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Which endometrial polyps should be resected?
February 1999, Vol. 6, No. 1 TheJournal of the American Association of Gynecologic Laparoscopists
Which Endometrial Polyps Should Be Resected? Tirso Perez-Medina, M.D., Oscar Martinez, M.D., Gonzalo Folgueira, M.D., and Jose Bajo, M.D.
Abstract
Study Objective. To evaluate the efficacy of color Doppler exploration after diagnostic hysteroscopy in choosing which endometrial polyps can be safely left in situ. Design. Prospective, long-term follow-up study (Canadian Task Force classification II-1). Setting. University hospital. Patients. Two hundred twenty women with hysteroscopically confirmed endometrial polyps. Interventions. Transvaginal ultrasonographic surveillance with color Doppler mapping and hysteroscopic resection. Measurements and Main Results. We removed 126 (57.2%) polyps because of positive color Doppler map, and 29 (13.1%) with a negative color Doppler map because of symptoms. Sixty-five (29.5%) polyps were not removed because they did not cause symptoms and no Doppler map was found. At follow-up, six were removed because of hemorrhagic episodes. At 3 years, 59 patients with endometrial polyps remained asymptomatic by clinical and ultrasonographic follow-up. Conclusion. In this series, 59 patients (26.8%) avoided surgical removal of polyps. (J Am Assoc Gynecol Laparosc 6(1):71-74, 1999)
With the advent of high-resolution transvaginal scans, the diagnosis of endometrial polyps (EP) has increased to almost 20% in women of reproductive age, 30% in postmenopausal women, and 25% in those with abnormal uterine bleeding (AUB). It was calculated that 24% of the general female population have EP. 1 The prevalence is high, and the number of positive diagnoses is increasing as routine transvaginal ultrasonography (TVS) in healthy women is becoming mandatory. The condition must be investigated further,
with outpatient hysteroscopy and directed biopsy the method of choice?, 3 The problem is how to manage so many polyps, but we have found no study addressing this concern. We know that all EP can be resected, but hysteroscopic surgery implies real, although minimal, risks, so removing them all may be too aggressive and leaving them all may be dangerous, as 0.5% will develop into malignant lesions .4 On the other hand, we do not perform surgery on asymptomatic fibroids,
From the Department of Obstetrics and Gynecology, Getafe University Hospital, Madrid, Spain (all authors). Address reprint requests to Tirso Perez-Medina, M.D., Hospital Universitario de Getafe, Carretera Madrid-Toledo Km. 12.500, Getafe, Madrid, Spain; fax 34 91 6839748. Accepted for publication May 31, 1998.
71
Which Endometrial Polyps Should Be Resected? Perez-Medina et al
for which malignant potential is around 0.1% to 0.6%. 5 Since the late 1980s TVS has been enhanced by color Doppler exploration, allowing us to see and measure the vascularity of normal pelvic structures and draw the vascular tree (color map) of tumors including EP. 6 Some EP show positive color map, reflecting functional activity, but others have no Doppler signal and may be considered nonfunctioning. 7 We attempted to determine which polyps must be removed and which ones can be safely left in situ based on color Doppler findings. Materials and Methods FIGURE 1. Color Doppler map reflects vascularity inside an endometrial polyp.
In this prospective study, 220 women with hysteroscopically diagnosed EP were referred from firstlevel screening ultrasound because of abnormal endometrial findings, or from the emergency room because of AUB. Hysteroscopy was performed with a Storz Hamou office hysteroscope of 5.1 mm diameter. Several hysteroscopically directed biopsies were performed in selected areas of the polyps with a 7-ram diameter operative sheet with a 7F channel for biopsy forceps. Biopsy specimens were classified pathologically as hyperplastic, functioning, or nonfunctioning EP. For ultrasonographic exploration, we used an Aloka SSD 2000 machine equipped with a 5-MHz transvaginal probe with a pulse repetition frequency between 2 and 42 kHz. Average space peak time was approximately 80 mW/cm2. The filter was preset at 50 Hz to distinguish between noise and low-frequency signal. A color Doppler map was assessed when even a minimal color signal with flow waveform was found inside the polyp (Figures 1 and 2). Polyps with a positive color Doppler map were removed hysteroscopically with an 8-mm Storz Hamou resectoscope under local anesthesia plus sedation. Premenopausal women were treated with gonadotropinreleasing hormone analogs for 2 months preoperatively. Polyps with negative color Doppler map were removed if they caused symptoms. They were left in situ if they were asymptomatic, and these women were followed clinically and with TVS every 6 months for 3 years. Sensitivity and specificity of the color map were determined to assess functional activity of polyps. Student's t test was used to compare patients' age and
FIGURE 2. Color Doppler shows vessels in the polyp stalk.
