AUB-ADENOMYOSIS

AUB-POLYP
DR. GARIMA (FACULTY)
DR. SOUMYA (PG)
DR.BHUVNANA(PG)
DR.ARPITA(PG)
CASE PRESENTATION 1
Mrs A, resident of Badarpur is a 42-year-old, housewife by occupation, belongs to
lower middle class family according to modified kuppuswamy scale presented with
CHIEF COMPLAINTS : heavy menstrual bleeding and painful menses since 8
months.
HOPI: Patient was apparently well 8 months back when she prolonged and heavy
menstrual bleeding, during regular menses, which was insidious in onset lasting for 8-
10 days with soakage of 4-5 pads per day, associated with passage of clots. Patient
also has complaint of pain during menses since 8 months, pain starts 1-2 days before
the onset of menses, intermittent dull aching pain in lower abdomen no aggravating
factors relieved with the onset of menses.
◦ No h/o intermenstrual bleeding, post coital bleeding, discharge per vagina.
◦ No h/o abdominal distention, increased urinary frequency, difficulty in micturition,
constipation
◦ No h/o fever, fatigue, loss pf appetite, weight gain or weight loss.
◦ No h/o hot and cold intolerance.
◦ No h/o acne, hirsutism, lactorrhea
◦ No h/o gum bleeding, joint swelling, blood transfusion, bleeding from other sites
◦ No h/o HTN or DM
◦ No h/o any hormonal contraceptives of Iud insertion
◦ No h/o other drugs: (NSAIDS, anticoagulants)
MENSTRUAL HISTORY
Menarche- 14 years
LMP 17/10/2023

Salient features Present menstrual history Previous Menstrual history

Frequency (days) 25 25

Duration (days) 8-10 (PROLONGED) 5

Regularity (variation days) ±4

+-4
Volume
(Number of pads used per day) 4-5 pads/day 2-3 pads/day
Obstetric history:
◦ Married for 20 yrs
◦ Non consanguineous marriage’
◦ P3L3
◦ All uneventful with no ANC/PNC complications.
Past history: No history of any chronic medical/ surgical illness. No h/o any prolonged
hospitalisation.

Family History: No history of any chronic illness in family. No h/o any malignancy.

Personal history: mixed diet, appetite normal, sleep adequate, no h/o any tobacco/alcohol or any
other substance intake.

Contraceptive history: used barrier contraception. No h/o any hormonal contraception or iud
insertion.
GENERAL PHYSICAL EXAMINATION:
◦ Patient is moderately built and average nourished
◦ Oriented to time, place, person

◦ Alert and cooperative

◦ Body wt: 62 kg

◦ Height 158cm
◦ BMI: 24.84 Kg/m2

◦ Pallor present cli 6 g%

◦ Icterus absent

◦ Cyanosis absent
◦ Clubbing absent

◦ Oedema absent
◦ Lymphadenopathy absent
◦ Thyroid normal
◦ No acne/ hirsutism
◦ Breast examination WNL
◦ Vitals bp 124/76 PR 78
SYSTEMIC EXAMINATION:

◦ Cardiovascular system: s1,s2 heard, no added sounds

◦ Respiratory system: Normal vesicular sounds heard on both sides, no added sounds
◦ CNS: normal sensory and motor functions
Abdominal examination:
Inspection:

Normal shape and size of abdomen

Umblicus central and flat
All quadrants move equally with respiration
No sinuses, dilated veins, visible pulsations seen on abdomen
All hernia sites free

Palpation:

No guarding tenderness, rigidity, uterus just palpable

Percussion:
Resonant, no dullness, shifting dullness, fluid thrill

Auscultation: normal bowel sounds heard

 PELVIC EXAMINATION:

◦ Inspection and palpation of external genitalia: vulva vagina looks

normal
◦ Per speculum examination: cervix vagina healthy. No discharge/
bleeding pv.
◦ Bimanual examination: uterus bulky 12 wks size, globular,
mobile, tenderness present. Bilateral fornices free, not tender
◦ Per rectal examination: rectal mucosa free, no abnormalities.
Provisional diagnosis:
42 yr old female P3L3 with AUB with moderate anemia

Differential diagnosis:
◦ Adenomyosis
◦ Fibroid
◦ Endometrial Hyperplasia
◦ Polyp
 Investigations
 UPT - Negative
 Hemogram with P/S – 7.9gm/dL platelet 1.8 lac
 TSH -1.75
 BT/CT- normal
 PT/aPTT – normal
 ESR, Mantoux, CXR – Normal

