Minimally Invasive Therapy & Allied Technologies

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Endometrial polyps: diagnosis and treatment

options – a review of literature

Nili Raz, Larissa Feinmesser, Omer Moore & Sergio Haimovich

To cite this article: Nili Raz, Larissa Feinmesser, Omer Moore & Sergio Haimovich (2021)
Endometrial polyps: diagnosis and treatment options – a review of literature, Minimally
Invasive Therapy & Allied Technologies, 30:5, 278-287, DOI: 10.1080/13645706.2021.1948867

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Published online: 06 Aug 2021.

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MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES
2021, VOL. 30, NO. 5, 278–287
https://doi.org/10.1080/13645706.2021.1948867

REVIEW ARTICLE

Endometrial polyps: diagnosis and treatment options – a review of literature

Nili Raza,b
, Larissa Feinmessera,b
, Omer Moorea,b and Sergio Haimovicha,b
a
Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel;
b
Technion Israel Institute of Technology, Haifa, Israel

ABSTRACT ARTICLE HISTORY

Introduction and aim: Endometrial polyps (EPs) are a common gynecologic condition, associ- Received 10 April 2021
ated with abnormal uterine bleeding (AUB), infertility, and premalignant and malignant condi- Accepted 23 June 2021
tions. Technologies for diagnosis and treatment of EPs are constantly evolving. We aim to
KEYWORDS
provide an updated review on diagnosis and management options for patients with EPs.
Endometrial polyp;
Material and methods: We conducted an electronic search in databases including MEDLINE, hysteroscopy; infertility
PubMed, Cochrane Central Register and others. We included 68 publications regarding EPs, their
clinical burden, diagnostic modalities, treatment options and new technologies.
Results: Transvaginal ultrasound (TVS) is the common modality for EP detection and color dop-
pler increases its diagnostic accuracy. Dilation and curettage (D&C) should be avoided for diag-
nosis and treatment of EPs. Hysteroscopy shows high diagnostic value in EPs and allows for
both histological diagnosis and effective treatment. Office hysteroscopy and see and treat hys-
teroscopy without anesthesia is feasible and safe for EP diagnosis and treatment, gaining more
trained surgeons globally. Effective and safe technological tools for EP resection include Laser,
resectoscopes, morcellators, MyoSure, Truclear and scissors\graspers.
Conclusions: EPs are safely and effectively diagnosed and treated with the hysteroscopic tools
reviewed in this article. More research is needed to define the best treatment modality.

Abbreviations: D&C: dilation and curettage; EP: endometrial polyp; GnRHa: gonadotropin-releas-
ing hormone agonists; HRT: hormone replacement therapy; TVS: transvaginal ultrasound

Introduction dysmenorrhea and infertility [3–5]. Molecular mecha-

Endometrial polyps (EPs) are a common etiology for
abnormal bleeding in both premenopausal and post-
menopausal women. EPs are localized exophytic over-
growths of endometrial glands and stroma which
protrude from the surface of the endometrium into
the uterine cavity [1].
Polyps may vary in number, texture and size.
Polyp size ranges from millimeters to several centi-
meters which might fill the entire uterine cavity [1,2].
Most polyps are benign, yet their differential diag-
nosis includes other intrauterine pathologies such as
endometrial hyperplasia, myoma, sarcoma and carcin-
oma [1,2].
The prevalence of EPs is 7.8%–34.9%. The inci-
dence of EPs increases with age throughout a wom-
an’s reproductive years [3].
Most EPs are asymptomatic while others may cause
symptoms such as abnormal uterine bleeding (AUB),
postmenopausal bleeding and in some cases,
nisms suggested for the development of EPs include
monoclonal endometrial hyperplasia, overexpression
of endometrial aromatase, and gene mutations. EPs
are known to express both estrogen and progesterone
receptors [6]. Increasing age, obesity, hypertension,
hormone replacement therapy (HRT) and tamoxifen
contribute to the increased incidence of polyps.
Although uncommon, both atypical hyperplasia and
endometrial cancer may originate from EPs.
Malignancy predictors were described as a size of
>10 mm, postmenopausal status, AUB, Tamoxifen
and Lynch and Cowden syndrome [5,7,8].
Material and methods
This review was produced by searching electronic
resources on several databases including MEDLINE,
PubMed, ClinicalTrials.gov, Cochrane Central
Register of Controlled Trials at the Cochrane Library,

CONTACT Nili Raz niliraz@gmail.com Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center,
Hadera, Israel; Technion Israel Institute of Technology, Haifa, Israel.