size of polyps. A comparison of proportions was performed for statistical analysis by Z 2. Results
One hundred twenty-six (57.2%) EP had a positive color Doppler map and were resected hysteroscopically. Histopathologically, 79 (35.9%) were functioning, 43 (19.5%) were hyperplastic (34 simple hyperplasia, 7 complex hyperplasia, 2 atypical hyperplasia), and 4 (1.8%) were nonfunctioning (atrophic). No cases of adenocarcinoma were found. Of 94 (42.7%) EP with negative color Doppler map, 29 (13.1%) were removed because of AUB.
72
February 1999, Vol. 6, No. 1 Thejournd of the American Association of Gynecologic Laparoscopists
Histopathologically, 27 were atrophic and 2 functioning. Sixty-five EP (29.5%) were left in situ. According to TVS and color Doppler, four EP were functioning, whereas histopathologically they were atrophic (false positives). Two EP were diagnosed by TVS and color Doppler as atrophic, whereas histopathologically they were functioning (false negatives). No false negatives were found for hyperplastic polyps. Sensitivity of preoperative examinations was 97.8% and specificity was 96.8% (Table 1). The EP were between 0.8 and 4.7 cm (mean 2.6 cm). A statistically significant difference was found between size of polyps and presence of symptoms (p <0.005). No statistical differences were found between size and menstrual status (p >0.005) or between symptomatology and patient age (p >0.005). Of 126 EP with positive color Doppler map, 105 (83%) were symptomatic, and only 29 (31%) of 94 with negative color Doppler caused AUB (p <0.001). Polyp size correlated with positive color Doppler map, but this was not statistically significant (p >0.005). Sixty-five EP (30%) were not removed. No symptoms and no color Doppler map developed after 3 years of follow-up in 59 women (26.8%). Six patients experienced hemorrhagic episodes during follow-up, and their EP were resected (6 atrophic).
The prevalence of polyps has been underestimated because they were found only in pathologic specimens after hysterectomy, being difficult to recognize at curettage because they were removed fragmented or frequently missed. 13'14With new generation of TVS color Doppler scans, diagnosis is as accurate as by hysteroscopy, which is considered the gold standard for polyp diagnosis. 15-1v Since the first reports conceming vascularity of pelvic tumors and their diagnosis by TVS color Doppler scan, 18 this method has been valuable in visualizing abnormal pelvic vessels and their characteristics, thus improving diagnostic accuracy. In women in our hysteroscopy unit, EP are the cause of menopausal uterine bleeding in 29% (361/1230 patients), 18% in the premenopausal group (387/3164 patients). It is important to know which ones should be resected and which can be safely left (as we do with asymptomatic myomas with similar malignant potential), thus avoiding anesthetic and surgical risks. Further studies are clearly necessary. References
1. Mazur MT, Kurman RJ: Polyps. In Diagnosis of Endometrial Biopsies and Curettings. Edited by MT Mazur, RJ Kurman. New York, Springer-Verlag, 1995, p 146
Discussion
2. Mencaglia L, Perino A, Hamou J: Hysteroscopy in perimenopausal and postmenopausal women with abnormal uterine bleeding. J Reprod Med 32:577-582, 1987
Endometrial polyps originate as focal hyperplasia of the basalis and develop into benign, localized overgrowths of endometrial tissue covered by epithelium. 8 In general, they are benign; with no malignant potential, 9 although occasional cases of carcinoma can be confined to a polyp. Furthermore, EP were associated with degeneration to carcinoma in several studies.10. 1~ Nonetheless, they are not regarded as a major risk factor for the development of carcinoma.12
3. Motashaw ND, Dave S: Diagnostic and therapeutic hysteroscopy in the management of abnormal uterine bleeding. J Reprod Med 35:616-320, 1990 4. Wolfe SA, Mackles A: Malignant lesions arising from benign endometrial polyps. Obstet Gyneco120:542-551, 1962 5. Seki K, Hoshihara T, Nagata I: Leiomyosarcomaof the uterus: Ultrasonography and serum lactate dehydrogenase level. Gynecol Obstet Invest 33:114-118, 1992
TABLE 1. Sensitivity, Specificity, and Positive and Negative Predictive Values in Statistical Analysis Positive
6. KurjakA, Shalan H, Kupesic S, et al: An attempt to screen asymptomatic women for ovarian and endometrial cancer with transvaginal color and pulsed Doppler sonography. J Ultrasound Med 13:295-301, 1994
Negative
Pathology
Pathology
Report
Report
Totals
7. Hata T, Hata K, Senoh D, et al: Doppler ultrasound assessment of tumor vascularity in gynecologic disorders. J Ultrasound Med 8:309-314, 1989
Doppler+ 122 4 126 Doppler2 92 94 Totals 124 96 220 Sensitivity 98.3, specificity 95.8, positive predictive value 96.8, negative predictive value 97.8.