USG(TVS) finding:
Uterus bulky, multiple intramyometrial cysts 2 to 7mm size, endo-
myometrial junction ill defined. ET = 10mm, B/L adnexa normal.
 Final Diagnosis

42 year old P3L3 women with AUB-Adenomyosis with

moderate anemia.
 WHAT IS ADENOMYOSIS?
Presence of ectopic rests of endometrium (both glands and stroma) in
the myometrium of the uterus, surrounded by reactive smooth
muscle hyperplasia.
EPIDEMIOLOGY
INCIDENCE:
 20-40 %
 may vary depending on histologic criteria and on the degree of sectioning . (Vercillini 2006)
 was found to be around 21 % in patients diagnosed using TVS alone. (Naftalin 2012 )

Williams Gyne 4e
More common in multiparous women.

Other risk factors :

 early menarche (</=10 years)
 shorter menstrual cycle duration
 use of menopausal hormone therapy
 history of prior uterine surgery
UpToDate
ADENOMYOSIS CHANGING
TREND
The disease is no longer considered typical of women above 40 years of age.
Affects 30% of young women, and infertile women.

Diagnosed in 22% of infertile women less than 40 years undergoing ART .

(Puente JM et al Reprod Biol Endocrinol 2016 )
 CLINICAL PRESENTATION

PELVIC PAIN INFERTILITY,RPL

ABNORMAL UTERINE BLEEDING
• Dysmenorrhea in 25- 80% • Altered uterine
• HMB is most common(50-60 %).
• Intermenstrual bleeding can be seen in • Dyspareunia in 15-20 %. peristaltic activity
• Chronic pelvic pain- 5% • Altered endometrial
adenomyotic polyp.
• Increased surface of the enlarged uterus, • Bleeding and swelling of receptivity at molecular
endometrial islands confined level.
overexpression of inflammatory mediators in
by myometrium. • Impaired implantation
the adenomyotic tissue, or contractile
dysfunction of the uterine smooth muscle as a
result of the ectopic endometrium. ASYMPTOMATIC-
33%
Pathogenesis:
Four theories are suggested :
◦ Downward invagination of endometrial basalis
layer into the myometrium (most accepted
theory).
◦ De novo from mullerian remnants.
◦ Microtrauma of the endometrial/myometrial
interface (i.e. junction zone JZ)
◦ Establishment of lesions from retrograde
menstruation of endometrial cells.

The lack of basement membrane between the

endometrium and myometrium likely influences these
processes.
PATHOPHYSIOLOGY:
ESTROGEN AND PROGESTERONE RECEPTOR UPREGULATION:
o Both receptors upregulation is noted.
o Exposure to estrogen modulator like TAMOXIFEN leads to cystic changes in myometrium similar to
adenomyosis histopathological changes.

AROMATASE RECEPTOR UPREGULATION:

o Therefore GnRH agonists& antagonists and danazol plays role in treatment.

PITUARY PROTEIN HORMONES ASSOCIATION:

o Prolactin, FSH, Oxytocin is found to be associated.
o Patients with adenomyosis and hyperprolactinemia on bromocriptine (dopamine agonist ) were shown to
have improvement in symptoms of dysmenorrhea.
o Progesterone upregulates prolactin receptors in endometrium according to some studies.
INFLAMMATION AND CELLULAR CHANGES:
o The presence of ectopic endometrial tissue within the myometrium triggers a local
inflammatory response.
o This leads to increased production of inflammatory mediators and cytokines.
o The abnormal growth and presence of these cells cause changes in the myometrial
architecture and can result in the enlargement and thickening of the uterus.
MUSCULAR DYSFUNCTION AND SYMPTOMS:
o Increase in uterine size is due to hypertrophy of myometrium surrounding the ectopic
rests.
o The abnormal positioning of endometrial tissue within the myometrium disrupts the
normal contractility of the uterine muscle
o This leads to heavy or prolonged menstrual bleeding, dysmenorrhea ,pelvic pain.
Mechanisms through which adenomyosis can cause poor
fertility outcome.
Associated with :
LEIOMYOMA (more common)
Similarity in pathogenesis i.e growth factor dysregulation and abnormalities of angiogenesis.

ENDOMETRIOSIS
Persistence of pelvic pain following optimal endometriosis surgical therapy strongly points towards adenomyosis.
Patients with adenomyosis compared with endometriosis had increased parity, earlier menarche, and shorter
menstrual cycles.

