldiameter hysteroscopes (SDHs), resec-toscopes, and morcellators enablephysicians to manage most EPs in eitheran outpatient or office setting. Theauthor has over 28 years of operativehysteroscopy experience—much of it inan accredited office-based surgery set-

ting in Rochester, New York. Ourapproach has been to minimize the stepsnecessary to diagnose and treat EPsincorporating a “see-and-treat”approach.2 This paper will review ourcurrent understanding of EPs and sum-marize the factors that determine ourindividualized approach to treating thiscommon gynecologic lesion.

Risk Factors

Endometrial polyps are estrogen-sensitive neoplasms whose prevalenceincreases with age, hormone replace-ment therapy, infertility, and tamoxifenuse.3-6 Obesity appears to be an inde-pendent risk factor for EPs even whencontrolled for serum estradiol levels.Onalan et al.7 studied 263 women who

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INTRODUCTION

Figure 3. Good example of polyp with stromal congestion and apical necrosis. Figure 4. Polyp containing complex hyperplasia with atypia.

Figure 1. Endometrial polyp arising from left uterine cornua. Figure 2. Sessile endometrial polyp surrounded by a latticework of vessels.

RISK FACTORS

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underwent office hysteroscopy prior toin vitro fertilization and discovered thatwomen with a BMI > 30 had a greaternumber of endometrial polyps com-pared to those with a BMI < 30.

Clinical Presentation and Epi-demiology

Although many EPs are asympto-matic, they are generally found in theevaluation of abnormal uterine bleedingor infertility. Polyp-related bleeding isthought to result from stromal conges-tion causing venous stasis and apicalnecrosis (Fig. 3). The reported preva-lence of endometrial polyps varies from7.8–34.9% depending on the diagnosticmethod employed, the populationunder study, and the histologic criteria.3Valle8 observed that endometrial polypsaccount for 39% of all abnormal vaginalbleeding in premenopausal women.Among postmenopausal women, polypsare responsible for 21–28% of all causesof uterine bleeding.8,9

Risk of Malignancy

The majority of endometrial polypsare benign, but have the potential tobecome hyperplastic and even malig-nant. Ben-Arie et al.10 reviewed 430consecutive cases of hysteroscopicpolypectomies and reported complexhyperplasia in 11.4%, atypical complexhyperplasia (Fig. 4) in 3.3%, and carci-noma in 3.0%. The greatest potentialfor malignancy appears to be in sympto-matic, post-menopausal women and inpolyps greater than 1.5 cm long.10,11Savelli et al.12 noted that, in addition toage and menopausal status, hyperten-sion appears to be an independent riskfactor for malignancy. Lastly, the use oftamoxifen is associated with anincreased probability of malignancywithin EPs.6

The Diagnosis of EndometrialPolyps—The Present Paradigm

Transvaginal ultrasound (TVUS) isoften employed in the initial evaluationof abnormal uterine bleeding (AUB) orinfertility. In Scandinavian countries,

routine sonography has already beenadopted as part of a woman’s annualexamination13—a practice that may wellgain widespread acceptance. Sonograph-ic findings that suggest an EP include anechogenic halo or a thickened tear-drop-shaped hyperechoic lesion (Fig. 5).Other sonographic findings include cys-tic spaces, and—in the presence ofblood—an auto-generated sonohystero-gram. While TVUS provides a minimal-ly invasive and inexpensive screening

tool,14 it is insufficient for differentiat-ing thickened endometrium from otherintrauterine lesions. Although a negativeultrasound finding may be helpful inevaluating women with AUB, the pres-ence of endometrial thickening, or aheterogeneous endometrial echo,requires additional assessment—salineinfusion sonography (SIS), or diagnostichysteroscopy.14,15Several authors15-17 have advocated

SIS to distinguish diffuse endometrial

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Figure 5. Tear-drop shaped endometrial echo in a woman with postmenopausal bleeding.

Figure 6. Office set-up for “see-and-treat” hysteroscopy.

CLINICAL PRESENTATION AND EPIDEMIOLOGY

RISK OF MALIGNANCY

THE DIAGNOSIS OF ENDOMETRIALPOLYPS—THE PRESENT PARADIGM

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thickening from other intrauterinepathology. While SIS provides signifi-cant information regarding the size andattachment points of an intrauterinelesion, it is often painful, does not reli-ably distinguish EPs from submucousleiomyomas, and is insufficient for sort-ing out the complexities generated bymultiple EPs or the coexistence ofpolyps and submucous leiomyomas.These limitations render SIS as simplyanother triage tool15-17 whose role islimited to determining whether or not aspecific case can be managed with ablind endometrial biopsy or will requirea diagnostic— and possibly operative—hysteroscopy in an outpatient or officesetting.

