Endometrium is the name given to the layer lining the inside of the uterus and the cells that form this layer. The masses that occur as a result of the uncontrolled growth of these cells, usually round in shape, are called endometrial polyps. Therefore, when endometrial polyps are examined under a microscope, cells belonging to the endometrium layer lining the inside of the uterus are seen. These endometrial polyps can range in size from a few millimeters to centimeters.
It is not known exactly why endometrial polyps form. However, some submicroscopic examinations detected in polyps have revealed that both the estrogen hormone and some activities in the polyp region change in polyp development.
Endometrial polyps, as described above, are caused by excessive growth of the endometrial tissue lining the inside of the uterus. Their formation is not cancerous. However, pathological examination of polyps has revealed cancer or precancerous lesions with a frequency of 0% to 13%. It has also been reported that endometrial polyps that cause irregular bleeding, those detected in patients with polycystic ovary syndrome, and those who bleed during menopause or over the age of 60 are more likely to be cancerous than polyps that are detected incidentally and do not cause abnormal bleeding. Therefore, endometrial polyps should be treated by taking these risks into consideration.
Endometrial polyps are usually a problem of the fertile age. Some patients may not show any symptoms. In other patients, they cause abnormal bleeding. Abnormal bleeding can cause problems such as increased menstrual bleeding in women who previously had regular menstrual periods, intermenstrual bleeding, in some cases, bleeding in the form of continuous menstrual bleeding, inability to conceive (infertility), or abnormal bleeding after menopause in women who have entered menopause. Sometimes, endometrial polyps grow excessively and extend down from the uterus to the cervix, where they can be seen as a mass during examination.
Women with endometrial polyps usually visit their gynecologist with complaints of abnormal bleeding, postmenopausal bleeding or inability to conceive. If there is an endometrial polyp protruding from the cervix during a gynecological examination, it can be detected during the examination. During a gynecological examination, a polyp or polyps with bright (hyperechoic) appearance that can be distinguished from normal endometrial tissue can be detected in the endometrial cavity during a transvaginal or transabdominal ultrasound. However, the diagnosis of endometrial polyps with ultrasonography is not 100% and a significant number of polyps may not be detected during ultrasonography.
The ultrasonographic diagnosis of endometrial polyps can be improved by injecting serum into the endometrial cavity through the cervix using saline infusion sonography (SIS). However, during this procedure, the fluid injected into the uterus through the cervix will be poured into the abdominal cavity through tubes. If there are cancer cells in the endometrium or on the polyp, there is a possibility that these cells will spread to the abdominal cavity due to the procedure we performed. Furthermore, since it will not be possible to understand whether there are cancer cells or bad cells on the polyp or in the uterus during this procedure, this procedure is not usually used much in routine practice.
In the diagnosis of endometrial polyps, a polyp can be diagnosed by entering the uterus with curettage cannulas and taking biopsy samples and pathologically examining these samples. In addition, this examination can also determine whether there are cancer cells in the uterus and on the polyp. These curettage biopsy procedures can be performed on an outpatient basis under local anesthesia or sedation without the need for an operating room.
The gold standard for diagnosing endometrial polyps is a procedure called hysteroscopy. Although hysteroscopy can be performed in office conditions (office hysteroscopy), if there is a polyp and it is to be removed, operative hysteroscopy, that is, hysteroscopy under anesthesia in operating room conditions, would be more appropriate. In hysteroscopic surgery, the cervix is dilated from the vagina and the endometrial cavity is entered with a camera. The inside of the uterus is inflated with various serums in order to obtain a camera image. If there are polyps in the endometrial cavity, they are seen during this procedure. Hysteroscopy allows the removal of these polyps and if there are any, the polyps can be removed. If patients have complaints of irregular menstrual bleeding, taking samples from the endometrial tissues in the form of curettage, whether there are polyps or not, and sending them for pathological examination will also provide diagnosis of additional problems (endometrial hyperplasia or cancer, etc.). Therefore, hysteroscopy is the gold standard in both the diagnosis and treatment of endometrial polyps. In our own practice, we prioritize hysteroscopy in patients with irregular menstrual bleeding due to its advantages in terms of both diagnosis and treatment.
The best and most definitive treatment method for endometrial polyps is hysteroscopy and polyp removal surgery. This procedure is performed in operating room conditions and under anesthesia. Before the procedure, the cervix is dilated enough for the camera to enter with special dilators. Then, it is entered into the uterus (endometrial cavity) by passing through the vagina and cervix. In order for the camera to work, the inside of the uterus will need to be filled with fluid. Previously, monopolar energy modalities were used and the inside of the uterus was inflated with high osmolar fluids. This procedure caused restrictions in the surgery. However, today, the use of bipolar energy modalities has allowed the use of fluids similar to body fluids and surgeries can be performed more comfortably.
After hysteroscopic surgery, patients are usually fit to be discharged a few hours after they recover and are discharged. However, patients who have additional problems such as diabetes, hypertension, obesity, old age, etc., and patients who come from distant areas where there is no hospital are usually hospitalized for one night.
The risks of hysteroscopy surgery are relatively low. Complications related to anesthesia, bleeding, infection, adhesions in the uterus, perforation of the uterine wall, pulmonary edema and related problems if there is excessive fluid absorption are rare problems that can be encountered after hysteroscopy surgery. It would be appropriate to inform patients about these situations before the procedure.
If endometrial polyps are removed with hysteroscopy and completely, that is, with the polyp base, the risk of recurrence is very low. The risk of recurrence for endometrial polyps has been reported to be between 2% and 4% in the literature.