ADVERSE PREGNANCY OUTCOMES

• Miscarriage
• preterm birth
• small-for-gestational age

INFERTILITY
Focal>diffuse
TYPES OF ADENOMYSOSIS:
DIFFUSE
GROSS: Uniformly enlarged and
boggy.
HPE- Myometrium thickened with
endometrial glands dispersed
throughout myometrium.
USG : If <25% of the circumference
of lesion is surrounded by normal
myometrium
HISTOPATHOLOGICALLY
JUNCTIONAL
ZONE DISEASE
FOCAL Endometrial tissue within the
myometrium at a distance of at
GROSS: Resembles leiomyoma without least two low-power fields from
pseudo capsule. JZ zone.
HPE: Nodular aggregates of endometrial
glands in one part of myometrium.
USG: >25% of the lesion is surrounded by
normal myometrium.
Williams 4e
EVALUATION
HISTORY TAKING
• Detailed menstrual history.
• To rule out other causes of AUB.
• Other relevant chronic illness.

GENERAL EXAMINATION
◦ Look for signs of anemia.
◦ Look for signs of malignancy.

ABDOMINAL EXAMINATION
• For palpable masses or free fluid.

PER SPECULUM EXAMINATION

◦ Can help us identify associated conditions
PELVIC EXAMINATION :
◦ Mobile
◦ Soft, boggy
◦ Symmetrically enlarged (not more than 12 weeks size)
◦ Globular uterus
◦ Tenderness- Halban sign
LABORATORY INVESTIGATION – similar to AUB management
◦ Urine Pregnancy test- to rule out pregnancy as most patients present
with AUB.
◦ CBC
◦ Coagulation profile (BT/CT/APTT/PTT/Vwf/factor viii/ristocetin factor
assay)- if indicated by a positive screening history for coagulopathy.
◦ S.TSH
◦ Blood sugar fasting &Postprandial
◦ LFT/ KFT- if clinically indicated.
◦ CA-125 levels may be raised.
NO DEFINITIVE LABORATORY INVESTIGATIONS FOR
ADENOMYOSIS.
IMAGING MODALITY
 TRANSABDOMINAL ULTRASOUND

 Findings- Uterine enlargement or asymmetric thickening of anterior and

posterior myometrial walls.
 Not reliable for diagnosis due to poor image resolution.
 TRANSVAGINAL ULTRASOUND

1ST investigation to be done.

MUSA Criteria for adenomyosis – presence of >/= 2 features out of 8.
 MUSA CRITERIA for diagnosis of adenomyosis :

A)Asymmetrical myometrial thickening

B)Myometrial cysts
C)Hyperechoic islands
D)Fan shaped shadowing
E)Echogenic sub endometrial lines and buds with linear striations
(venetian blind appearance)
F)Trans lesional vascularity
G)irregular junctional zone
H)Interrupted junctional zone
NORMAL TRANSVAGINAL ULTRASOUND
MYOMETRIAL
CYSTS

VENETIAN BLIND APPEARANCE

◦ FOCAL ADENOMYOSIS APPEARS AS DISCRETE HYPOECHOIC
NODULE .
◦ Can be differentiated from leiomyoma by
 ELLIPTICAL SHAPE
 MINIMAL MASS EFFECT ON SURROUNDING
TISSUES
 LACK OF CALCIFICATIONS

DOPPLER - shows diffuse vascularity in affected myometrium.

 MR
I
Gold standard imaging modality for assessing the junctional zone.
MRI clearly distinguishes focal and diffuse adenomyosis from leiomyomatosis. The common
features on MRI include –

 Thickening of the JZ, JZ thickens ≥ 12mm or

 Irregular junctional thickness with a difference of >5 mm between the maximum & minimum
thickness.
 Islands of ectopic endometrial tissue identified as punctate foci of high signal intensity on T1
weighted image.
 An ill-defined low signal intensity in the myometrium on > 2 weighted MR images.
Not the first imaging modality & reserved for patients
• Distinguish Diffuse and focal adenomyosis.
• Distinguish Focal adenomyosis and leiomyomas.
• and/or to help with treatment (e.g., surgical, interventional) planning.

SENSITIVITY SPECIFICITY

ULTRASOUND 72 81

MRI 77 89
Features of adenomyosis can also change with the menstrual cycle. For example, cysts may become larger
and echogenic masses within the myometrium may change in echogenicity during the menstrual cycle.