8. Dallenbach C, Hellweg N: Endometrium. In Histopathology of the Endometrium. Edited by C Dallembach, N Hellweg. New York, Springer-Verlag, 1985, p 196 73
Which Endometrial Polyps Should Be Resected? Perez-Medina et al
15. Fedele L, Bianchi S, Dorta M, et al: Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas. Obstet Gynecol 77:745-748, 1991
9. Schlaen I, Bergeron C, Ferenczy A: Endometrial polyps; A study of 204 cases. Surg Pathol 1:375-382, 1988 10. Salm R: The incidence and significance of early carcinomas in endometrial polyps. J Pathot 108:47-53, 1972
16. Syrop CH, Sahakian V: Transvaginal sonographic detection of endometrial polyps with fluid contrast augmentation. Obstet Gynecol 79:1041-1043, 1992
11. Silverberg SG, Major FJ, Blessing JA: Carcinosarcoma (malignant mixed mesodermal tumors) of the uterus. A gynecologic oncology group pathologic study of 203 cases. Int J Gynecol Pathol 9:1-19, 1990
17. Parsons AK, Lense JJ: Sonohysterography for endometrial abnormalities: Preliminary results. J Clin Ultrasound 21:87-95, 1993
12. Peterson WF, Novak ER: Endometrial polyps. Obstet Gynecol 8:40--49, 1956 13. Scott R: The elusive endometrial polyp. Obstet Gynecol 1:212-218, 1953
18. Kurjak A, Kupesic S: Transvaginal color Doppler and pelvic tumor vascularity: Lessons learned and future challenges. Ultrasound Obstet Gynecol 6:145-159, 1995
14. Word B: Pitfalls of uterine curettage. South Med J 47:38-47, 1954
74
Which Endometrial Polyps Should Be Resected? Tirso Perez-Medina, M.D., Oscar Martinez, M.D., Gonzalo Folgueira, M.D., and Jose Bajo, M.D.
Abstract
Study Objective. To evaluate the efficacy of color Doppler exploration after diagnostic hysteroscopy in choosing which endometrial polyps can be safely left in situ. Design. Prospective, long-term follow-up study (Canadian Task Force classification II-1). Setting. University hospital. Patients. Two hundred twenty women with hysteroscopically confirmed endometrial polyps. Interventions. Transvaginal ultrasonographic surveillance with color Doppler mapping and hysteroscopic resection. Measurements and Main Results. We removed 126 (57.2%) polyps because of positive color Doppler map, and 29 (13.1%) with a negative color Doppler map because of symptoms. Sixty-five (29.5%) polyps were not removed because they did not cause symptoms and no Doppler map was found. At follow-up, six were removed because of hemorrhagic episodes. At 3 years, 59 patients with endometrial polyps remained asymptomatic by clinical and ultrasonographic follow-up. Conclusion. In this series, 59 patients (26.8%) avoided surgical removal of polyps. (J Am Assoc Gynecol Laparosc 6(1):71-74, 1999)
With the advent of high-resolution transvaginal scans, the diagnosis of endometrial polyps (EP) has increased to almost 20% in women of reproductive age, 30% in postmenopausal women, and 25% in those with abnormal uterine bleeding (AUB). It was calculated that 24% of the general female population have EP. 1 The prevalence is high, and the number of positive diagnoses is increasing as routine transvaginal ultrasonography (TVS) in healthy women is becoming mandatory. The condition must be investigated further,
with outpatient hysteroscopy and directed biopsy the method of choice?, 3 The problem is how to manage so many polyps, but we have found no study addressing this concern. We know that all EP can be resected, but hysteroscopic surgery implies real, although minimal, risks, so removing them all may be too aggressive and leaving them all may be dangerous, as 0.5% will develop into malignant lesions .4 On the other hand, we do not perform surgery on asymptomatic fibroids,
From the Department of Obstetrics and Gynecology, Getafe University Hospital, Madrid, Spain (all authors). Address reprint requests to Tirso Perez-Medina, M.D., Hospital Universitario de Getafe, Carretera Madrid-Toledo Km. 12.500, Getafe, Madrid, Spain; fax 34 91 6839748. Accepted for publication May 31, 1998.
