High number of endometrial polyps is a strong predictor of recurrence: findings of a prospective cohort study in reproductive-age women

The association between preoperative vaginal dysbiosis and endometrial polyp recurrence after hysteroscopic polypectomy: A retrospective-prospective cohort study

AIM

To explore whether preoperative vaginal dysbiosis influences the recurrence of endometrial polyps after hysteroscopic polypectomy.

DESIGN

Retrospective-prospective observational cohort study.

METHODS

A total of 679 patients from our university-affiliated hospital were included in this study. All patients underwent hysteroscopic polypectomy and were subsequently monitored for endometrial polyp recurrence through transvaginal ultrasonography at six-month intervals. Comprehensive clinical data were collected, encompassing preoperative vaginal dysbiosis, parity, polyp size, polyp number, the presence of uterine fibroids, polycystic ovary syndrome, endometriosis, and body mass index. The cohort was categorized into recurrence and non-recurrence groups, with comparative analyses conducted to assess the impact of these factors.

RESULTS

Preoperative vaginal dysbiosis and endometriosis were significantly associated with endometrial polyp recurrence (P < 0.05). The odds ratio (OR) for preoperative vaginal dysbiosis was 3.286 (95 % confidence interval [CI]: 2.675-3.786), and for endometriosis, it was 3.328 (95 % CI: 2.567-3.643). Further analysis revealed that bacterial density, bacterial diversity, and the Lactobacillus detection rate were significantly higher in the non-recurrence group compared to the recurrence group (P < 0.05). In contrast, increased leukocyte esterase activity, Gardnerella vaginalis presence, and Candida detection were significantly more prevalent in the recurrence group than in the non-recurrence group (P < 0.05).

CONCLUSION

This study identifies preoperative vaginal dysbiosis as an independent risk factor for Endometrial Polyp recurrence after Hysteroscopic Polypectomy. Endometriosis is also associated with recurrence. Close monitoring of preoperative vaginal microecological parameters and targeted interventions could help manage dysbiosis and reduce recurrence.

IRB APPROVAL

The First Affiliated Hospital of Guangxi Medical University Ethical Review Committee. Approval number: 2024-E817-01.

Repeat hysteroscopic polypectomy: Impact of hysteroscopic instrumentation and provision of anesthesia

STUDY OBJECTIVE

To determine the association of repeat polypectomy with patient and/or polyp characteristics, surgical setting, and type of hysteroscopic equipment.

METHODS

Retrospective cohort study including all women who had undergone operative hysteroscopy for the removal of endometrial polyps between 1/2012-12/2022 in our division. Operative hysteroscopy with resection of endometrial polyps was performed using a bipolar loop resectoscope, miniaturized hysteroscopic instruments (bipolar needle, scissors, and graspers), or a tissue-removal device (from April 2021), with or without general anesthesia.

RESULTS

Benign polyps were removed in 722 women in an outpatient setting and without any anesthesia (n = 64, 8.9 %) or in an operating theatre under general anesthesia (n = 658, 91.1 %). Their mean age was 55.8 ± 12.4 years, 432 (59.8 %) were menopausal, and 41 (5.7 %) reported having previously undergone a polypectomy. The mean size of the resected polyp was 19.9 ± 8.0 mm, and ≥ 2 polyps were removed in 188 (26.0 %) cases. Repeat polypectomy was performed in 32 (4.4 %) women after 3.0 ± 1.9 years, and it was significantly more common among women whose index polypectomy was performed in an outpatient setting (12.5 % versus 3.6 % operating theatre, p = 0.005), and in women who underwent polypectomy by miniaturized hysteroscopic instruments compared with a loop resectoscope or a tissue removal device (8.3 %, 4.2 %, and 0 %, respectively, p = 0.03). On the multivariate analysis, hysteroscopy without anesthesia was significantly associated with repeat polypectomy (odds ratio = 3.5, 95 % confidence interval 1.1-12.1, p = 0.04), while the choice of hysteroscopic equipment was not (odds ratio = 1.1, 95 %, confidence interval 0.3-3.5, p = 0.9). Patient age, menopausal status, and size and number of polyps were not significantly associated with repeat polypectomy.

CONCLUSIONS

Repeat hysteroscopic polypectomy is relatively uncommon and possibly associated with the choice of hysteroscopic equipment and provision of anesthesia.

Chronic endometritis multiplies the recurrence risk of endometrial polyps after transcervical resection of endometrial polyps: a prospective study

BACKGROUND

To investigate the impact of chronic endometritis (CE) on the recurrence of endometrial polyps (EPs) in premenopausal women after transcervical resection of endometrial polyps (TCRP).