Nili Raz and Larissa Feinmesser are co-authors.
ß 2021 Society of Medical Innovation and Technology

Google Scholar, national guidelines and manual
searching of bibliographies of known primary
research and review articles. Databases were searched
from the inception of each database to March 2021.
The search terms used were the following text words
and Medical Subject Headings terms: ‘Uterine polyp’,
‘Endometrial polyp’, ‘hysteroscopy’, ‘uterine polyp
treatment’, ‘abnormal uterine bleeding’, ‘polypectomy’,
‘polyp and management’, ‘polyp and diagnosis’, ‘polyp
guidelines’ and ‘polyp and malignancy’. Relevant
articles were identified and reviewed by team mem-
bers. Final decisions regarding inclusion or exclusion
were made on the basis of the methodologic quality.
Sixty-eight publications were included regarding EPs,
their clinical burden, diagnostic modalities, treatment
options and new technologies.
Diagnosis
Routine use of pelvic ultrasonography allows inciden-
tal EPs diagnosis in asymptomatic patients. A hypere-
choic lesion with regular contours within the uterine
lumen, surrounded by a thin hyperechoic halo is how
the typical polyp appears on transvaginal ultrasound
(TVS). Cystic spaces may be seen within the polyp
and are of no prognostic value. A preferred time for
TVS is the proliferative phase of the menstrual cycle,
and repeating TVS after menstruation may assist in
differentiating a real polyp from endometrial thicken-
ing. TVS sensitivity for polyp diagnosis is 19–96%
and specificity is 53–100% in comparison with hys-
teroscopic-guided biopsy. Power Doppler increases
sensitivity to >90% by demonstrating the polyp blood
vessels [5,9]. The addition of intrauterine saline infu-
sion or gel installation to the sonography may
improve diagnostic accuracy of small polyps.
Sonohysterography has a sensitivity of 58–100% and
specificity of 35–100%, compared to Hysteroscopy
with biopsy Sonohysterography has advantages com-
pared with hysteroscopy, being able to assess both the
uterine cavity, tubal patency and other uterine and
pelvic structures, yet hysteroscopy has advantages
over sonohysterography since it allows a sight-
directed biopsy and simultaneous treatment of the
polyp. 3D ultrasound (US) or magnetic resonance
imaging (MRI) do not significantly improve detection
compared with 2D TVS [5,10].
The use of a blind biopsy, whether dilation and
curettage (D&C) or endometrial biopsy is inaccurate
for diagnosing EPs. Compared with hysteroscopic-
guided biopsy a low sensitivity of 8–46% and negative
predictive value (NPV) of 7–58% were detected, thus
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 279
hysteroscopic-guided biopsy is superior to blinded
biopsy; thus blind D&C or biopsy should not be used
for diagnosis of EPs [8,11]. Hysterosalpingography
has a high sensitivity (98%), yet low specificity (35%)
compared with hysteroscopic diagnosis for EPs while
being involved in patient discomfort [5].
The gold standard for polyp diagnosis is hystero-
scopy with guided biopsy. The major advantage of
hysteroscopy is the ability to visualize and concur-
rently remove polyps. Diagnostic hysteroscopy alone
only allows subjective size, location, number and tex-
ture evaluation of the mass, with reported sensitivity
of 58–99%, specificity of 87–100%, positive predictive
value (PPV) of 21–100%, and NPV of 66–99% when
compared with hysteroscopy with guided biopsy.
With the development of see and treat ambulatory
office procedures and narrow diameter hysteroscopes,
hysteroscopy-guided biopsy and polypectomy are feas-
ible for better diagnosis. Complication rates of diag-
nostic hysteroscopy are <0.5% [12].
Treatment
Up to 30% of polyps, mostly small ones, may regress
spontaneously [5,13]. Several studies have demon-
strated that the removal of EPs may improve fertility
in infertile women [4].
Indications for treatment of women with EPs
are [3,14]:
 Symptomatic EPs (most commonly manifested by
AUB) – symptomatic EPs should be removed in
all women.
 Polyps with high risk of malignancy, as discussed
previously in this review.
 Infertility: About 8% of infertile patients under-
going uterine evaluation are diagnosed with polyps
and according to some studies treating the polyp
may improve the fertility status. For example, a
systemic review showed a higher pregnancy rate in
women undergoing intrauterine insemination
(IUI) who underwent polyp removal compared
with hysteroscopy alone [14]. The effect of poly-
pectomy on fertility and pregnancy outcomes is
still controversial.
During the course of history, several treatment
