Patricia S. Huguelet
History of present illness
A 34-year-old gravida 3, para 3 woman presents complaining of heavy and irregular bleeding. She reports menarche at the age of 14, with regular menses until 1 year ago. At that time, she began having much heavier but regular periods. She describes heavy flow once a month, where she changes fully saturated tampons hourly. The bleeding is precipitated by breast tenderness, bloating, and cramping. Over the past three months, she has begun having three to four days of midcycle spotting. Her husband underwent a vasectomy after the birth of her third child two years ago.
She has no significant past medical or surgical history.
Her gynecologic history is negative, including no history of sexually transmitted infections or abnormal cervical screening tests. She is sexually active without any other gynecologic complaints. She denies any significant weight changes, and a full review of systems was otherwise negative.
Physical examination
General appearance:Healthy-appearing woman, obese, and in no apparent distress
Vital signs:
Temperature: 36.9°C Pulse: 78 beats/min
Blood pressure: 120/75 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 99% on room air BMI: 31 kg/m2
HEENT:Unremarkable
Neck:Supple without thyromegaly
Cardiovascular:Regular rate and rhythm, without rubs, murmurs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:Soft, nondistended, active bowel sounds in all four quadrants, nontender without masses or hernias Pelvic:Normal external genitalia; vagina notable only for physiologic discharge; cervix grossly normal; uterus slightly enlarged to six- to eight-week size, mobile, and nontender;
no cervical motion or adnexal tenderness Extremities:Normal
Laboratory studies:
Urine pregnancy test: Negative Hb: 13.3 g/dL (normal 12.1–16.3 g/dL)
Ht: 38.1% (normal 35.7–46.7%)
Neisseria gonorrhoeaeandChlamydia trachomatis endocervical amplified probes: Negative
Imaging:Transvaginal ultrasound was performed (Fig. 37.1)
How would you manage the patient?
The patient has an endometrial polyp. Transvaginal ultrasound imaging demonstrates a nondescript, thickened endomet- rium, with heterogenous features suggestive of endometrial pathology.
Subsequent saline infusion sonohysterography (SIS) clearly delineates the presence of a circumscribed mass, including its size and location (Fig. 37.2).
The patient was counseled and underwent an uneventful operative hysteroscopy with polypectomy (Fig. 37.3).
Pathology confirmed a benign endometrial polyp without hyperplasia or malignancy. Endometrial curettings showed proliferative endometrium. After the procedure, the patient experienced several weeks of light, irregular bleeding, which progressively improved until her next menses. Thereafter, her menses were much lighter, and the intermenstrual bleeding resolved.
Menometrorrhagia and endometrial polyps
Structural abnormalities are frequent causes of abnormal bleeding, and of these, leiomyomas and endometrial polyps are the most common. Endometrial polyps are soft, fleshy intrauterine growths comprised of endometrial glands and fibrotic stroma, covered by a surface epithelium. In contrast, leiomyomas are benign smooth muscle neoplasms that typic- ally originate from the myometrium. Endometrial polyps are common, occurring in 24–41% of women who have abnormal bleeding, and in about 10% of asymptomatic women. The prevalence of endometrial polyps increases with age [1]. Clin- ically, endometrial polyps have been associated with various bleeding patterns including heavy menstrual bleeding, inter- menstrual bleeding, spotting, or postmenopausal bleeding.
Despite these common complaints, most women with polyps are asymptomatic and many polyps are found as incidental findings.
While the majority of endometrial polyps are benign, some polyps may contain premalignant or malignant changes. Pre- malignant changes include hyperplasia, both with and without atypia. However, data regarding atypia is based on diffuse Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
endometrialhyperplasia, not polyps. In studies of women with endometrial hyperplasia, the presence of atypia increases the risk of progression to neoplasia. Furthermore, in the presence of endometrial hyperplasia with atypia, the risk of occult malignancy approaches 40% [2]. In a recent systematic review, the prevalence of premalignant or malignant polyps was 5.42% in postmenopausal women, compared with 1.7% in reproductive-aged women. The prevalence of neoplasia within polyps in women with symptomatic bleeding was 4.15% com- pared with 2.16% of those without bleeding [3]. Based on data from these observational studies, symptomatic vaginal bleed- ing, hypertension, size greater than 1 cm, and postmenopausal
status are all associated with an increased risk of endometrial malignancy [3,4,5].
In the setting of abnormal uterine bleeding due to endomet- rial polyps, the diagnostic goal is exclusion of hyperplasia and malignancy, followed by therapeutic intervention to correct the abnormal bleeding. For women struggling with infertility, restoring normal anatomy may also improve fertility outcomes.
The initial diagnostic evaluation should include pregnancy testing, followed by directed laboratory testing and imaging based on the clinical history. In an effort to create a universally accepted system of nomenclature to describe uterine bleeding abnormalities, a new classification system was introduced by
Fig. 37.2 Subsequent saline infusion sonohysterogram.