METHODS

This prospective study enrolled 507 women who underwent TCRP between January 1, 2022 and December 31, 2022. The patients were divided into a CE group (n = 133) and non-CE group (n = 374) based on the expression of CD138 in the endometrium. The EP recurrence rate at 1 year after TCRP was compared between the CE and non-CE groups and between groups with mild CE and severe CE. The impact of CD138 expression by resected EPs on EP recurrence also was investigated.

RESULTS

The EP recurrence rate at 1 year post-TCRP was higher in the CE group than in the non-CE group (25.6% vs. 10.4%) and also higher in the severe CE group than in the mild CE group (34.5% vs. 18.7%). Additionally, the EP recurrence rate was higher among patients with CD138-expressing EPs than among those with EPs lacking CD138 expression (30.5% vs. 6.5%). The odds ratio (OR) for EP recurrence in the CE cohort compared with the non-CE cohort was 3.10 (95% confidence interval [CI] 1.84-5.23) after adjustment for EP number and precautions against EP recurrence. The ORs for EP recurrence in patients with mild CE and severe CE were 2.21 (95%CI 1.11-4.40) and 4.32 (95%CI 2.26-8.26), respectively. Similarly, the OR for EP recurrence in cases with CD138-expressing EPs relative to cases with EPs lacking CD138 expression was 6.22 (95%CI 3.59-10.80) after adjustment for EP number and precautions against EP recurrence.

CONCLUSIONS

CE multiplied the recurrence rate of EPs in premenopausal women after TCRP, and this effect positively correlated with CE severity. CD138 expression by EPs also was associated with a higher risk for EP recurrence.

Associations between vaginal microbiota and endometrial polypoid lesions in women of reproductive age: a cross-sectional study

RESEARCH QUESTION

What are the different characteristics of vaginal microbial composition between patients with endometrial polypoid lesions and controls?

DESIGN

This cohort study compared the pre-operative microbial compositions of vaginal samples in a cohort of 703 women with endometrial polypoid lesions [293 and 410 women diagnosed and not diagnosed with polyps pathologically (polyps group and not-polyps group, respectively] and 703 women in the control group. Bacterial abundance, diversity, differential taxa and microbial network structure were assessed using 16S rRNA gene sequencing. Predictive algorithms were used to determine the functional pathways of vaginal microbiota within the cohort.

RESULTS

The control group exhibited higher relative abundance of Lactobacillus crispatus in comparison with the polypoid lesions group (P = 0.0427). Beta diversity of vaginal microbiota differed significantly between the groups (P < 0.05). Comparing the polyps group with the not-polyps group, Leptotrichia spp. and Cutibacterium spp. were more abundant in the polyps group, and Fannyhessea spp., Acinetobacter spp. and Achromobacter spp. were more abundant in the not-polyps group. The control group exhibited higher abundance of Bifidobacterium spp., Achromobacter spp. and Escherichia/Shigella spp. (false discovery rate < 0.05). Furthermore, the polyps group and not-polyps group displayed more complex co-occurrence networks compared with the control group.

CONCLUSIONS

The results of this study provide compelling evidence supporting associations between vaginal microbiota and endometrial polypoid lesions, highlighting the potential relationship between a well-balanced vaginal microbial ecosystem and a healthy intrauterine environment.

Pretreatment with long-acting gonadotropin-releasing hormone agonists improved pregnancy outcomes after hysteroscopic multiple polypectomies: A retrospective study of 660 frozen-thawed embryo transfer cycles

OBJECTIVE

To compare the reproductive pregnancy outcomes of pretreatment with long-acting gonadotropin-releasing hormone agonist (GnRH-a) plus hormone replacement therapy (HRT) with HRT-only cycles, and investigate differences between single polypectomy and multiple polypectomies, and between one or two doses of GnRH-a.

MATERIALS AND METHODS

This was a retrospective cohort study on patients undergoing polypectomy who underwent frozen-thawed embryo transfer (FET) from March 2018 to May 2019. They were divided into GnRH-a pretreatment and HRT-only groups. Each group was divided into single polypectomy or multiple polypectomies (in a single hysteroscopic session) subgroups. Clinical pregnancy rate and live birth rate (LBR) were the main outcomes. The effect of GnRH-a dosage was further analysed.

RESULTS

There were 212 GnRH-a pretreatment cases (45 single and 167 multiple polyps) and 448 HRT-only cases (228 single and 220 multiple polyps). The LBR of the GnRH-a pretreatment group (53.3%) was significantly higher than the HRT group (43.3%; P = 0.016). Logistic regression analysis showed that GnRH-a pretreatment significantly affected the LBR (odds ratio, OR 1.470, 95% confidence interval, Cl 1.046-2.065; P = 0.026). In the multiple polypectomy subgroup, the LBR with GnRH-a pretreatment was higher than with HRT-only (54.5% vs 43.6%; P = 0.034). However, the LBR was not different between the respective single polypectomy subgroups (48.9% vs 43.0%; P = 0.466). For patients with multiple polyps, two GnRH-a pretreatments produced a higher LBR than a single GnRH-a pretreatment (62.7% vs 47.8%), but without significant difference (P = 0.055).