Computed tomography (CT) has no role in the assessment of adenomyosis .

Katsumata et al :1989
 SHEAR WAVE ELASTOGRAPHY
◦ Along with TVS/MRI to measure myometrial stiffness may improve diagnostic
accuracy.
◦ Decrease in the elasticity is noted.
 HSG

◦ HSG is not used in the diagnosis of adenomyosis.

◦ Occassional findings of spiculations (1-4 mm) from endometrium towards
myometrium can be seen.
 HYSTEROSCOPY
◦ Done as a part of workup as most of the patients present with AUB.
◦ Findings suggestive are :
• HYPERVASCULARIZATION
• IRREGULAR ENDOMETRIUM WITH ENDOMETRIAL
DEFECT
• CYSTIC HEMMORHAGIC LESION (STRAWBERRY
PATTERN)

oLimited data on diagnostic accuracy.

 ENDOMETRIAL BIOPSY
◦ Endometrial biopsy is not informative in the diagnosis of adenomyosis since it is a myometrial disease.
◦ Often required in patients with adenomyosis since they have AUB, and endometrial hyperplasia or
carcinoma must be excluded.
◦ In addition, thickening of the junctional zone on ultrasound can sometimes be misinterpreted as
endometrial thickening, which may lead to additional endometrial evaluation (e.g. endometrial biopsy,
dilation and curettage with hysteroscopy) in some patients.

(?)NEEDLE BIOPSY
• Not common practice and is reserved for clinical situations in which a malignancy needs to be
excluded.
• Sensitivity of needle biopsy depends on several factors, including the extent of disease, number of
biopsy specimens obtained, sampling site, needle gauge, and operator experience.
 DEFINITIVE DIAGNOSIS -
HISTOPATHOLOGY

 Presence of endometrial tissue more than 2.5 mm below the endomyometrial junction or a JZ
>12 mm thickness.
 According to the depth of adenomyotic foci:

DEEP SUPERFICIAL
(>80%) INTERMEDIATE (<40%)
(40%-80%)
MANAGEMENT OF
ADENOMYOSIS
NON HORMONAL HORMONAL

NSAIDS Progesterone-oral
(First line) Injectable: DMPA
LNG IUS: Mirena (Preferred
first line)

Antifibrinolytic Estrogen +progesterone(OCP)

Danazol

GnRH Analogue

GnRH Antagonist

Mifepristone
 NON-HORMONAL
NSAIDS
TRANEXAMIC ACID
 PG synthesis inhibitor- COX 1 (present on platelets) and COX 2. MOA- Antifibrinolytic action.
 Decreases inflammatory mediators thus giving pain relief. Decrease blood loss by 40-50%.
Minimal side effects.
 Cost effective and well tolerated.
 Decreases blood loss by 25 percent.
 EG. MEFENEMIC ACID,IBUPROFEN , NAPROXEN.
 Side effect-GI side effect, gastritis
NSAID DOSAGE
1)MEFENEMIC 500 mg TDS X 5 days.
ACID
2)NAPROXEN 550 mg on first day then 275 mg daily.
3)IBUPROFEN 600 mg daily throughout menses.
TXA 1.3 g 3 times daily x 5 days.

Williams gyne 4e
 LOCA PROGESTERON
L
E IUS- “MIRENA”
LNG
1st line of treatment
Contains 52 mg LNG
Releases- 20 mcg/day
Life - 5 years
Efficacy- 94-96% decreases blood loss
MOA- 1)decidualization of endometrial stroma
2)atrophy of endometrial glands
Advantages
• effective for long term
• decrease need for hysterectomy
• decrease dysmenorrhea
EXPULSION RATE – 16%
PREMATURE REMOVAL-
18%
 ORAL PROGESTERON
EACETATE (Dose- 5 mg TDS to a maximum of 10 mg TDS)
NORETHISTERONE
MEDROXYPROGESTERONE ACETATE (Dose 10-20 mg/day)
• Efficacy :20-30% decrease in bleeding
DECREASED
• Mechanism –Conversion of E2 to E1 (rapidly cleared from body) ESTROGEN
Inhibits estrogen receptor replenishment LEVELS