options were introduced: conservative, medical and
surgical approaches.
280 N. RAZ ET AL.
Conservative management
Given that most polyps are not malignant, the option
for expectant management with no intervention can
be considered. There is evidence that polyps may
spontaneously regress in approximately 25% of cases,
with smaller polyps more likely to regress compared
to polyps 10 mm in length. Asymptomatic postmeno-
pausal polyps are unlikely to be malignant and obser-
vation is an option after discussion with the
patient [5].
Medical management
Medical management has a limited role for EPs.
Although gonadotropin-releasing hormone agonists
(GnRHa) could be used as an adjunctive treatment
before hysteroscopic resection [15], this must be bal-
anced against medication costs and side effects and
excisional surgery alone. There are no data to support
the use of GnRHa in this setting. The use of some
types of hormonal therapies may have a preventive
role for polyp formation [16]. The use of levonorges-
trel-releasing intrauterine system in women taking
tamoxifen is reported to reduce the incidence of EPs.
However, its use for the treatment of polyps should
be currently limited to research protocols [17].
Surgical approaches
Surgical approaches can be divided into conservative
and radical surgical approaches. Conservative options
can be further divided into blind and hysteroscopic
methods whereas the radical options include hysterec-
tomy in women who have completed their reproduc-
tion phase of life.
Conservative surgical management
The traditional treatment for EPs is blind dilatation
and curettage (D&C) [18], this procedure has been
reported to remove only 8% of EPs, whereas the add-
ition of polyp forceps increases complete extraction to
41% [5]. Other studies indicate that removal of endo-
metrial disease by blind curettage is successful less
than 50% of the time, and in many cases, removal is
incomplete [8,11,17]. Recent studies demonstrated
that hysteroscopy is safer and more effective than
D&C in achieving complete removal of EPs [11,19].
Hysteroscopy offers direct visualization of the
entire uterine cavity and provides the possibility of
performing targeted biopsies of suspected areas and
lesions [20], which are potentially missed by blind
techniques. For these reasons, hysteroscopy has
become the gold standard technique for the manage-
ment of EPs [21,22] and the treatment of EPs by
blind curettage should not be used as a diagnostic or
therapeutic intervention.
Radical surgical options
While hysterectomy can be associated with 100% suc-
cess in treating AUB with no risk of recurrence of
EPs, in the age of minimally invasive surgery, this is
considered an overly aggressive approach for the
treatment of EPs. Moreover, laparoscopic hysterec-
tomy with its less invasive supracervical option is
commonly associated with the use of laparoscopic
power – morcellation and this should be carefully
weighed in women with EPs, and even abandoned,
due to the risk of cell cancer dissemination [23]. Also,
this major surgical procedure, with significantly
greater costs and potential for morbidity should be
used judiciously and only after discussion with the
patient about its implications. There are no compara-
tive data for conservative and radical treatments [5].
Hysteroscopic polypectomy (HP)
Transcervical resection (HP) is effective and safe as
both a diagnostic and therapeutic intervention. HP
performed in the outpatient setting under local or no
anesthesia has been found to be non-inferior to
inpatient polypectomy under general anesthesia in the
outcomes of improvement of bleeding as well as feasi-
bility and acceptability of the procedure [24].
Resection is feasible in an outpatient setting without
general anesthesia; this has become possible due to
small diameter instruments, which obviate the need
for cervical dilatation. See-and-treat outpatient hys-
teroscopy is more cost-effective than inpatient hys-
teroscopy under general anesthesia and allows faster
recovery [2,11].
For these reasons, outpatient HP with direct visual-
ization represents the optimal treatment modality for
endometrial polypectomy.
There is direct and circumstantial evidence that
HP of EPs under vision is safe, simple and superior
to blind techniques:
 Malignant cells at the base of the polyp can be
missed with blind avulsion [22,25].
 Hysteroscopic resection avoids excessive cervical
dilatation, which is when uterine perforation and
creation of a false passage usually occur.
 Not a single recurrence of EPs was reported when
resection under vision was compared with removal