CONCLUSION

GnRH-a pretreatment improved the LBR for FET cycles after hysteroscopic multiple polypectomies, independent of dose.

Clinical outcomes in women with endometrial polyps underwent conservative management

OBJECTIVE

To evaluate the regression rate of endometrial polyps (EPs) in a cohort of asymmetric women after conservative follow-up.

MATERIALS AND METHODS

In this retrospective cohort study, a total of 1006 women with asymptomatic EPs were treated with expectant management or hormonal drugs between June 1999 and May 2018. Four hundred forty-eight women (44.5%) were administered with hormonal medications and 558 women were managed expectantly (55.5%). Office hysteroscopy was performed to confirm the diagnosis and regression of EPs. Hormonal administration included oral contraceptives, progestin and cyclic estrogen/progestin regimen according to physicians' preferences. Clinical characteristics, including the patient's age, body mass index, parity, and type of conservative management were collected.

RESULTS

The mean observation time was 14.1 ± 18.5 months (range, 1-162 months). The overall regression rate of EPs in this cohort was 33.5%, 24.6% occurred after medication and 8.9% after expectant management. Patient age (<50 years) (p < 0.001), follow-up period (p = 0.005) and hormonal drugs used (p < 0.001) were significantly associated with EP regression. Twenty-four (7.1%) of the 337 EP regression patients later developed recurrent disease. Follow-up period (p < 0.001) and hormonal drugs used (p = 0.032) were closely related to polyp recurrence after initial regression. Nevertheless, multivariate logistic regression analysis revealed that hormonal drugs used was significantly associated with the regression (p < 0.001) and recurrence (p = 0.016) of EPs.

CONCLUSION

Women aged 50 or less are more suitable for conservative treatment for EPs. Hormonal drugs used could increase the incidence of EP regression.

Chronic endometritis increases the recurrence of endometrial polyps in premenopausal women after hysteroscopic polypectomy

BACKGROUND

The reported recurrence rate of endometrial polyps (EPs) after hysteroscopic polypectomy varied widely, and the factors influencing the recurrence of EPs are still controversial. Furthermore, the known definite independent risk factors are almost unchangeable, such as the number of EPs and previous polypectomy history. The aim of this study was to evaluate the impact of chronic endometritis (CE) on the recurrence of EPs in premenopausal women who underwent hysteroscopic polypectomy.

METHODS

A retrospective study was conducted at a university-affiliated hospital. Premenopausal women who underwent hysteroscopic polypectomy were enrolled, and those with definite confounding factors for polyp recurrence were excluded, including endometriosis and previous polypectomy history. A total of 233 women were enrolled in this study, including 64 (27.5%) cases with CE and 169 (72.5%) cases without CE. CE was diagnosed via immunohistochemical detection of CD138 on the endometrial specimen. Comparison of the recurrence rate of EPs was performed in women with or without CE at each monitoring stage (i.e., at 3, 6, 9 and 12 months) after hysteroscopic polypectomy.

RESULTS

The recurrence rates of EPs at one year in patients with and without CE were 26.6% (95% confidence interval [CI] 15.8-37.4%) and 9.5% (95% CI 5.0-14.0%), respectively, with an overall recurrence rate of 14.2% (95% CI 9.7-18.7%). The hazard ratio (HR) for EPs recurrence in the EPs with CE cohort versus the EPs without CE cohort was 3.08 (95% CI 1.56-6.09) (P = 0.001). Similarly, the recurrence rate of EPs was significantly higher in women with CE than in those without CE at each monitoring stage (i.e., 3, 6 and 9 months). CE and multiple EPs were risk factors for EPs recurrence. The HR for EPs recurrence in the EPs with CE cohort compared with the EPs without CE cohort was 3.06, after adjustment for the number of EPs.

CONCLUSIONS

CE was a harmful factor for the recurrence of EPs in premenopausal women after hysteroscopic polypectomy. Thus, routine screening for CE during hysteroscopic polypectomy was needed. Frequent monitoring was needed for multiple EPs as the number of EPs also contributed to polyp recurrence.

Multivariate Analysis of Recurrence after Hysteroscopic Diagnosis and Treatment of Endometrial Polyps following IVF-ET Failure

Objective

To explore the risk factors affecting the recurrence of endometrial polyps (EPs) after hysteroscopic diagnosis and treatment of EPs following in vitro fertilization-embryo transfer (IVF-ET) failure by multivariate analysis.

Methods

The clinical data of 369 patients with EPs hysteroscopically treated in our department due to IVF-ET failure from January 2017 to January 2020 were retrospectively analyzed, including the number and size of polyps, postoperative treatment, endometriosis (EM), hydrosalpinx (HSP), and polycystic ovarian syndrome (PCOS), and the effects of these factors on EP recurrence were observed.