• Duration of treatment-Ovulatory:5-25 day ENDOMETRI

AL THINNING
Anovulatory:15-25 day
Hyperplasia: high dose

NICE 2007
 INJECTABL PROGESTERON
E
E

DMPA:
150 mg i.m 3 monthly.
Long acting.
Initially –irregular bleeding.
Can induce amenorrhea in 50% users after 1 year and 80% after 5 years.
OCP’s
◦ Has majorly Progesterone as its component.
◦ Regulates AUB.
◦ Dose-1 pill daily. X 3 weeks and 1 week off.
◦ MOA-Decidualization & atrophy of endometrial tissue &
decrease of retrograde menstruation. Regimen
• Cyclic
◦ Side effects -Nausea/vomiting, headache, irregular • Extended
bleeding, hypercoagulation status • Continuous

Product Estrogen Progestin

Mala N, Mala D Ethinyl Estradiol 30mcg Levonorgesteral 150mcg
Yasmin EE 30 mcg Drosperinone 3mg
Ovral G EE 50mcg Norgestrel 0.5mg
GnRH agonists
MOA- Down regulation of gonadotropin releasing
hormone.
Given by I.M route
BENEFIT: In 3 months
90% decrease in HMB
35-50% decrease in uterine volume
SIDE EFFECTS :
Osteoporosis (6% trabecular loss in 6 months)
vasomotor symptoms, mood swings.
ADD BACK THERAPY :
To counteract the hypoestrogenic side effects.
Low dose estrogen combined with progestin is added .
DRUG DOSAGE

LEUPROLIDE (ONLY FDA APPROVED 3.75 mg monthly/ 11.25 mg 3 monthly i.m

)
GOSERELIN 3.6 mg monthly/10.8 mg 3 monthly s.c

TRIPTORELIN 3.75 mg monthly/ 11.25 mg 3 monthly i.m

NAFARELIN 200 mcg twice daily nasal spray

GnRH
ANTAGONISTS

Advantage – Initial flare is avoided.

Add back therapy is needed after 6 months .
Drugs- None are FDA approved as of yet .
◦ Elagolix plus estradiol and norethindrone.
◦ Relugolix plus estradiol and norethindrone.
 DANAZOL
Dose-200-400mg/day (max-800mg)*4-6 month.

MOA-aromatase inhibitor (synthetic steroid)

antiestrogen, antiprogesterone eeffect .

Efficacy- 80% decrease in blood loss.

Disadvantages-Androgenic effect(therefore not preferred), Hypoestrogenism

SELECTIVE
PROGESTERONE
RECEPTOR MODULATOR
ULIPRISTAL ACETATE
• Dose-5 or 10 mg OD for 3 months then
1 month off.
• maximum upto 4 times
• Baseline LFT
• S/E- hepatic toxicity
•Not recommended
•Off label use.
MIFEPRISTONE
◦ PROGESTERONE ANTAGONIST
◦ MOA- competitively binds and inhibit
progesterone receptor.
 cause atrophy of spiral artery and inhibit
angiogenesis .
 induce anovulatory amenorrhea without
hypoestrogenism.
 Dose- 10mg oral daily.
AUGUST 2023
SURGICAL MANAGEMENT
CONSERVATIVE PROCEDURES
Uterus-sparing resection:
◦ Adenomyomas are not easily excised.
◦ Surgical plane often cannot be easily developed, and sharp dissection is required.
◦ The consistency is woody , suturing is difficult in this environment.
◦ Preoperative MRI is necessary .
◦ Preoperative GnRH agonists are administered.
◦ Disadvantage :
1) Uterine rupture in a future pregnancy is reported to be 4 percent and occurs between 12
and 35 weeks of gestation.
2) Abnormal placental attachment.
◦ It is important to know the type of adenomyosis according to the depth by MRI.
WHO WILL BENEFIT FROM THESE
PROCEDURES ?
 ABNORMAL UTERINE
BLEEDING
NOT RESPONDING TO MEDICATION

 DYSMENORRHEA
NOT RESPONDING TO MEDICATION

 RECURRENT ABORTION

 IVF FAILURES
DUE TO IMPLANTATION FAILURE

Osada et al 2018
Techniques:
ADENOMYOMECTOMY
(Open/Laparoscopic/Hysteroscopic)
(H-incision technique/Wedge resection)

Lap MYOMETRIAL ELECTROCOAGULATION

ENDOMETRIAL ABLATION
(Hysteroscopically-In TYPE 1 AD)