with a grasping forceps (recurrence rate
15%) [2,11,25].
Currently, there are a variety of methods available
for HP, including grasper-scissor resection, electrosur-
gical removal [26–28] the use of diode laser [29], or
mechanical morcellation [30–32]. However, no single
hysteroscopic equipment and technique should be
considered as preferred over others considering the
effectiveness, safety, and costs to generalize its use in
all patients [5,23]. The type of technique and setting
employed varies across centers according to local
access, costs and surgeon’s preference [33].
Mechanical approach
The classic approach uses reusable graspers
and scissors.
The simplest technique is using a hysteroscope
with scissors and grasper. It is a well-tolerated and
low-cost procedure used to remove polyps by under
vision resection with cold scissors followed by hys-
teroscopic grasper retrieval.
Electrosurgical approaches
Hysteroscope with monopolar radiofre-
quency energy
Radiofrequency energy is another modality used in
the removal of polyps and myomas. The modern
resectoscope is an endoluminal device made up of an
hysteroscope, two sheaths (inner and outer), for
inflow and outflow, and the loop (active or cold) that
interfaces a specially designed electrode with a radio-
frequency electrosurgical generator [5].
These resectoscopes are the most traditional and
universal equipment used with general anesthesia or
sedation, but due to the complications associated with
glycine solution medium, their use is commonly lim-
ited to the operating room [29].
Hysteroscope with bipolar radiofrequency energy
Newer resectoscopic instruments use a bipolar device
containing both electrodes on the loop.
Animal studies have shown that monopolar and
bipolar resectoscopes have similar properties and both
devices can be used to resect polyps. The depth of
thermal damage when cutting or desiccating was
similar between the two modalities [22].
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 281
Mini-resectoscope
Bipolar energy coupled with small diameter hystero-
scopes that have a continuous flow system [28]. A
mini-resectoscope was first introduced in 2009 when
26 patients underwent an office polypectomy and all
lesions were resected [34]. From then on, proving its
advantages, the mini-resectoscope reducing medical
costs, improving patient tolerability, and reducing
complications associated with traditional resectoscope.
Unipolar energy resectoscopy is optional with cut-
ting loops (angled or straight) with a great number of
electrodes (pointed or Collins electrode, ball-end
coagulating electrodes, spike electrode, roller elec-
trode, and VaporCut(.
Laser
The diode laser was introduced to hysteroscopy in the
1970s and 1980s in the USA. Diode lasers, like most
other lasers, incorporate an optical gain medium in a
resonant optical cavity. They produce wavelengths
from 980 to 1470 nm. These wavelengths issued sim-
ultaneously confer a contemporary absorption in
hemoglobin and H2O and therefore excellent ability
of hemostasis, cutting and vaporization. Compared to
the CO2 laser, the diode laser creates a significantly
higher hemostasis The thermal penetration of the
diode laser is smaller compared to the Nd:YAG laser
and then surgery is precise and safe also close to deli-
cate anatomical structures. The diode laser is the
most widely used in biomedicine due to its intrinsic
characteristics. The main advantages using laser
energy are very low pain levels, low relapse rate, and
high patient satisfaction compared with the electrical
bipolar procedure. The results do not seem to be
related to size or number of pathologies, and a 12-
month follow-up shows both the lowest recurrence
and complications rates [29,35].
Hysteroscope with tissue removal system
Morcellators
In 2005, the first hysteroscopic mechanical resection
device was approved (Truclear hysteroscopic morcel-
lator; Smith & Nephew, Andover, MA, USA). In
2009, the MyoSure Tissue Removal System (Hologic,
Bedford, MA, USA) was approved by the US Food
and Drug Administration [28,30]. Hysteroscopic
mechanical resection functions by a rotating cutting
blade, thus using mechanical vs. electrical energy. The
blade handpiece is attached to suction, allowing
282 N. RAZ ET AL.
resected pieces to be removed immediately with the
handpiece and collected in a specimen trap [28].
Advantages:
 It prevents the theoretical risks of electrosurgery