Results

Of the patients enrolled, 184 cases (49.9%) were treated by curettage, and 185 cases (50.1%) by electrotomy. A total of 72 cases (19.5%) of postoperative recurrence were determined, including 34 cases (9.2%) without postoperative medication, 31 cases (8.4%) with one month of postoperative Didroxyprogesterone (DG) administration, and 7 cases (1.9%) with three months of postoperative DG administration. Surgical methods, 3 months of postoperative medication, PCOS, and polyp number and size significantly influence the recurrence of EPs, which were all the influencing factors of polyp recurrence. After controlling for other factors, the risk of EP recurrence after electrotomy was found to be lower than that after curettage, with an odds ratio (OR) (95% confidence interval (CI)) of 0.354 (0.163–0.767); the risk of EP recurrence after 3 months of postoperative medication was lower than that without postoperative medication, with an OR (95% CI) of 0.024 (0.005–0.104); the risk of EP recurrence in patients with PCOS was higher than that without PCOS, and the OR (95% CI) was 2.505 (1.113–5.639); patients with multiple polyps (≥2) were at an increased risk of recurrence than those with a single polyp, with an OR (95% CI) of 66.552 (14.711–301.084); patients with polyp diameter ≥ 2 cm had a higher risk of recurrence than those with polyp diameter < 2 cm, and the OR (95% CI) was 1084.76 (148.743–7910.999).

Conclusions

PCOS patients are at an elevated risk of EP recurrence than non-PCOS patients. In patients with multiple polyps, those with a diameter ≥ 2 cm have an increased risk of polyp recurrence compared with those with polyp diameter < 2 cm; electrotomy is associated with a lower recurrence risk of EPs than curettage. The risk of EP recurrence in patients treated with postoperative progesterone for 3 months is lower than that of patients without postoperative medication.

Symptom-related Ki-67 expression in endometrial polyps

OBJECTIVE

The aim of this study was to compare Ki-67 expression in endometrial polyps that present with different abnormal uterine bleeding patterns.

STUDY DESIGN

A total of 120 women diagnosed with endometrial polyps were included in the study. In this prospective study, tissue samples taken by hysteroscopic polypectomy method between September 2019 and September 2020 at Bursa City Hospital were examined. The main study groups were determined as premenopausal and postmenopausal patients. The patients' complaints at first admission to the hospital, demographic, histopathological and immunohistochemical features were recorded.

RESULTS

Ki-67 glandular and stromal expressions were higher in the premenopausal patient group (p = 0.016 and p = 0.005 respectively). Median Ki-67 gland and stroma measurements; was higher in patients with heavy menstrual bleeding (HMB) than in patients with intermenstrual bleeding (IMB), patients with postmenopausal bleeding (PMB), and patients who were asymptomatic [(p = 0.012, p = 0.011 and p = 0.009 respectively); (p < 0.001, p < 0.001 and p = 0.004 respectively)]. The median Ki-67 stroma measurement was found to be higher in the patient group whose complaint persisted after polypectomy (p = 0.034). In the estimation of response to treatment, the cut-off value for Ki-67 stromal expression was determined as ≤ 6%.

CONCLUSION

High Ki-67 expression in endometrial polyps is associated with HMB and may predict the continuation of abnormal uterine bleeding after polypectomy.

LIN28B Polymorphisms Confer a Higher Postoperative Recurrence Risk in Reproductive-Age Women with Endometrial Polyps

The RNA-binding protein LIN28B is an important factor for cell proliferation. Because LIN28B polymorphisms have been shown to be relative with the recurrence of some hyperplastic diseases, we hypothesized that genetic variants of LIN28B gene were associated with postoperative recurrence risk in reproductive-age women with endometrial polyps (EP). In a hospital-based cohort of 351 reproductive female patients underwent hysteroscopic polypectomies between May 2018 and Jan 2020, we genotyped two common polymorphisms in LIN28B gene (rs369065 C > T and rs314280 A > G) and analyzed their associations with the risk of postoperative recurrence in multiple Cox regression model. When followed up to Jun 2021, carries of rs369065 TT genotype had an increased risk of polyp recurrence (adjusting hazard ratio [HR] = 1.883, 95% confidence interval [CI] = 1.033 − 3.434) and had a shorter time to recurrence (median time 352 vs. 342 days, log-rank P < 0.01), compared to the CC/CT genotype. Further stratification analysis showed that the increased risk of rs369065 TT genotype was more evident in patients who were older than 33 years (adjusted HR = 2.597, 95%CI = 1.037 − 6.505), had a single polyp (adjusted HR = 2.545, 95%CI = 1.059 − 6.113), and had smaller polyps (<1.2 cm, adjusted HR = 2.708, 95%CI = 1.042 − 7.043). However, no significant association between rs314280 A > G polymorphism and the risk of polyp recurrence was found. Our study suggests that rs369065 TT genotype of LIN28B gene is associated with an increased postoperative recurrence risk in EP patients, especially in those with fewer and smaller polyps. These findings implicate a precise choice of clinical counseling and decision making. Larger studies in different ethnic populations are warranted.