71
Which Endometrial Polyps Should Be Resected? Perez-Medina et al
for which malignant potential is around 0.1% to 0.6%. 5 Since the late 1980s TVS has been enhanced by color Doppler exploration, allowing us to see and measure the vascularity of normal pelvic structures and draw the vascular tree (color map) of tumors including EP. 6 Some EP show positive color map, reflecting functional activity, but others have no Doppler signal and may be considered nonfunctioning. 7 We attempted to determine which polyps must be removed and which ones can be safely left in situ based on color Doppler findings. Materials and Methods FIGURE 1. Color Doppler map reflects vascularity inside an endometrial polyp.
In this prospective study, 220 women with hysteroscopically diagnosed EP were referred from firstlevel screening ultrasound because of abnormal endometrial findings, or from the emergency room because of AUB. Hysteroscopy was performed with a Storz Hamou office hysteroscope of 5.1 mm diameter. Several hysteroscopically directed biopsies were performed in selected areas of the polyps with a 7-ram diameter operative sheet with a 7F channel for biopsy forceps. Biopsy specimens were classified pathologically as hyperplastic, functioning, or nonfunctioning EP. For ultrasonographic exploration, we used an Aloka SSD 2000 machine equipped with a 5-MHz transvaginal probe with a pulse repetition frequency between 2 and 42 kHz. Average space peak time was approximately 80 mW/cm2. The filter was preset at 50 Hz to distinguish between noise and low-frequency signal. A color Doppler map was assessed when even a minimal color signal with flow waveform was found inside the polyp (Figures 1 and 2). Polyps with a positive color Doppler map were removed hysteroscopically with an 8-mm Storz Hamou resectoscope under local anesthesia plus sedation. Premenopausal women were treated with gonadotropinreleasing hormone analogs for 2 months preoperatively. Polyps with negative color Doppler map were removed if they caused symptoms. They were left in situ if they were asymptomatic, and these women were followed clinically and with TVS every 6 months for 3 years. Sensitivity and specificity of the color map were determined to assess functional activity of polyps. Student's t test was used to compare patients' age and
FIGURE 2. Color Doppler shows vessels in the polyp stalk.
size of polyps. A comparison of proportions was performed for statistical analysis by Z 2. Results
One hundred twenty-six (57.2%) EP had a positive color Doppler map and were resected hysteroscopically. Histopathologically, 79 (35.9%) were functioning, 43 (19.5%) were hyperplastic (34 simple hyperplasia, 7 complex hyperplasia, 2 atypical hyperplasia), and 4 (1.8%) were nonfunctioning (atrophic). No cases of adenocarcinoma were found. Of 94 (42.7%) EP with negative color Doppler map, 29 (13.1%) were removed because of AUB.
72
February 1999, Vol. 6, No. 1 Thejournd of the American Association of Gynecologic Laparoscopists
Histopathologically, 27 were atrophic and 2 functioning. Sixty-five EP (29.5%) were left in situ. According to TVS and color Doppler, four EP were functioning, whereas histopathologically they were atrophic (false positives). Two EP were diagnosed by TVS and color Doppler as atrophic, whereas histopathologically they were functioning (false negatives). No false negatives were found for hyperplastic polyps. Sensitivity of preoperative examinations was 97.8% and specificity was 96.8% (Table 1). The EP were between 0.8 and 4.7 cm (mean 2.6 cm). A statistically significant difference was found between size of polyps and presence of symptoms (p <0.005). No statistical differences were found between size and menstrual status (p >0.005) or between symptomatology and patient age (p >0.005). Of 126 EP with positive color Doppler map, 105 (83%) were symptomatic, and only 29 (31%) of 94 with negative color Doppler caused AUB (p <0.001). Polyp size correlated with positive color Doppler map, but this was not statistically significant (p >0.005). Sixty-five EP (30%) were not removed. No symptoms and no color Doppler map developed after 3 years of follow-up in 59 women (26.8%). Six patients experienced hemorrhagic episodes during follow-up, and their EP were resected (6 atrophic).