RADIOFREQUENCY ABLATION
(Transcervically / laparoscopic / USG guided)
Excisional Surgical Technique
TRANSVERSE H- INCISON
TECHNIQUE
WEDGE RESECTION OF
UTERINE
WALL(OPEN/LAPAROSCOPIC)
ASYMMETRIC DISSECTION OF
UTERUS
Method
H- shaped incision on anterior uterine wall & serosa is widely separated from the
underlying myometrium. The
adenomyoma tissue is removed using an electro surgical scalpel or scissors. A
tension-less suturing technique is used to apposition the myometrial edges and
close the wound in one or two layers.
Part of seromuscular layer with adenomyoma removed by wedge resection after a
sagittal incision in the
uterine body.
Uterus dissected in asymmetrical fashion, removing adenomyotic lesion using
loop electrode and a high
frequency cutter. From the incision, the myometrium is dissected diagonally as if
hollowing out the uterine cavity.
While inserting the index finger in tothe uterine cavity, the adenomyosis lesion is
excised to >5 mm of the inner myometrium. The lesion is then excised to >5 mm
of the serosal myometrium. Afterwards, the uterine cavity is sutured and closed,
followed by uterine reconstruction.
 TRIPLE FLAP METHOD

a) Adenomyomectomy.
b) Reconstruction of a uterine cavity which can sustain subsequent
pregnancy in which an endometrial uterine muscle flap is prepared by
metroplasty.
c) Reconstruction of a uterine wall resistant to rupture. The uterine
muscle on the serosal side is used to fill the large uterine wall muscle
defect.

54 % PREGNANCY RATE, NO RUPTURE

 Uterus is bisected with a scalpel from the serosal surface of the fundus, in the midline and in the
sagittal plane, all the way down through the adenomyosis until the uterine cavity is reached (Figure
3A).
 Entire extent of the adenomyosis is clearly visible, with the landmarks of the endometrium and the
serosal surface always in clear .
 The endometrial cavity is opened sufficiently to permit the introduction of the index finger to protect
and help guide during excison.
 The adenomyotic tissues are grasped with Martin forceps and excised from surrounding myometrium
leaving a myometrial thickness, from the serosa above and the endometrium below, of 1 cm.
 This results in an external uterine wall composed of serosa and also 1 cm of myometrium and an inner
uterine wall composed of the same thickness of myometrium and normal endometrial lining (Figure
3B and C).
The endometrial lining is then approximated with interrupted sutures of 3–0 Vicryl (Figure
3D).

Myometrial defect has to be closed with the triple-flap overlap method, with care being taken
to avoid overlapping suture lines.
On one side of the bisected uterus the myometrium and serosa are approximated in the antero-
posterior plane with many interrupted sutures of 2–0 Vicryl (Figure 3E).

Then the contralateral side of the uterine wall (composed also of serosa and myometrium) is
brought over the reconstructed first side in such a way as to cover the seromuscular suture
line (Figure 3F).
Suture lines must not overlap; only myometrial tissue flaps overlap.
 Family complete:

HYSTERECTOMY – Definitive management.

UTERINE ARTERY EMBOLIZATION-
Who have failed hormonal treatment and decline, or have contraindications to, hysterectomy,
uterine artery embolization (UAE) may be used to reduce symptoms related to adenomyosis.
264 Women with adenomyosis treated with UAE
(252 completed 12 months follow up/ 195 completed 5 years followup)

 70% had improvement in dysmenorrhea.

 1.5% failed therapy.
 3.0% had POF within 3 months of treatment.
 9 patients had hysterectomies.
 22% lost to follow up.

Zhou et al, 2016

 ADENOMYOSIS AND FERTILITY

• Routine infertility workup is done for women presenting with adenomyosis associated infertility.
• A long protocol GnRH agonist suppression is given for women with normal ovarian function for
spontaneous conception.
• Immediate IVF is advised to women with low ovarian reserve.
• Surgery is not taken in to consideration before ART.
• Repeat long protocol GnRH agonist based IVF/ICSI treatment if natural conception is not possible.
• Indication of conservative surgery if there are severe symptoms & repeat failure of long protocol
GnRH agonist based IVF/ICSI therapy.
• Long protocol.
AUB-POLYP
Types of polyps
Endometrial polyps
Endo cervical polyps
What is endometrial polyp?
Endometrial polyp is hyperplastic growth of endometrial glands and stroma
around a vascular core which forms a sessile or pedunculated projection from
surface of endometrium.
Epidemiology
Prevalence of endometrial polyp in
General population is 9%
Pre menopausal female 7.6%
Post menopausal female 13%
Prevalence is higher in patients undergoing endometrial biopsy
Those with infertility undergoing in vitro fertilization 6 to 30%
Endometrial polyps are rare among adolescent patients

