NAME: Dique, Vincent Dave A.

GROUP AND SECTION: Grp 26, 13G

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Polypectomy Possible Endometrial sampling

Endometrial polypectomy is a procedure to remove polyps in the lining of the womb using
a cutting device. This procedure can be safely performed in an outpatient clinic. You will
not need a general anaesthetic. Endometrium is the name given to the lining of your
womb. Polyps are skin tag like structures that grow from the lining of the womb and can
cause period problems, bleeding between periods or bleeding in menopausal women.
When polyps are seen in the lining of the womb, the gynecologist will offer the option of
having them removed. If you are not having any bleeding problems, it is still advisable to
have any polyps removed to check that there is no cancer in the polyp. Polyps are also
removed in some postmenopausal women to make sure there are no tissue changes
such as cancer. This procedure can also be performed in theatre under general
anaesthetic (while you are asleep). Endometrial Sampling also known as an endometrial
biopsy, it involves the collection of a small sample of tissue from the lining of the uterus
(endometrium). It helps diagnose conditions such as abnormal bleeding, endometrial
hyperplasia, or endometrial cancer. An endometrial polyp, also known as a uterine polyp,
is an abnormal growth that contains glands, stroma, and blood arteries that protrude from
the uterine lining (endometrium) and occupy areas small or large enough to fill the uterine
cavity. They are present in both the reproductive and postmenopausal stages of life. The
majority of polyps are found in the fundus, frequently in the corneal area, where curettage
presents clear technical challenges. They can range in size from 5 mm to as large as
covering the entire uterine cavity and can be detected in all age groups, but are most
common between the ages of 40 and 49. If an endometrial polyp is linked to the uterine
surface by a narrow elongated pedicle, it is called pedunculated; however, if it has a wide
flat base and no stalk, it is called sessile. The gross morphological appearance is smooth,
spherical or cylindrical in structure, and the color ranges from brown to yellow. In the
presence of endometrial polyps, the endometrium can range from normal cycling
endometrium to simple or complex hyperplasia, and in rare cases, endometrial cancer.
Endometrial polyps are the most common pathological finding in the uterus and are
usually harmless lesions. Although the actual prevalence of endometrial polyps is
unknown, 82% of women with histology confirmed abnormalities were asymptomatic.
Nonetheless, endometrial polyps have been linked to around 50% of cases of irregular
uterine bleeding8 and 35% of cases of infertility.
Diagnosis.
There are several options available for the macroscopic diagnosis of endometrial polyps.
Transvaginal ultrasonography.
Transvaginal ultrasound is the main method used to diagnose endometrial polyps at the
initial stage (TVUS). This is accomplished by passing an ultrasonic probe via the vagina
to view the uterus. Endometrial polyps manifest as a regular-shaped, hyperechogenic
lesion. It is possible to see cystic glands inside the polyp.
Color-flow or power Doppler.
The addition of 'Color-Flow or Power Doppler' may enhance TVUS' diagnostic capacity.
Color-flow Doppler imaging may reveal the single feeding vessel characteristic of
endometrial polyps. Power Doppler has been shown to boost sensitivity to roughly 97%,
while increasing specificity and NPV to 95% and 94%, respectively. Sono hysterography
(SHG) with intrauterine contrast may highlight tiny endometrial polyps undetected on
greyscale TVUS and is likely to increase diagnosis accuracy.
Saline infusion sonography or Sono hysterography.
Saline infusion sonography (SIS) or SHG s the gold standard for diagnosing endometrial
polyps increases contrast of the endometrial cavity enabling the viewing size, location
and other features of endometrial polyps. Endometrial polyps appear as echogenic
smooth masses. SIS or SHG method improved diagnosing accuracy, picking up small
polyps missed on TVUS. Differentiating endometrial polyps from submucosal fibroid is
also difficult using SIS. SIS, however, has the advantage of assessing both the uterine
cavity and other pelvic structures visualizing potential myometrial and adnexal
abnormalities. The main disadvantage is its ability to determine final endometrial disease
as it does not allow for a histological diagnosis. Patient discomfort due to fluid leakage or
pain with the use of a balloon catheter. Furthermore, saline solution infusion may enhance
sonographic details.
Histological diagnosis.
Endometrial polyps can be diagsuspected hysteroscopically by the treating clinician,
however, must be confirmed microscopically by the pathologist. The initial clue that a
polyp is present, under microscopic examination utilizing low power objective, is that there
is often a cocktail of fragments that are morphologically different from normal cyclical
endometrium. The stroma is dense fibrous tissue compared with the surrounding
endometrium, parallel arrangement of endometrial gland long axis to the surface
epithelium which is characteristic for the disease, glandular structural anomalies and
glands are often dilated, spaced closely together and are unusual in shape, extracellular
connective tissue and other features include thick-walled stromal blood vessels and
proliferative activity is common in endometrial polyps, even when activity is arrested in
the surrounding endometrium.
Treatment.
Hysteroscopy.
Hysteroscopic polypectomy has been recommended to be the optimal treatment for the
removal of endometrial polyps. Hysteroscopy polypectomy still remains the gold standard
for surgical treatment. Evidence regarding the cost and efficacy of different methods for
hysteroscopic resection of endometrial polyps in the office and outpatient surgical settings
has begun to emerge. It is usually the preferred therapy, and removal of the endometrial
basalis at the endometrial polyp origin appears to prevent recurrence of further
endometrial polyps. The resection of polyps by surgical treatments has resulted in being
highly satisfactory with a reduction in patients’ bleeding symptoms. Hysteroscopy has a
higher accuracy than other imaging and also allows for directed sampling and removal of
endometrial polyps. Satisfactory outcomes of hysteroscopic polypectomy treatments
remain the same regardless of menopausal status, size and number of polyps.
Hysteroscopic resection of endometrial polyps results to the definitive treatment of the
disease.