and low-viscosity anionic distention media.
 It overcomes the challenge of tissue retrieval.
 One may choose to avoid electrosurgical energy
and possible burns.
 Prevents the need for insertion and reinsertion
cycle for chip removal (ICRRI cycle).
 Requires a shorter learning curve.
 Suitable for ‘see-and-treat’ hysteroscopy.
Disadvantages:
 The use of a relatively cumbersome ‘offset’ opera-
tive hysteroscope equipped.
 Hysteroscopic morcellators are limited by their
side-cutting windows which are ideally designed
for operating in the lower 2/3 of the uterus. They
function poorly at the fundus and uterine cornua.
 Mechanical systems are associated with intrauter-
ine pressure loss.
 Relatively high-cost technology.
MyoSure/Truclear
The MyoSure and the Truclear tissue removal system
uses a probe with a small blade powered by an elec-
tromechanical drive system, which enables simultan-
eous rotation and reciprocation of the cutter to
remove quickly both fibroids and polyps. It has a
fast-cutting rate of 1.5 g per minute. The specimen is
captured intact (since there is no radiofrequency
energy used) in a vacuum canister. The unique cutter
is also connected to a vacuum source that continu-
ously aspirates resected tissue. This is done via a side-
facing cutting window in the outer tube which limits
the depth of tissue resected. This decreases the chan-
ces of perforation. When the device is not cutting, the
cutting window automatically closes to prevent a loss
of uterine distension [29,36].
Comparisons of techniques for the treatment
of polyps [28]
Medical management has a limited role in the treat-
ment of EPs. Surgical removal of the polyps has
become the first-line treatment. Researchers have con-
cluded that blind curettage removes less than 50% of
polyps, with a recurrence rate of roughly 15%, and
thus should not be used if hysteroscopy is available
[2,3,10,11,21,30,37,38]. Several retrospective and
randomized studies as well as meta-analysis compared
surgical techniques described above [37,39,40] and
their findings are summarized in the following.
When comparing the surgical time of mechanical
technique to radiofrequency energy in 240 women
who underwent polypectomy, operative time was
found to be statistically significantly longer with the
resectoscope vs. the other techniques (31.9 ± 8.3 min
vs. micro scissors, 23.1 ± 4.7 min, vs. grasping forceps,
20.9 ± 3.9 min; p < .05) [39]. These results were sup-
ported by Hamerlynck et al. in a randomized con-
trolled trial when used for polyps >1 cm. The study
showed a 38% decrease in operating time when mech-
anical resections (resectoscope) were used in compari-
son to bipolar radiofrequency (4 min compared with
6 min, respectively (p ¼ .028) [41,42]. Pampalona et
al. [43] randomly assigned 133 patients to mechanical
resection or bipolar resectoscopic polypectomy. The
mechanical tissue removal system was significantly
faster (3 min, 7 s vs. 8 min, 25 s; p < .01) and had a
shorter learning curve than the resectoscope. In
another randomized study of 121 patients, removal of
polyps with mechanical resection was significantly
faster (5 min, 28 s vs. 10 min, 12 s; p < .001) and less
painful (mean pain score, 35.9 vs. 52; p < .001) than
removal with bipolar electrosurgical resection [44].
The recurrence rates were found to be lower with the
resectoscope when compared with microscissors and
grasping forceps (0 vs. 2 [5%] vs. 3 [15%], respect-
ively) [39]. Other studies have found the recurrence
rate of EPs after resectoscopic removal to range from
0% to 13% [37,40].
The shorter operative time may be related to oper-
ator experience. Garuti et al. [45] compared mechan-
ical resection with bipolar resection during
polypectomy in 101 postmenopausal patients and
found no significant difference in surgical time
(15 min vs. 15.5 min, p ¼ .53) or pain (visual analog
scale, 3.7 vs. 3.2; p ¼ .48) between the techniques.
When comparing incomplete removal rates
between mechanical resection and electrosurgical
resection, the metanalysis of randomized controlled
trials found a lower odds or incomplete resection
with mechanical resection (odds ratio: 0.12; 95% CI:
0.03–0.45) [44]. When looking at long-term outcomes
after mechanical resection vs. radiofrequency resec-
tion, one finds that the recurrence rates after both
methods are low. After 4 years of follow-up, there
was no significant difference in the recurrence of
AUB when 311 women underwent hysteroscopic