Optimal waiting period for frozen embryo transfer after hysteroscopic polypectomy: A propensity score matching analysis

OBJECTIVE

To evaluate the optimal waiting period for frozen-thawed embryo transfer (FET) after hysteroscopic polypectomy (HSC-P).

DESIGN

Retrospective cohort.

SETTING

University-affiliated hospital.

PATIENTS

All patients included in this research underwent hysteroscopy before the first FET cycle after whole embryo freezing. A total of 206 patients had undergone HSC-P, and 3681 patients without endometrial polyps were defined as the controls.

INTERVENTIONS

HSC-P.

MAIN OUTCOME MEASURES

The HSC-P group was divided into three subgroups based on the time interval between HSC-P and the start of an FET cycle. Subgroup 1 consisted of patients who underwent FET after their next menses, subgroup 2 after two menstrual cycles, and subgroup 3 after three or more menstrual cycles. Demographics, baseline in vitro fertilization (IVF) characteristics, and pregnancy outcomes, especially perinatal outcomes after FET were compared among the groups.

RESULTS

There were 137 patients in subgroup 1, 40 in subgroup 2, and 29 in subgroup 3. There were no differences in the baseline characteristics of the three groups. IVF-related data and FET-related data, such as endometrial thickness and ET no. Of embryoes, were similar among the three subgroups. The three subgroups showed no significant differences in implantation rate, biochemical pregnancy rate, abortion rate, clinical pregnancy rate or live birth rate. Besides, There was no significant difference in perinatal outcomes including very preterm delivery, preterm delivery, low birth weight, macrosomia, small for gestational age, large for gestational age, birth weight(g), birth-height(cm)and Apgar Scores.

CONCLUSIONS

Compared with FET after their next menses, FET after two or more menstrual cycles after HSC-P does not necessarily produce superior outcomes.

Endometrial polyps: diagnosis and treatment options - a review of literature

INTRODUCTION AND AIM

Endometrial polyps (EPs) are a common gynecologic condition, associated with abnormal uterine bleeding (AUB), infertility, and premalignant and malignant conditions. Technologies for diagnosis and treatment of EPs are constantly evolving. We aim to provide an updated review on diagnosis and management options for patients with EPs.

MATERIAL AND METHODS

We conducted an electronic search in databases including MEDLINE, PubMed, Cochrane Central Register and others. We included 68 publications regarding EPs, their clinical burden, diagnostic modalities, treatment options and new technologies.

RESULTS

Transvaginal ultrasound (TVS) is the common modality for EP detection and color doppler increases its diagnostic accuracy. Dilation and curettage (D&C) should be avoided for diagnosis and treatment of EPs. Hysteroscopy shows high diagnostic value in EPs and allows for both histological diagnosis and effective treatment. Office hysteroscopy and see and treat hysteroscopy without anesthesia is feasible and safe for EP diagnosis and treatment, gaining more trained surgeons globally. Effective and safe technological tools for EP resection include Laser, resectoscopes, morcellators, MyoSure, Truclear and scissors\graspers.

CONCLUSIONS

EPs are safely and effectively diagnosed and treated with the hysteroscopic tools reviewed in this article. More research is needed to define the best treatment modality.

Removal of uterine polyps: clinical management and surgical approach

Endometrial polyps have a reported prevalence from 7.8% up to 30% and are one of the most cost-consuming gynecological conditions for our specialty. There are strong practitioner beliefs that surgical removal of endometrial polyps is highly beneficial, particularly for those with abnormal uterine bleeding and infertility. Additionally, polypectomy is indicated to reduce the risk of malignancy. Transvaginal ultrasound is the first-line diagnostic option for detection of endometrial polyps, while sonohysterography has similar accuracy as hysteroscopy in the diagnostic confirmation. Blind dilatation and curettage is not recommended for polyp removal; rather, hysteroscopy in the operating room and office setting using small-diameter hysteroscopic equipment is the standard approach. This can be performed without anesthesia in most women. While hysteroscopy is an effective method for polypectomy with a low complication rate, it is unknown whether this is truly beneficial for reproductive-age women with infertility and prior assisted reproduction therapy. The risk of malignancy in women with postmenopausal bleeding justifies the necessity of polypectomy with histologic tissue examination. In asymptomatic women, the risk of malignancy is low, and there are no known benefits of polyp removal in the prevention of malignant transformation. Cost-effective studies remain to be done to provide us with the optimal approach to endometrial polyps including the management of asymptomatic and/or infertile women, ideal location including office-based or the operating room setting, complication prevention including intrauterine adhesions, and recurrence issues.