From TVUS to “See-and-Treat”Hysteroscopy—A New Paradigm

While the role of SIS could be justi-fied in an era of large diameter hys-teroscopes, its current place ingynecology deserves thoughtful re-examination given the proliferation ofsmall diameter hysteroscopes (SDHs)that offer considerably more informa-tion in an office setting. By substitutinga SDH (< 5 mm) for a similarly-sizedSIS catheter, the operator can easilydistinguish thickened endometriumfrom EPs or submucous leiomyomasand gain essential information in devel-oping a management strategy. Theadditional data supplied by hys-teroscopy includes an understanding ofthe number and type of EPs, the loca-tion and nature of their attachmentpoints, and the degree to which theuterine surface area is involved. Addi-tionally, the coexistence of leiomyomasand the presence of significant intraop-erative challenges—such as relativecervical stenosis, a deep uterine sep-tum or a cornual polyp (Fig. 1)—canbe readily identified. The wealth ofinformation afforded by SDHs make ita superior triage tool allowing us todecide whether a patient requires addi-tional counseling prior to offering asurgical management strategy or if wecan proceed directly to surgical thera-py at the time of diagnosis. “See-and-treat” hysteroscopy in an

office setting requires (1) the trainingand credentialing necessary to admin-ister appropriate analgesia and seda-tion, (2) a large array of specialized

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Figure 7. Array of resectoscopes from 4.3 to 9.7 mm diameter.

Figure 8. The use of a 13 Fr resectoscope in a postmenopausal uterus.

Figure 9. Treatment of an isolated endometrial polyp with care to minimize collateral thermal damage.

FROM TVUS TO “SEE-AND-TREAT” HYS-TEROSCOPY—A NEW PARADIGM

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instrumentation—including smalldiameter resectoscopes (SDRs)—tomanage a broad range of intraoperativescenarios, and (3) experience in opera-tive hysteroscopy in a more traditionalambulatory surgical setting. The “see-and-treat” approach, in a properly edu-cated and prepared patient, allows usto proceed seamlessly from diagnosticto operative hysteroscopy, providingmanagement in the comfor t of anoffice environment with the fewestnumber of interventions.

Operating Room Equipmentand Set-Up for “See and Treat”Hysteroscopy

Nearly all of our procedures arecarried out in an accredited office-based surgery center as required byNew York State Public Health Law andin compliance with the policies andguidelines issued by The AmericanCongress of Obstetricians and Gyne-cologists and the American Society ofAnesthesiologists.18 Our operatingroom set up for “see-and-treat” hys-teroscopy is identical to what theauthor has previously described foroperative hysteroscopies in an office-based setting (Fig. 6).18,19 In additionto the commonly used hysteroscopesand resectoscopes that are found inmost ambulatory surgery centers, wehave an array of bipolar and unipolarresectoscopes of assorted dimensionsthat are able to accommodate a largevariety of different clinical scenarios.While many hysteroscopic polypec-tomies can be safely performed with-

out ultrasound guidance (USG), theuse of sonography proves indispens-able when dealing with the small,hypoplastic uterus or in unanticipatedcases of marked cervical stenosis. Inaddition, USG dramatically improvesthe safety of more aggressive resecto-scopic surgery19 and is essential if aconcomitant endomyometrial resec-tion is anticipated.The management of endometrial

polyps in postmenopausal women hasbeen greatly facilitated by the additionof a small-diameter resectoscope(SDR) that is 4.3 mm in diameter x23 cm long. Additionally, we haveresectoscopes that vary from 7.0 to9.7 mm in diameter and from 35 to 43cm in length (Fig. 7). This large vari-ety allows us to manage a wide varietyof clinical scenarios.The importance of SDRs for man-

aging endometrial polyps cannot beoverstated. The challenges of the post-menopausal uterus are three-fold.First, the cervix is often stenotic andprecludes the introduction of conven-tional resectoscopes (22-26 Fr). Sec-ond, the uterine cavity is typicallysmall, restr ict ing one’s abi l i ty tomanipulate larger resectoscopes.Third, the myometrial layer is typicallythin, thereby increasing the risk ofuterine perforation or rupture. Wehave enjoyed great success utilizing a13 Fr (4.3 mm) x 23 cm pediatricresectoscope (Karl Storz Endoscopy,Culver City, California) that allows usto explore and operate within the con-f ines of a small postmenopausaluterus. Figure 8 illustrates the removalof an asymptomatic 15 mm polyp inthe uterus of a 77-year-old woman.