Fig. 37.1 Transvaginal ultrasound. (Images courtesy of William W. Brown III, MD.)
the International Federation of Gynecology and Obstetrics in 2011 [6]. The new system is known by the acronym PALM- COEIN, which stands for polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunc- tion, endometrial, iatrogenic, and not yet classified. PALM refers to structural causes and COEIN to nonstructural causes.
When first approaching this clinical scenario, obtaining a detailed menstrual history is paramount, as it is important to establish whether the bleeding pattern is ovulatory or anovulatory [6]. In the absence of ovulation, bleeding will occur erratically, often without moliminal symptoms, suggest- ing a hormonal etiology and nonstructural causes (COEIN).
Conversely, abnormal ovulatory bleeding strongly suggests an anatomic lesion (PALM), as was evident in our case presenta- tion. Physical examination allows the physician to evaluate for vaginal and cervical lesions, as well as to assess uterine size and tenderness.
Once visible lesions have been ruled out, the next step involves assessment of the endometrial cavity. Various tools have been studied to determine their accuracy for detecting endomet- rial pathology. The preferred imaging study for the detection of focal endometrial pathology is SIS. In one study, 160 women suffering from menometrorrhagia were evaluated for the presence of endometrial pathology. All women underwent transvaginal ultrasound, followed by sonohysterography. The final diagnosis was established by diagnostic hysteroscopy and directed biopsy. In this study, the sensitivity and specificity for detection of endometrial polyps by transvaginal ultrasound was 65% and 75% versus SIS which was 93% and 94%, respectively (P<0.001). Transvaginal ultrasound resulted in false positive and false negative rates of 25% and 36.2%, whereas SIS resulted in only a 8.0% false positive and 5.4% false negative rate [7].
Dopplerflow demonstrating a central feeding blood vessel fur- ther increases the specificity of both tests.
In this case scenario, the ovulatory bleeding pattern suggested an anatomic source. After physical examination ruled out a cervical problem, transvaginal imaging was ordered to evaluate for leiomyomas or polyps. The transvaginal ultra- sound did not reveal any intramural pathology but did suggest heterogeneity within the endometrium. To better define the endometrial pathology, a saline infusion ultrasound was subsequently performed.
Transcervical resection is regarded as the optimal treat- ment of endometrial polyps [8]. Resection may be accom- plished with various hysteroscopic instruments, including monopolar and bipolar resectoscopes utilizing radio-freqency energy, as well as newer devices that operate with a rotating mechanical blade. Choice of instrumentation depends primar- ily on provider preference, but does require careful attention to distension media andfluid deficit [9]. Hysteroscopy and polyp resection is generally performed under general anesthesia, but small endometrial polyps that don’t require significant cervical dilation may be amenable to resection in the office setting under local anesthesia, with minimal discomfort to the patient.
These procedures are generally considered safe, with low risk of complications depending on the approach. The most common complications associated with operative hysteroscopy include hemorrhage, cervical laceration, uterine perforation, and volume overload [9].
The treatment of asymptomatic polyps remains controver- sial because the risk of malignancy within these polyps is low and spontaneous regression may occur. Lieng and colleagues prospectively estimated the prevalence and 1-year regression rate of incidentally diagnosed endometrial polyps in women aged 40–45 years [10]. Women were randomly selected and underwent transvaginal ultrasound and SIS in order to esti- mate the prevalence of asymptomatic polyps in their popula- tion. Repeat imaging and hysteroscopy were then performed
(a) (b)
Fig. 37.3 Hysteroscopic confirmation of endometrial polyp at time of resection. (Images courtesy of William W. Brown III MD.)
Case 37: Midcycle spotting and worsening menorrhagia
12 months later. They discovered polyps in 12% of women with a spontaneous regression rate of 27% at 1 year [10].
Patients with incidental/asymptomatic polypfindings should thus be counseled regarding the risks and/or benefits of inter- vention versus expectant management given their clinical context.
The primary goals of treatment of symptomatic polyps are to relieve abnormal uterine bleeding and to rule out hyperpla- sia and malignancy, especially in women with risk factors for neoplasia. According to a recent systematic review by Nathani and Clark, polypectomy improved abnormal bleeding (range 75–100%), with follow-up ranging from 2 to 52 months [11].
In this clinical scenario, the patient was seen at her six-week postoperative visit where she reported resolution of her mid- cycle spotting, as well as decreasedflow during her menses. She was advised that she did not require further follow-up, unless her abnormal bleeding returned.
Key teaching points
Endometrial polyps are a frequent cause of heavy menstrual bleeding, intermenstrual spotting, or postmenopausal bleeding.
Endometrial polyps are present in approximately 10% of asymptomatic women.
The preferred imaging study for detection of an endometrial polyp is saline infusion sonohysterography (SIS). Dopplerflow demonstrating a central feeding blood vessel further increases the specificity of the test.
The risk of hyperplasia and malignancy within
endometrial polyps is overall low but is increased in the postmenopausal patient. Treatment should be directed by patient symptoms and/or risk factors for malignancy.
Hysteroscopic resection is the recommended treatment for endometrial polyps.
References
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