Endometrial polyps. An evidence-based diagnosis and management guide

OBJECTIVE

To provide an updated practice guideline for the management of patients with endometrial polyps.

MATERIALS AND METHODS

A committee of six expert researchers draw the recommendations according to AGREE II Reporting Guideline. An electronic search was performed querying the following databases MEDLINE (accessed through PubMed), Scopus, PROSPERO, EMBASE, CINAHL, Cochrane Library (including the Cochrane Database of Systematic Reviews), Scielo.br, Google Scholar, from inception to May 2020. A combination of text-words and Medical Subject Headings (MeSH) regarding endometrial polyps, diagnosis, management and treatment was used. Trials were assessed for methodologic rigor and graded using the United States Preventive Services Task Force classification system.

RECOMMENDATIONS

Transvaginal ultrasonography (TVUS) should be the imaging modality of choice for the detection of endometrial polyps in woman of fertile age (level B). Its accuracy increases when color-doppler, 3D investigation and contrast are used (level B). Dilation and Curettage (D&C) should be avoided for the diagnosis and management of polyps (level A). In office hysteroscopy showed the highest diagnostic accuracy in infertile patients with suspected endometrial polyps (level B). Polyps might alter endometrial receptivity, and embryo implantation reducing pregnancy rates (level C). Hysteroscopic polypectomy is feasible and safe with negligeble risk of intrauterine adhesion formation (level B). Polypectomy does not compromise reproductive outcomes from subsequent IVF procedures but the removal of polyps as a routine practice in sub-fertile women is not currently supported by the evidence (level B). Cost-effectiveness analysis suggest performing office polypectomy in women desiring to conceive (level B). Saline infused sonohysterography is highly accurate in detecting polyps in asymptomatic postmenopausal women (level B). Postmenopausal women with vaginal bleeding and suspected endometrial polyp should be offered diagnostic hysteroscopy with hysteroscopic polypectomy if endometrial polyps are present (level B). In-office hysteroscopy has the highest diagnostic accuracy with high cost-benefits ratio for premalignant and malignant pathologies of the uterine cavity (level B). Due to risk of malignancy, histopathological analysis of the polyp is mandatory (level B). Blind D&C should be avoided due to inaccuracy for the diagnosis of focal endometrial pathology (level A). Expectant management is not recommended in symptomatic patients especially in postmenopausal women (level B). In case of atypical hyperplasia or carcinoma on a polyp, hysterectomy is recommended in all post-menopausal patients and in premenopausal patients without desire of future fertility (level B). Asymptomatic endometrial polyps in postmenopausal women should be removed in case of large diameter (> 2 cm) or in patients with risk factors for endometrial carcinoma (level B). Excision of polyps smaller than 2 cm in asymptomatic postmenopausal patients has no impact on cost-effectiveness or survival (level B). Removal of asymptomatic polyps in premenopausal women should be considered in patients with risk factors for endometrial cancer (level B).

A prospective, open-label, single-arm study to evaluate the efficacy of dydrogesterone in the treatment of endometrial polyps

OBJECT

To evaluate the efficacy of dydrogesterone for the treatment of premenopausal patients with endometrial polyps (EPs).

METHODS

A single-center, open-label, prospective, single-arm clinical treatment trial was conducted in patients of reproductive age with EP(s). Patients were prescribed dydrogesterone from day 15 to day 24 of the menstrual cycle over a period of 3 months. At the 3-month follow-up, the efficacy of dydrogesterone was evaluated based on changes in self-report symptoms and ultrasonographic characteristics. The predictive factors of efficacy as well as the predictive value of the significant factors were also assessed.

RESULTS

A total of 60 patients were included. Improvements in both symptoms and ultrasound findings occurred in 31 patients, achieving an efficacy rate of 51.67%. Of 41 patients with clinical presentations, 39 (95.1%) reported improvements in symptoms. In terms of ultrasound findings, 33 (55%) of patients demonstrated improvements. Significant decreases were observed in the mean endometrial thickness (1.17 ± 0.33 cm vs 0.90 ± 0.35 cm, p < .001) and polyp size (1.10 ± 0.34 cm vs 0.74 ± 0.65 cm, p = .001) after the application of dydrogesterone. Age (p = .006), polyp size (p = .006), and blood flow within polyps (p = .035) were significant predictors of dydrogesterone efficacy. These factors, when combined, demonstrated a good predictive value ([area under the curve (AUC)=0.81]).

CONCLUSION

Dydrogesterone is effective in the management of EPs in premenopausal patients. Age, polyp size and blood flow should be taken into consideration when prescribing dydrogesterone for this population of women.

Endometrial polyps: Is the prediction of spontaneous regression possible?