mechanical resection vs. radiofrequency resec-
tion [37].
Jenifer Rovira Pamplona et al. compared Truclear
(office procedure) to Versapoint (bipolar). They
obtained a 91% success rate with the TRUCLEAR
SystemV compared to a 69% success rate with the
R
VersapointV system for endometrial polypectomy.
R
Total operating time was 6.36 min in the TRUCLEAR
System group vs. 10.82 min in the Versapoint system
group (p < .05), with a polypectomy time of 3.06 and
7.91 min, respectively (p < .05). There were no signifi-
cant differences between the two techniques when
analyzing pain using the visual analogue scale. No
complications were recorded for either technique. The
mechanical energy system presents a significant
decrease in the total duration of polypectomy and
hysteroscopy when performed both by experienced
staff and by staff in training, resulting in higher suc-
cess rates without complications with respect to con-
ventional hysteroscopy with bipolar energy [36,45].
A recent study by Smith et al. [44] compared the
polyp resection time of several techniques: Biopolar
Electrode – 10 min and 12 s vs. Morcellator – 5 min
and 28 s. Antonio Perino et al. compared a mean time
required for polypectomy with the Diode Laser (of
4 min and 6 s was) vs. 5 min and 29 s with the
Versapoint. The time difference between both studies
may be explained by the fact that in Smith’s study,
time was measured from the vaginoscopy, while in
the present study time was measured upon entry into
the uterine cavity [46]. The most interesting finding
of the present study was the higher percentage of
patients with polyp relapses in the Versapoint group
as compared to the Laser group at 3 months (32.6 vs.
2.2%, p1=4 .001). This may be explained by the cap-
acity of laser to engage with water and hemoglobin
allowing greater penetration in the soft tissues and
consequently an adequate ablation and vaporization
effect. Another study focused on the risk of relapses
after hysteroscopic polypectomies found that relapse
is also higher in the resection group using monopolar
energy as compared to morcellation [37]. In conclu-
sion, polypectomy with diode laser resulted in fewer
relapses and a higher procedure satisfaction rate as
compared to Versapoint [46].
Pain and anxiety management during office
hysteroscopy
Pain experienced during hysteroscopy is negatively
affected by preprocedural anxiety, and both lower the
success rates of office hysteroscopy. Overcoming these
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 283
obstacles may improve success rates. Patient pain and
anxiety are reduced by listening to music during pro-
cedures and distracting conversation by a staff mem-
ber, use of small diameter devices such as the mini
hysteroscopes, atraumatic insertion of the instru-
ments, with no need for a speculum or tenaculum, no
need for cervical dilatation and the use a nonirritant
distention media such as isotonic normal saline.
Under such conditions no anesthesia (neither local or
systemic) or analgesia are necessary. It is also possible
to use analgesia by several suggested proto-
cols [47,48].
Polyp resection complications
HP is considered a procedure with low odds of com-
plications, reported up to 0.95% of the procedures
[23,49,50], where the operator experience has a pro-
tective effect [51]. Polypectomy complications are div-
ided into those related to hysteroscopy in general and
those related to a specific method or instrument used
[51]. The complications, in general, can be further
divided into intraoperative – uterine perforation,
major bleeding, air/gas emboli, fluid overload and
thermal injuries and postoperatively – infection and
intrauterine adhesions. Excessive fluid absorption/def-
icit being the most frequent complication of hystero-
scopy should be noticed by the surgeon [50] who has
a threshold for procedure completion. As the office
hysteroscopy procedures become more common, the
surgeon should also be aware of the vasovagal reac-
tion during procedures [51].
When comparing polypectomy to other operative
hysteroscopy procedures, it is associated with the low-
est occurrence of complications (0.4%) [23,50,51].
Office HP (see and treat) has been gaining more
popularity in recent years, being more cost-effective
and tolerable by patients. Amongst polypectomy com-
plications, the most frequent is uterine perforation,
which occurs mostly in the operating room, under
variable types of anesthesia, rather than in office pro-
cedures [33]. As complicated cases such as larger pol-
yps are selectively referred to an operating room, a
selection bias is inevitable. Thus, comparison between
office HP complications and polypectomy under anes-
thesia is challenging. However, it seems that the risk
of uterine perforation can be reduced by preoperative
treatment with Misoprostol for cervical dilation in
premenopausal women [52].
The use of tissue removal systems or morcellators,
due to their atraumatic tip, showed a reduction of