The prevalence of polyps has been underestimated because they were found only in pathologic specimens after hysterectomy, being difficult to recognize at curettage because they were removed fragmented or frequently missed. 13'14With new generation of TVS color Doppler scans, diagnosis is as accurate as by hysteroscopy, which is considered the gold standard for polyp diagnosis. 15-1v Since the first reports conceming vascularity of pelvic tumors and their diagnosis by TVS color Doppler scan, 18 this method has been valuable in visualizing abnormal pelvic vessels and their characteristics, thus improving diagnostic accuracy. In women in our hysteroscopy unit, EP are the cause of menopausal uterine bleeding in 29% (361/1230 patients), 18% in the premenopausal group (387/3164 patients). It is important to know which ones should be resected and which can be safely left (as we do with asymptomatic myomas with similar malignant potential), thus avoiding anesthetic and surgical risks. Further studies are clearly necessary. References
1. Mazur MT, Kurman RJ: Polyps. In Diagnosis of Endometrial Biopsies and Curettings. Edited by MT Mazur, RJ Kurman. New York, Springer-Verlag, 1995, p 146
Discussion
2. Mencaglia L, Perino A, Hamou J: Hysteroscopy in perimenopausal and postmenopausal women with abnormal uterine bleeding. J Reprod Med 32:577-582, 1987
Endometrial polyps originate as focal hyperplasia of the basalis and develop into benign, localized overgrowths of endometrial tissue covered by epithelium. 8 In general, they are benign; with no malignant potential, 9 although occasional cases of carcinoma can be confined to a polyp. Furthermore, EP were associated with degeneration to carcinoma in several studies.10. 1~ Nonetheless, they are not regarded as a major risk factor for the development of carcinoma.12
3. Motashaw ND, Dave S: Diagnostic and therapeutic hysteroscopy in the management of abnormal uterine bleeding. J Reprod Med 35:616-320, 1990 4. Wolfe SA, Mackles A: Malignant lesions arising from benign endometrial polyps. Obstet Gyneco120:542-551, 1962 5. Seki K, Hoshihara T, Nagata I: Leiomyosarcomaof the uterus: Ultrasonography and serum lactate dehydrogenase level. Gynecol Obstet Invest 33:114-118, 1992
TABLE 1. Sensitivity, Specificity, and Positive and Negative Predictive Values in Statistical Analysis Positive
6. KurjakA, Shalan H, Kupesic S, et al: An attempt to screen asymptomatic women for ovarian and endometrial cancer with transvaginal color and pulsed Doppler sonography. J Ultrasound Med 13:295-301, 1994
Negative
Pathology
Pathology
Report
Report
Totals
7. Hata T, Hata K, Senoh D, et al: Doppler ultrasound assessment of tumor vascularity in gynecologic disorders. J Ultrasound Med 8:309-314, 1989
Doppler+ 122 4 126 Doppler2 92 94 Totals 124 96 220 Sensitivity 98.3, specificity 95.8, positive predictive value 96.8, negative predictive value 97.8.
8. Dallenbach C, Hellweg N: Endometrium. In Histopathology of the Endometrium. Edited by C Dallembach, N Hellweg. New York, Springer-Verlag, 1985, p 196 73
Which Endometrial Polyps Should Be Resected? Perez-Medina et al
15. Fedele L, Bianchi S, Dorta M, et al: Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas. Obstet Gynecol 77:745-748, 1991
9. Schlaen I, Bergeron C, Ferenczy A: Endometrial polyps; A study of 204 cases. Surg Pathol 1:375-382, 1988 10. Salm R: The incidence and significance of early carcinomas in endometrial polyps. J Pathot 108:47-53, 1972
16. Syrop CH, Sahakian V: Transvaginal sonographic detection of endometrial polyps with fluid contrast augmentation. Obstet Gynecol 79:1041-1043, 1992
11. Silverberg SG, Major FJ, Blessing JA: Carcinosarcoma (malignant mixed mesodermal tumors) of the uterus. A gynecologic oncology group pathologic study of 203 cases. Int J Gynecol Pathol 9:1-19, 1990
17. Parsons AK, Lense JJ: Sonohysterography for endometrial abnormalities: Preliminary results. J Clin Ultrasound 21:87-95, 1993
12. Peterson WF, Novak ER: Endometrial polyps. Obstet Gynecol 8:40--49, 1956 13. Scott R: The elusive endometrial polyp. Obstet Gynecol 1:212-218, 1953
18. Kurjak A, Kupesic S: Transvaginal color Doppler and pelvic tumor vascularity: Lessons learned and future challenges. Ultrasound Obstet Gynecol 6:145-159, 1995
14. Word B: Pitfalls of uterine curettage. South Med J 47:38-47, 1954
74