Polyps: Hysteroscopic Diagnosis and Management

Abstract

Endometrial polyps are localized hyperplastic overgrowths of the endometrium. The true incidence remains unknown as most of the polyps are asymptomatic. The associated risk factors for their development are increasing age, obesity, hypertension, diabetes, hormone replacement therapy (HRT), and tamoxifen use. The prevalence is also higher in infertile women. Although most of the polyps remain asymptomatic, abnormal uterine bleeding is the most common clinical presentation. The natural history of polyps is not well understood, but 25% of the smaller polyps do regress spontaneously. The modalities commonly used for diagnosing an endometrial polyp include transvaginal ultrasound (TVUS), saline infusion sonography (SSG), hysterosalpingography (HSG), and hysteroscopy. TVUS provides reliable information for the detection of endometrial polyps and should be the initial investigation of choice where available. Hysteroscopy is the method of choice for the diagnosis of endometrial polyps, and it is the only modality which offers an opportunity for concurrent treatment. As small polyps tend to regress spontaneously, expectant management seems reasonable in small polyps (<10 mm), particularly when the woman is premenopausal and asymptomatic. Hysteroscopic polypectomy is the gold standard for the management of polyps. It can be done either as an office procedure or after indoor admission, based on patient preference, instrument availability, the choice of the surgeon, and the number, size, and location of polyps. Different hysteroscopic systems and instruments used for hysteroscopic removal of polyps include hysteroscopic microscissors, graspers, and resectoscopes with monopolar loop cautery, bipolar resectoscope, and hysteroscopic morcellators. There is no evidence to favor any one hysteroscopic polypectomy technique over the others in terms of clinical outcome presently. Whenever associated with infertility, hysteroscopic polypectomy is indicated as it improves not only spontaneous pregnancy rates but also the outcome of assisted reproductive technology. Management of newly diagnosed endometrial polyps during IVF should be individualized.