The Limitations of Hystero-scopic Polypectomy

Prior to undergoing hysteroscopicpolypectomy as part of a “see-and-treat”management scheme, the physician andpatient should discuss the following limi-tations of hysteroscopic polypectomy.First, endometrial polyps have a sig-

nificant recurrence risk.20-24 Preutthipanet al.20 and Yang et al.21 describe therecurrence risk of EPs in pre-menopausalwomen to vary from 15-43% respective-ly following hysteroscopic polypectomy.Second, hyperplastic changes within thepolyp are often located at its base. Lienget al.13 noted that “in about one third ofthe patients with hyperplasia with atypiaand malignancy, the tissue changes wereconfined to the endometrial biopsy spec-imens from the base of the polyp.” Lienget al.13 concluded that it was “beneficialto remove the basis of the endometrialpolyp to detect and prevent early prema-lignant and malignant changes in theendometrium.” Third, removing thepolyp or polyps may not entirely resolvesymptoms of AUB. Nagele et al.25 andHenriquez et al.26 demonstrated that40–60% of women respectively, whounderwent hysteroscopic polypectomyfor AUB, required additional treatmentfor persistence or recurrence of symp-toms within several years.The high failure rate of hysteroscopic

polypectomy, in treating AUB, suggeststhat in symptomatic premenopausal, andeven postmenopausal women, additionaltherapy may often be appropriate. Hen-riquez et al.26 suggests that outcomes fol-lowing hysteroscopic polypectomy canbe improved by the insertion of a lev-onorgestrel-releasing intrauterine deviceor by performing a concomitantendometrial ablation. Both Gao et al.27and Goldenberg et al.28 were able toreduce the incidence of surgical re-inter-vention by performing endometrial abla-tion at the time of hysteroscopicpolypectomy.

Preoperative Counseling Prior to the“See-and-Treat” Hysteroscopy—Knowns and Unknowns

Patient counseling prior to “see andtreat” hysteroscopy can be complex and isinfluenced by a variety of surgical“knowns” and “unknowns” that determine

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Figure 10. Right cornual endometrial polyp with apical necrosis.

OPERATING ROOM EQUIPMENT ANDSET-UP FOR “SEE AND TREAT”

HYSTEROSCOPY

THE LIMITATIONS OF HYSTEROSCOPICPOLYPECTOMY

PREOPERATIVE COUNSELING PRIOR TO THE“SEE-AND-TREAT” HYSTEROSCOPY—

KNOWNS AND UNKNOWNS

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the optimal management for a particu-lar woman—these items are summa-rized in Table I. It must be understood,however, that not all patients withabnormal ultrasound findings can bemanaged with a “see-and-treat”approach, but whenever possible thismodality is presented in order to mini-mize unnecessary re-interventions.In order to simplify preoperative

counseling following an ultrasoundexamination that warrants fur therinvestigation, we ask women to consid-er three different intraoperative sce-narios at the time of hysteroscopy.

I. Diffuse endometrial thickening withouta discovery of polyps or fibroids. Notall diffuse endometrial thickeningfound on TVUS turns out to be anabnormal intrauterine structure.In the absence of polyps orfibroids, our goal is generally toobtain an adequate volume of tis-sue for diagnosis. We generallyperform suction curettage with asmall diameter Vacurette—6 mmor smaller—to obtain sufficienttissue for diagnosis. For womenwho have completed their child-bearing and have failed to respondto medical therapy for AUB, it maybe appropriate to discuss minimal-ly invasive procedures such asendomyometrial resection.29

II. Isolated endometrial polyp or smallgrade 0 submucous leiomyoma. Themanagement of an isolated polypor fibroid is fairly straightforwardin a woman wishing to retain herfertility—the goal is simply toremove the structure while mini-mizing any collateral damage tothe adjacent endometrium.Figure 9 depicts a 37-year-old nul-ligravid woman who is about toundergo an excision of an isolatedEP with care to avoid collateralthermal injury to the adjacentendometrium.Collateral damage may be obviatedby utilizing an inactive loop elec-trode at the polyp—or myoma—base or by substitutinghysteroscopic scissors andgraspers. If appropriate, the patientshould be given the choice to havea levonorgestrel-containing IUDinserted immediately following herprocedure in order to prevent fur-ther bleeding symptoms, particu-larly if they are inconsistent with

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Figure 11 a, b. Resection of endometrial polyp in lower uterine segment.

Figure 11c. The appearance of a second and third endometrial polyp at the fundus.

a

c

b

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the observed pathology. In women who have completedtheir childbearing, the author per-forms a wide local excision of anyendometrial polyps along with theadjacent endomyometrium inorder to minimize the risk ofrecurrence and to obtain a suffi-cient specimen of the base todetermine the coexistence of anysignificant pathology.13 In the pres-ence of cornual endometrialpolyps, it is often necessary toremove some endomyometrium inorder to gain sufficient access tothe polyp’s base. Consider the 47-year-old woman depicted in Figure10 with a right cornual EP. Beforethe base of the polyp could be ade-quately excised, it was first neces-sary to remove theendomyometrium from the proxi-mal cornua.