Objective

Endometrial polyps have been considered as a hyperplastic growth of endometrial stromal and glandular tissues. Even asymptomatic polyps in premenopausal women are usually removed as soon as they are diagnosed, although it is still unknown how often endometrial polyps disappear spontaneously. The aim of this study was to investigate the regression rate of endometrial polyps and the possible factors related to their spontaneous regression.

Methods

A total of 197 women with endometrial polyps were treated with operative hysteroscopy between January 2017 and April 2019 at our tertiary center. Of these, 123 patients who preferred conservative follow-up were enrolled in the study. Clinical and pathological data were obtained from electronic medical records.

Results

Patients with endometrial polyps were followed up for a median period of 62 days (range 30–360 days). Most women with endometrial polyps (84%) were reported to have gynecologic symptoms. Spontaneous polyp regression was observed in 28 (23%) patients who underwent surgery reevaluation. Patient age (<45 years), premenopausal period, and polyp size (<2 cm) were found to be associated with spontaneous endometrial polyp regression (P<0.05). We also observed more polyp regression in women with abnormal uterine bleeding (P=0.05). Second-look hysteroscopy showed that all postmenopausal women had persistent endometrial polyps.

Conclusion

Patient age (<45 years), premenopausal period, polyp size (<2 cm), and abnormal uterine bleeding may be associated with spontaneous endometrial polyp regression.

Multiple endometrial polyps is associated with higher risk of chronic endometritis in reproductive-aged women

AIM

To determine whether single endometrial polyp (EP) or multiple EP (polyp number ≥ 6) are associated with chronic endometritis (CE).

METHODS

From June 2017 to December 2018, this study enrolled a total of 277 patients, including 92 patients with multiple EP, 82 patients with a single EP and 103 patients without polyps who underwent hysteroscopic examination and polypectomy. Polyps and endometrium samples were obtained and subjected to immunohistochemistry for CD138 to identify plasma cells and CE was diagnosed as CD138-positive plasma cells greater than or equal to 5/high power field. The prevalence of CE was compared and analyzed using the logistic regression model.

RESULTS

All baseline parameters were comparable among the three groups except that the prevalence of abnormal uterine bleeding (AUB) was much higher in both polyp groups than the non-polyp control. The prevalence of CE was significantly higher in the multiple EP group than in the single EP group (58.7% vs 28.0%, P < 0.001). There was no difference on the prevalence of CE between the single EP and the non-polyp groups (28.0% vs 29.1%, P = 0.872). Multivariable analysis revealed that AUB (adjusted OR 2.81, 95% CI 1.35-5.87) and multiple EP (adjusted OR 2.58, 95% CI 1.38-4.82) were independently associated with CE, while the single EP did not increase the odds of CE compared to the non-polyp group (adjusted OR 0.74, 95% CI 0.38-1.45).

CONCLUSION

Multiple EP were positively associated with CE among reproductive-aged women, suggesting a possible hidden etiopathogenetic link between chronic inflammation and multiple EP.

Optimal time interval between hysteroscopic polypectomy and frozen-thawed blastocyst transfer: A retrospective study

The optimal timing of frozen-thawed blastocyst transfer following hysteroscopic polypectomy is an important and unanswered clinical question. In this study, we conducted a retrospective survey of cases from an infertility center at an academic hospital. We reviewed the charts of all patients who received in-vitro fertilization and frozen-thawed blastocyst transfers (FBT) at the center from January 2009 to November 2019. One hundred and two patients with prior diagnosis of endometrial polyp that were treated with hysteroscopic polypectomy before received their first FBT at the center were identified as cases. Patients without prior diagnosis of endometrial polyp, and who received their first FBT at the center were defined as controls. Controls were enrolled at a 1-to-1 ratio to the cases. The cases and controls did not show differences in baseline characteristics, endometrial thickness, or the number of good blastocysts transferred. The clinical pregnancy rates and live birth rates were similar. Regarding the optimal interval between polypectomy and FBT, a cut-off of 120 days was identified from the ROC curve. A stratified analysis showed that when FBT was performed within an interval of 120 days after polypectomy, there were higher biochemical pregnancy rates (73.2%, 45.2%; OR 3.3; P = .007) and clinical pregnancy rates (64.8%, 41.9%; OR 2.54; P = .032), when compared with intervals greater than 120 days. There were no significant differences in implantation and live birth rates. In conclusion, pregnancy rates following FBT in patients who had received prior endometrial polypectomy were comparable to pregnancy rates after FBT in patients without endometrial polyp. Subgroup analysis showed that an interval greater than 120 days between hysteroscopic polypectomy and FBT was associated with decreased pregnancy rates. Patients who wish to receive embryo transfer after polypectomy should wait no longer than 120 days.