perforation rates when compared to bipolar resection
284 N. RAZ ET AL.
[51]. The evidence is still low, and more studies are
still needed.
Intraoperative US guidance may help in cases of
atresia or stenosis of the endocervical canal. By using
either a transrectal or transabdominal approach the
risk of uterine perforation is reduced [51].
The rate of clinically important intrauterine adhe-
sions after polypectomy is extremely low. Hence,
according to a meta-analysis, there is no benefit in
using gels and other methods for prevention [53].
However further research is needed for the assess-
ment of adhesions following polypectomy.
Polypectomy is associated with a minimal, but signifi-
cantly higher risk of residual polyp in outpatient set-
tings [53]. EP recurrence is related to incomplete
resection (residual polyp tissue) and to the number of
polyps resected [54]. The risk is ranging between
2.5% and 43% and may reach 68% in >3-year follow-
up. The residual polyp tissue is more commonly seen
after office procedures [28]. According to a single
study, the recurrence rate 1 year after polypectomy, of
a single polyp was 13% vs. 45% in case of multiples
polyps [55]. A meta-analysis of randomized controlled
trials comparing incomplete removal rates between
mechanical resection vs. bipolar electrosurgical poly-
pectomy found a lower odd of incomplete resection
with mechanical resection (odds ratio: 0.12; 95% CI:
0.03–0.45) [42].
Polyp resection outcomes
Polyp resection impact on AUB resolution, patient
satisfaction, malignancy detection and fertility were
studied. The resection of polyps by surgical treat-
ments results in high satisfaction with a reduction in
patients’ bleeding symptoms. Nathani et al. described
a symptomatic improvement in 75–100% of symp-
tomatic patients in a two to 52-month follow-up.
Hysteroscopic diagnosis and under vision polypec-
tomy have good malignancy prediction values.
Daniele et al. concluded diagnostic hysteroscopy is a
good predictor of malignant EPs. With a 100% NPV,
i.e., hysteroscopy correctly excluded malignancy, and
86% PPV, i.e., accurate prediction of malignant EPs
[38,56,57]. The effect of polypectomy on fertility,
however, remains controversial. Several studies dem-
onstrated infertile patients treated with HP were up
to twice as likely to become pregnant than infertile
patients with a polyp that was not resected, prior to
IUI [58,59]. Other studies demonstrated no benefit to
HP [59]. However, no clear benefit was observed for
clinical pregnancy, live birth, miscarriage, or
implantation rates in patients who underwent in vitro
fertilization/intracytoplasmic sperm injection cycles
[60]. More research is needed to evaluate the effect of
polypectomy on fertility [60].
Discussion
EPs are a common gynecologic condition, associated
with AUB, infertility, and premalignant and malig-
nant conditions. EP may be found incidentally or due
to the above symptoms. The incidence increases with
age [3]. Eps are reliably detected by US mostly using
doppler to enhance specificity and by sonohysterogra-
phy [1,2]. The gold standard for polyp diagnosis is
hysteroscopic-guided biopsy [15,32]. There is no rec-
ommendation for routine screening for polyps in
asymptomatic individuals. Management of EP may be
conservative in low-risk patients with small asymp-
tomatic polyps. In other high-risk patients, hystero-
scopic resection is considered an effective and safe
method for treating the polyp by resection, while his-
tologically sampling the polyp. High-risk factors
include: advanced age, obesity, hypertension, HRT,
tamoxifen treatment and suspected family history,
Blind techniques should be avoided when visual tech-
niques are available for excision [8,53,61].
The different technological modalities and
approaches for HP are summarized in this review
including grasper-scissor resection, electrosurgical
removal, diode laser and mechanical morcellation.
However, one does not fit all. Thus, no single hys-
teroscopic instrument, as advanced as it may be,
should be considered as preferred over others in all
patients. Rather an individualized approach ought to
be taken when choosing the operating method and
tools, considering operator experience, effectiveness,
safety, and costs of the instrument. Although all poly-
pectomy technologies mentioned above have high effi-
cacy rates and low potential complication rates, one
has to remember that up to 22% of the polyps will
regress spontaneously [57]. EP removal by blind
methods using curettage or polyp forceps following
dilatation of the cervix is not recommended. Risking
for residual polyp tissue or uterine and visceral
trauma [8,53,61].
It is interesting to note that retained products of
conception (RPOCs) could mimic the signs and
symptoms of EPs in women of reproductive age.
There is much similarity in hysteroscopic treatment
of both RPOC and polyp as the new instrumentation
we discussed above may be applicable for both.