III.Women with multiple endometrialpolyps. This scenario is typicallyfound in perimenopausal and post-menopausal women with AUB, aswell as those with morbid obesity.Figures 11a to c depict a 70-year-old woman with an incidental find-ing of endometrial thickening onTVUS. At the time of her “see-and-treat” hysteroscopy, a long del-icate endometrial polyp is noted,attached in the lower uterine seg-ment in the region of the rightposterolateral wall. After itsremoval, two other broad-basedpolyps were noted at the fundus.The literature, to date, has notadequately addressed the manage-ment of multiple endometrialpolyps or ones that involve muchof the endometrial surface. Amongthe concerns for women with mul-tiple EPs are whether or not theyare at increased risk for recur-rence. We offer women with mul-tiple EPs a total or partialendomyometrial resection depend-ing on such factors as the anticipat-ed use of HRT or tamoxifentherapy. Women must be cau-tioned, however, that once a totalEMR has been performed, futureaccess to the endometrial cavityfor endometrial biopsy, SIS, or hys-teroscopy is limited.30 Rarely,women have an abundance of EPs(Fig. 12a) that can only be man-aged with a total or near-totalEMR (Fig. 12b).

Conclusions

Endometr ial polyps after oftendetected in the evaluation of abnormalbleeding patterns in both pre- andpost-menopausal women. With theincreasing use of imaging, they areoften identified in the asymptomaticpatient as well. Whenever possible, weadvocate a “see-and-treat” approach inan office-based setting which providesthe patient with an expedient means todeliver an accurate diagnosis and treat-ment. This approach is facilitated by anexper ienced team working in anaccredited office-based setting thatprovides adequate analgesia, compre-hensive patient counseling, and anarray of hysteroscopy equipment

(including small diameter hystero-scopes and resectoscopes). In additionto providing a complete histologicspecimen, our approach also addressesthe issue of the high rate of recurrenceand re-intervention following simplehysteroscopic polypectomy. Womenwho have completed their childbear-ing, have multiple endometrial polyps,or require the use of tamoxifen, mayconsider partial or total endomyome-trial resection along with hysteroscopicpolypectomies. However, before offer-ing total endomyometrial resection orany form of endometrial ablation,women must be properly counseledthat these procedures will leave theuterine cavity distorted and will obvi-ate future endometrial sampling andassessment by conventional methods.

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Figure 12a. 52 year old woman with menometorrhagia, severe dysmenorrhea, and multiple EPs.

Figure 12b. Multiple polypectomies followed by endomyometrial resection.

STI

CONCLUSIONS

a

b

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Author’s Disclosures

The author has no conflicts of inter-est to disclose.

References

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ic Polypectomy. PLoS One 2015;10(12):e0144857.22.Cravello L, Stolla V, Bretelle F, et al. Hys-teroscopic resection of endometrial polyps: astudy of 195 cases. Eur J Obstet GynecolReprod Biol 2000;93:131–4.23.Yang JH, Chen CD, Chen SU, et al. Fac-tors influences the Recurrence Potential ofBenign Endometrial Polyps after Hysteroscop-ic Polypectomy. PLoS One 2015;11:10(12):e01448576.doi.24.Jimenez-Lopez JS, Granado-San Miguel A,Tejerizo-Garcia T, et al. Effectiveness of tran-scervical hysteroscopic endometrial resectionbased on the prevention of the recurrence ofendometrial polyps in post-menopausalwomen. BMC Women’s Health 2015;15:20DOI 10.1186/s12905-015-0179-0.25.Nagele F, Mane S, Chandrasekaran P, etal. How successful is endometrial polypecto-my? Gynecol Endoscopy 1996; 5:137–140.26.Henriquez DD, van Dongen H, Wolter-beek R, et al. Polypectomy in premenopausalwomen with abnormal uterine bleeding:effectiveness of hysteroscopic removal. JMinim Invasive Gynecol 2007;14:59–63.27.Gao W, Zhang L, Li W, et al. Three-yearfollow-up results of polypectomy withendometrial ablation in the management ofendometrial polyps associated with tamoxifenin Chinese women. Eur J Obstet GynecolReprod Biol 2012;161:62-5.28.Goldenberg M, Nezhat C, Seidman DS. Arandomized prospective study of the use ofendometrial ablation for prevention of recur-rent endometrial polyps in breast cancerpatients receiving tamoxifen. Prim CareUpdate Ob Gyns 1998;5:160.29.Wortman M, Daggett A. Hysteroscopicendomyometrial resection: a new techniquefor the treatment of menorrhagia. ObstetGynecol 1994;83:295–8.30.McCausland AM, McCausland VM. Long-term complications of endometrial ablation:cause, diagnosis, treatment and prevention. JMinim Invasive Gynecol 2007:399–406.

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REFERENCES

AUTHOR’S DISCLOSURES