Comparison of endometrial polyp recurrence in fertile women after office hysteroscopic endometrial polypectomy using two widely spread techniques

AIM

To compare the recurrence of benign endometrial polyps after office hysteroscopic polypectomy performed with a bipolar electrode (BE) or a small diameter hysteroscopic tissue removal system (HTRs).

METHODS

From July 2018 to December 2019 we evaluated the charts of 114 asymptomatic fertile women who underwent office hysteroscopic polypectomy, 1 year before, for a single large benign endometrial polyp (size between 10 and 20 mm) using a 4 mm continuous flow hysteroscope with a BE or a 5 mm HTRs. Patients, divided into two groups according to surgical procedure, each performed exclusively by one expert gynecologist, were scheduled for a 12-month postoperative transvaginal sonography to evaluate the recurrence of endometrial polyps.

RESULTS

Forty-eight women of the BE group and 42 of the HTRs group were considered for the 1-year transvaginal sonography follow-up. Five polyps were identified in the BE group and three in the HTRs group (5/48 vs 3/42, P = n.s.). All polyps were removed hysteroscopically (in three out of five and in two out of three cases, respectively, in the same places of the previous polypectomy) and evaluated as 'benign' by the pathologist.

CONCLUSION

Office hysteroscopic endometrial polypectomy with small HTRs compared to BE revealed at a 1-year follow-up no difference in terms of complete removal and recurrence of polyps. HTRs polypectomy resulted in less pain and significantly quicker time of procedure compared to BE. This data should be kept in mind for patient comfort any time hysteroscopic polypectomy is planned in an office setting.

Immunohistochemical expression of estrogen receptor α, Bcl-2 and NF-κB P65 in the polyps of patients with and without endometriosis

AIM

To compare the expression of estrogen receptor α (ERα), Bcl-2 and NF-κB P65 in endometrial polyps from patients with and without endometriosis.

METHODS

Immunohistochemistry was used to characterize the expression of ERα, Bcl-2 and NF-κB P65 in proliferative phase endometrial polyps from patients with and without endometriosis. H-Scores indicating the staining intensity for ERα, Bcl-2 and NF-κB P65 in the glandular epithelium and stroma were measured separately. Apoptotic cells were detected with the use of the dUTP nick-end labeling (TUNEL) assay.

RESULTS

Bcl-2 was expressed in the cytoplasm of glandular epithelial cells, whereas ERα was expressed in the nuclei of both glandular epithelial and stromal cells. NF-κB P65 was observed in the cytoplasm of both glandular epithelial and stromal cells. The H-scores for Bcl-2 in the endometrial glands significantly higher in the endometriosis polyp group than in the non-endometriosis polyp group. The H-scores for ERα in both stromal and glandular epithelial cells were significantly higher in the endometriosis polyp group than in the non-endometriosis polyp group. The H-scores for Bcl-2 and ERα were positively correlated in all of the women examined. Apoptotic cells in the endometriosis polyp group were significantly less than that of the non-endometriosis polyp group.

CONCLUSION

There expression levels of Bcl-2 and ERα, both of which were significantly increased in the polyps of endometriosis patients compared to those of patients without endometriosis, were positively correlated. These results suggested that imbalanced apoptosis secondary to abnormally high ERα expression was responsible for the high prevalence of polyps in endometriosis patients.

Prevention of Benign Endometrial Polyp Recurrence Using a Levonorgestrel-releasing Intrauterine System in Premenopausal Patients: A Retrospective Cohort Study

STUDY OBJECTIVE

To evaluate the levonorgestrel-releasing intrauterine system (LNG-IUS) to prevent the recurrence of endometrial polyps (EPs) after hysteroscopic polypectomies in premenopausal female patients.

DESIGN

A retrospective cohort study.

SETTING

A tertiary-care women's hospital.

PATIENTS

A total of 451 premenopausal female patients underwent hysteroscopic polypectomies between January 1, 2016, and December 31, 2017.

INTERVENTIONS

Treatment with LNG-IUS after hysteroscopic polypectomies.

MEASUREMENTS AND MAIN RESULTS

After the hysteroscopic polypectomies and placement of LNG-IUS, transvaginal ultrasounds were performed every 6 months to measure the recurrence of EPs. Overall, 5 (3.47%) of 144 patients in the LNG-IUS cohort and 49 (15.96%) of 307 patients in the control cohort experienced EP recurrence within the follow-up period of up to 3 years. The recurrence exhibited a strongly negative correlation when LNG-IUS was inserted (relative risk, 0.218; 95% confidence interval, 0.089-0.535; p <.05), but this did not significantly correlate with age, polyp size, number of polyps, previous history of polypectomy, and abnormal uterine bleeding. For the LNG-IUS and control cohorts, the recurrence in the first postoperative year was 1.39% and 6.19%, respectively, and 5.41% and 19.23% in the second postoperative year, respectively.

CONCLUSION

LNG-IUS reduces the recurrence of postoperative EPs in premenopausal patients.