RPOC see and treat resection is safe effective and
timely procedure [62,63].
EPs are commonly found in infertile patients, with
prevalence reaching up to 32% [64]. This may raise a
question regarding the polyp role in infertility since a
similar prevalence may be found in the general
healthy population [3]. The EP could potentially
interfere mechanically with the endometrium causing
fertility issues. Releasing molecules that adversely
affect the sperm transport or embryo implantation
(glycodelin, aromatase, inflammatory markers and
reduced levels of HOXA-10 and -11 messenger RNA)
[65–67] Yet, there are no studies comparing these
molecules expression before and after polypectomy.
Polypectomy effect on infertility remains controversial
and further research is needed to determine which
polyp (dimensions, number, location) and which
patient (age, infertility reason, infertility protocol)
may be more affected than others.
There is an association between EPs and AUB,
documented in the FIGO classification system for
causes of AUB during the reproductive years (‘PALM
COEIN’) with the ‘P’ denoting a ‘polyp’ [68].
According to several studies polypectomy beneficial
effect on AUB is established, having high patient sat-
isfaction and high bleeding resolution rates [38,68].
The recurrence rate of polyps following a polypec-
tomy of a single polyp is up to 13% and up to four
times higher when multiple polyps are resected [54].
Other factors increasing the recurrence rate are preme-
nopausal status, incomplete resection and longer follow-
up [55]. Office polypectomy was associated with a min-
imal, yet higher risk of residual EPs compared with hys-
teroscopy with esthesia [33]. However, we believe that it
is related to the deficient experience of the operator in
office procedures. HP in an office setting is a safe and
effective method. It is cost-effective and results in high
patient satisfaction rate. Office HP allows the operator a
variety of surgical instruments, leading to a better safer
result. When considering effective treatment for AUB
together with optional malignancy diagnosis, for a
patient desiring fertility and uterine cavity preservation,
HP remains the option of choice.
EPs are frequently asymptomatic and thus discov-
ered incidentally during a rutinary US scan. Due to a
possible effect on young women’s fertility, or a poten-
tial low risk of malignancy in postmenopausal women
the advice is to perform a hysteroscopy polypectomy
preferable in the office setting. Thanks to the new
technologies designed for office settings, polypectomy
has become an easy procedure even in the hands of
young professionals. The actual evidence is scarce and
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 285
more well-designed studies are needed in order to
define the ideal approach to this pathology.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
ORCID
Nili Raz http://orcid.org/0000-0002-7048-3648
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