Ref-UpToDate
Williams gyne 4th ed
Risk factors
Obesity
Compared BMI of >/= 30kg/m2 versus <30kg/m2,rate of polyps 52% and 15% respectively
Advanced age
Tamoxifen use
Endometrial Polyps are diagnosed in 30-60% of patients on tamoxifen therapy
Polyps are most common type of endometrial pathology associated with Tamoxifen use
Hormone replacement therapy
Syndromes-lynch syndrome, cowden syndrome
The presence of more than one polyp and endometriosis may be independent risk factors of
recurrent polyps
Ref-UpToDate
Williams gyne 4th ed
Protective factors
Oral contraception use
Levonorgestrel IUD
Pathogenesis
Molecular mechanisms
Monoclonal endometrial hyperplasia
 Overexpression of endometrial aromatase
 Somatic gene mutation
 Age-related accumulation of low-frequency single nucleotide variants in
oncogenes, including mutations in KRAS, PTEN, and TP53
Endometrial polyps express both estrogen and progesterone receptors and
these hormones may play a role in pathogenesis
Ref-UpToDate
Williams gyne 4th ed
Clinical presentation 72% asymptomatic

Most common clinical manifestation of polyp is

Abnormal uterine bleeding 1.Heavy menstrual bleeding
2.Prolonged bleeding
3.Inter menstrual bleeding

1.In pre menopausal female-inter menstrual bleeding or irregular bleeding

2.In post menopausal female-post menopausal bleeding
Cause bleeding due to vascular fragility, chronic inflammation and surface erosions
Polyps may be a cause of infertility but do not lead to adverse pregnancy outcomes
Endometrial polyps are found in 3-5% of infertile women
Ref-UpToDate
Williams gyne 4th ed
Risk of malignancy in endometrial
polyp
95% cases of polyps are benign
The risk of malignancy is higher in selected patients

• Postmenopausal patients-3 fold higher risk when compared to pre menopausal

females(5.4% versus 1.7%)
• Patients with symptoms(bleeding)-1.2%(10 times higher than
asymptomatic,which is 0.1%)
• Patients using tamoxifen
• Those with a hereditary cancer syndrome
• Co existing hyperplasia-especially in post menopausal women
Ref-UpToDate
Williams gyne 4th ed
EVALUATION
HISTORY TAKING
• Detailed menstrual history.
• To rule out other causes of AUB.
• Other relevant chronic illness.

GENERAL EXAMINATION
• Look for signs of anemia.
• Look for signs of malignancy.

ABDOMINAL EXAMINATION  Beefy red in color

• For palpable masses or free fluid.  Arising from endocervical
canal
PER SPECULUM EXAMINATION  Smooth surface
 Generally pedunculated with
• Endo cervical polyps are diagnosed by per speculum examination
thin base
PELVIC EXAMINATION :  Soft and friable to touch
• Normal  Detailed glands sometimes be
visualized
• LABORATORY INVESTIGATION – similar to AUB management
• Urine Pregnancy test- to rule out pregnancy as most patients present
with AUB.
• CBC
• Coagulation profile (BT/CT/APTT/PTT/Vwf/factor viii/ristocetin factor
assay)- if indicated by a positive screening history for coagulopathy.
• S.TSH
• Blood sugar fasting &Postprandial
• LFT/ KFT- if clinically indicated.
1.1st imaging in AUB patient-TVS(trans vaginal ultrasound)
2.Investigation of choice for endometrial polyp-Diagnostic Hysteroscopy
3.Gold standard investigation for endometrial polyp-Histopathology
4.Other investigation-Sonohysteroscopy (saline infusion sonography)
 TVS(Trans Vaginal Ultrasound)
Hyperechoeic
Well defined, homogenous polypoid lesion isoechoic to endometrium
Narrow base
88% sensitive,82% specific
On doppler-feeder vessel sign(pathognomic Of polyp)
HYSTEROSCOPY
Smooth,soft,friable
Reddish beefy structure
Pedunculated
No surface vessels

SALINE INFUSION SONOGRAPHY

 Well-defined
88% sensitivity,92% specificity
 Homogeneous
 Polypoid lesion iso echoic to the endometrium with
preservation of the endometrial-myometrial interface
HISTOPATHOLOGY
Endometrial glands, stroma and central vascular channels
Definitive diagnosis of polyp made only after histopathology
report (therefore all polyps removed to be sent for HPE)
HPE also excludes malignancy
endometrial sampling cannot be used to reliably assess
the histology of the polyp as it is blind procedure
 Cervical polyp presents with inter
menstrual bleeding,post coital
Differential diagnosis bleeding and vaginal discharge