Dilation and curettage.

Dilation and curettage (D&C) combined with the use of polypectomy forceps used to be
the standard method for investigating abnormalities. However, there is a potential for
polyps to be missed. This procedure is known as a ‘blind procedure’ as its limitations are
well known, and polyps have the potential to be missed in excess of 50%–85% of cases
due to their mobility. In order to reduce the risk of missing a polyp, the uterus should be
investigated prior to the procedure using grasping forceps. However, there are also
possible risks and complications of a D&C procedure: the risks associated with
anaesthesia such as an adverse reaction to medication and breathing problems,
haemorrhage or heavy bleeding, infection in the uterine or other pelvic organs, perforation
or puncture to the uterus, laceration or weakening of the cervix, scarring of the uterus or
cervix, which may require further treatment, incomplete procedure that requires another
procedure to be performed.
HRT.
The effect of HRT may be due to reduced endometrial thickness through estrogen
suppression and thus reduction of polyp development. There was no effect of HRT in
reducing polyp size probably because of lack of PRs in endometrial polyps.
Dienogest and danazol.
On a comparative study of desogestrel and danazol as a preoperative endometrial
preparation for hysteroscopic surgery. Their observations were that desogestrel caused
less side effects and presented obvious outcomes in inducing endometrial atrophy, this
allowed for a better intraoperative management and was shown to cause less side effects
during treatment. Dienogest, respective of danazol has been reported to be more effective
for the preparation of the endometrium in patients whom have to undergo hysteroscopic
surgery for submucous myomas and has been found to cause less side effects. The
usage of dienogest has been further reported to be effective in reducing the thickness of
the endometrium, and the severity of bleeding and also of operative time, with a reduced
number of side effects in comparison with other pharmacological preparations or no
treatment.

Signs/Symptoms.
The most common symptom of uterine polyps is abnormal bleeding. Abnormal bleeding
includes vaginal bleeding after menopause and irregular menstrual periods. Most periods
last four to seven days. Normal menstrual cycles usually occur every 28 days but can
range from 21 days to 35 days. Many people with uterine polyps have irregular periods.
The symptoms of uterine polyps include:
• Irregular menstrual periods. (unpredictable timing and flow).
• Unusually heavy flow during menstrual periods (heavy menstrual bleeding).
• Bleeding or spotting between periods (intermenstrual bleeding)
• Infertility (being unable to become pregnant or carry a pregnancy to term).
• Vaginal spotting or bleeding after menopause (red, pink, or brown blood).
• Bleeding after intercourse.
Your healthcare provider may discover asymptomatic polyps during a procedure to
diagnose a separate issue. Polyps can sometimes prolapse, or slip, through your cervix.
The cervix is the opening between your vagina and your uterus. In these instances, your
provider may be able to see the polyp during a physical exam.

References:
Nijkang, N. P., Anderson, L., Markham, R., & Manconi, F. (2019). Endometrial polyps:
Pathogenesis, sequelae and treatment. SAGE Open Medicine, 7, 205031211984824.
https://doi.org/10.1177/2050312119848247

Uterine Polyps: Causes, Symptoms, Diagnosis & Treatment. (n.d.). Cleveland Clinic.
https://my.clevelandclinic.org/health/diseases/14683-uterine-polyps

Outpatient “See and treat” hysteroscopy and endometrial polypectomy. (n.d.). Retrieved
November 17, 2023, from
https://www.gloshospitals.nhs.uk/media/documents/Outpatient_See_and_treat_hysteros
copy_and_endometrial_polypectomy_GHPI1579_09_22.pdf