Intra cavitary leiomyoma Endometrial hyperplasia or Prolapsed leiomyoma

carcinoma
On USG-hypoechoic with
shadowing and peripheral Differentiated from cevical
can be differentiated from
vascularity polyp by visualising or
polyp by hysteroscopy but
On hysteroscopy-firm,sessile palpating stalk.
histopathology excludes
and pale color For cervical polyp -
malignancy
soft,friable and stalk from
endocervical cnanl
For prolapsed leiomyoma-
firm mass and stalk not
visualised
Management
1.Expectant management-In asymptomatic patient
Incidental finding
No risk factor for malignancy
2.polypectomy-Vaginal polypectomy
Hysteroscopic polypectomy

Endometrial polyps resolves spontaneously if small size(<1.5mm)

Indictions for polypectomy
In all post menopausal female irrespective of symptoms
In pre menopausal female if
1.AUB
2.Infertility
3.Multiple polyps
4.Size of polyp>1.5cm
5.Prolapsed polyp
6.Recurrent polyp
Hysteroscopic polypectomy
Polypectomy under hysteroscopic guidance is the treatment of choice for most
endometrial polyps
Polyp base can be incised with-1.Hysteroscopic scissor
2.Resectoscope
3.Morcellator
Pre operative evaluation
Patient evaluation-pre op Trans vaginal sonography or Saline infusion sonography to
know size,number and location of polyp

Consent-complications rare but informed consent for bleeding,infection,uterine

perforation,fluid overload and air embolism to be taken

Patient preperation-
1.usually performed during follicular phase of menstrual cycle
2.preoperative endometrial biopsy completed as part of AUB evaluation
3.Pre operative antibiotics,analgesia and VTE prophylaxis not required
Intra operative
Instruments-Resectoscope with 90 degree loop electrode ideal
other-Intra uterine morcellator can also be used

Anesthesia-local anesthetic(para cervical block) or IV sedation is suitable

Position-Lithotomy,vagina is surgically prepared and bladder drained

Medium selection-If monopolar resectoscope is used,non electrolyte solution is required

If morcellator or bipolar resectoscope is used,normal saline preferred

Cervical dilation-depending on size of hysteroscope chosen(usually>/=8mm)

cervical ripening with miso also done
Resection-
1.Medium flow is begun, and the resectoscope is inserted into the endocervical canal with
direct hysteroscopic guidance.
2.panoramic inspection is completed to identify the location and number of polyps.
3.The resecroscope loop then is extended to reach behind each polyp
4.polyp is grasped and extracted along with hysteroscope through
the cervical os.
5.If polyp is large, several passes with the loop electrode may be required to complete excision.

Morcellation
1.After distention medium flow started-hysteroscope and morcellacion device housed
within its operating channel are inserted.
2.Excision proceeds from polyp tip toward the base
The morcellacor also provides suction, which can clear blood, tissue debris, and clots during
resection oflarge growths.
Control of bleeding
1.Coagulation with same resectoscope loop
2.Foley catheter with 30ml balloon as tamponade to stop bleeding

Instrument removal
1.Flow of distension media stopped
2.Hysteroscope and tenaculum removed
3.Fluid deficit must be calculated

Reference
Williams gyne 4th ed
Post operative care
Recovery is rapid within 24 hours(resumes normal activity within 24 hours)
Usually patients experience post operative cramping and light bleeding
Acetaminophen or NSAIDS for pain

Complications
Most common complication-Perforation of the uterus (0.12 percent)
Other complications
1.Fluid overload (0.06 percent)
2.Intraoperative hemorrhage (0.03 percent)
3.Bladder or bowel injury (0.02 percent)
4. Endomyometritis (0.01 percent). Reference
UpToDate
Hysteroscopic polypectomy(resectoscope)

Hysteroscopic polypectomy using morcellator

 Vaginal polypectomy
Done for cervical polyps
Pre operative evaluation same as hysteroscopic polypectomy
Steps-lithotomy position
If pedicle is
vaginal preperation done and bladder emptied thick,surgical ligation
vaginal walls retracted and excision is done to
avoid excessive bleeding
polyp identified
grasped by ring forceps
polyp twisted repeatedly about base of its stalk polyp removed from its base