Hysteroscopic resection of endometrial polyps: a study of 195 cases

Hysteropathological Correlation in Abnormal Uterine Bleeding in a Tertiary Care Hospital in South India

Background

Abnormal uterine bleeding is a common problem mainly encountered in reproductive age group and post-menopausal women. Hysteroscopy is a safe, simple, well tolerated and reliable procedure for the diagnosis of AUB across all age groups. The aim of the study is to determine the association of hysteroscopy and histopathologic examination (HPE) findings in abnormal uterine bleeding. The secondary objective of the study are to enumerate the hysteroscopy findings in patients with AUB and to evaluate the pattern of AUB.

Materials and Methods

Observational cross-sectional study among 60 women in reproductive and post-menopausal age group presenting with features/symptoms suggestive of abnormal uterine bleeding were studied. All patients reporting in the outpatient department (OPD) and who are eligible to participate were included in the study, after obtaining written informed consent. Detailed history, Clinical examination, Ultrasound pelvis and endometrial thickness assessment is done. Hysteroscopic findings were compared against histopathological findings.

Results

The various patterns of bleeding documented in our study population were menorrhagia, metrorrhagia, menometrorrhagia, polymenorrhea, and post-menopausal bleeding. Out of these patterns, the commonest was menorrhagia at 50.0% and post-menopausal bleeding at 26.67%. In our study population, the various hysteroscopy findings were strawberry, tongue-shaped projections, pebble stones, polypoidal patterns, and cerebroid patterns. Out of these, the most common was a polypoidal pattern, strawberry pattern, and tongue-shaped projections with 45%, 31.67%, and 26.7%, respectively. The most common histopathology finding was secretory and proliferative constituting 35% and 26.67%, respectively. Carcinoma endometrium constitutes about 6.67% of the study population. The sensitivity, specificity, PPV, and NPV of strawberry appearance in hysteroscopy in comparison with secretory changes in histopathology were 52.38%, 79.49%, 57.89%, and 75.61%, respectively. The sensitivity, specificity, PPV, and NPV of tongue-shaped projections appearance in hysteroscopy in comparison with HPE findings was 60%, 76.36%, 18.75%, and 95.45%, respectively. The sensitivity, specificity, PPV, and NPV of polypoidal pattern in hysteroscopy in comparison with Endometrial hyperplasia in histopathology was 66.67%, 56.14%, 7.41%, and 96.97%, respectively. The sensitivity, specificity, PPV, and NPV of cerebroid appearance in hysteroscopy in comparison with carcinoma endometrium in histopathology were 75.0%, 100%, 100%, and 98.25%, respectively. This correlation of cerebroid pattern with carcinoma endometrium was highly significant. Among all correlations, the highly reliable was in Carcinoma endometrium followed by endometrial polyps.

Conclusion

Hysteroscopy has high sensitivity and specificity in diagnosing intrauterine pathology especially endometrial cancer followed by endometrial polyps. Among the various patterns of abnormal uterine bleeding, menorrhagia was the most common. A combination of hysteroscopy and endometrial sampling was found to increase diagnostic accuracy in patients with abnormal uterine bleeding and will effectively guide us in planning the appropriate management for these 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.

Vaginal Myomectomy for Prolapsed Submucous Fibroid: It is Not Only About Size

Leiomyoma of the uterus, also called fibroids, are common in women. In this case report, we describe the case of a nulliparous woman with a large, prolapsed submucous uterine leiomyoma of 10 × 11 cm was vaginally impacted. The aim is to highlight the challenges in managing such uncommon clinical scenario focusing on the factors predicting the success of vaginal myomectomy including the size of the myoma but also the role of vaginal laxity to allow the steps of devascularization, detachment, and removal of the myoma. We also describe the preoperative and intraoperative methods that can be used to minimize intraoperative blood loss and enhance the safety and feasibility of the surgical procedure. Gonadotropin therapy was not applicable in our patient, and other treatments were also unavailable such as temporary ligation of uterine arteries, while others were unsuccessful like devascularization by hysteroscopy, twisting, and ligation of the pedicle. The final resort used in our case was morcellation of the myoma with intact pedicle, which should be attempted by experienced gynecologic surgeons only.

Prediction of the operative time for hysteroscopic myomectomy for leiomyomas penetrating the intramural cavity using leiomyoma weight and clinical characteristics of patients

PURPOSE

To preoperatively predict the operative time (OT) for hysteroscopic myomectomy for G1 or G2 leiomyoma based on leiomyoma weight.

METHODS

The data from 544 patients who underwent one-step hysteroscopic myomectomy were analyzed retrospectively. A total of 340 patients with leiomyoma penetrating the intramural cavity were identified as suitable candidates for calculation of the OT based on leiomyoma weight; we considered leiomyoma weight to be the most objective parameter for evaluating leiomyoma tissues. Additionally, 460 patients with a single leiomyoma were analyzed to estimate the weight of the resected leiomyoma based on its diameter.

RESULTS

Considering total leiomyoma weight (TLW) and two additional coefficients (1.5: G2 leiomyoma, 0.75: vaginal parity of the patient), we demonstrated that our formula correlated well with OT (R 2 = 0.72). TLW also correlated well with the cube of the average diameter (AD) of leiomyomas (R 2 = 0.89). Predicting TLW significantly improved the application of specific coefficients depending on its value (1.0: AD 0.1-2.0 cm, 0.8: AD 2.1-3.0 cm, 0.7: AD 3.1-5.7 cm).

CONCLUSION

The OT for hysteroscopic myomectomy of intracavital leiomyoma can be predicted prior to surgery using simple clinical information of the target leiomyoma and the patient.

A randomised controlled trial of Outpatient versus inpatient Polyp Treatment (OPT) for abnormal uterine bleeding

BACKGROUND

Uterine polyps cause abnormal bleeding in women and conventional practice is to remove them in hospital under general anaesthetic. Advances in technology make it possible to perform polypectomy in an outpatient setting, yet evidence of effectiveness is limited.

OBJECTIVES

To test the hypothesis that in women with abnormal uterine bleeding (AUB) associated with benign uterine polyp(s), outpatient polyp treatment achieved as good, or no more than 25% worse, alleviation of bleeding symptoms at 6 months compared with standard inpatient treatment. The hypothesis that response to uterine polyp treatment differed according to the pattern of AUB, menopausal status and longer-term follow-up was tested. The cost-effectiveness and acceptability of outpatient polypectomy was examined.

DESIGN

A multicentre, non-inferiority, randomised controlled trial, incorporating a cost-effectiveness analysis and supplemented by a parallel patient preference study. Patient acceptability was evaluated by interview in a qualitative study.

SETTING

Outpatient hysteroscopy clinics and inpatient gynaecology departments within UK NHS hospitals.

PARTICIPANTS

Women with AUB - defined as heavy menstrual bleeding (formerly known as menorrhagia) (HMB), intermenstrual bleeding or postmenopausal bleeding - and hysteroscopically diagnosed uterine polyps.

INTERVENTIONS

We randomly assigned 507 women, using a minimisation algorithm, to outpatient polypectomy compared with conventional inpatient polypectomy as a day case in hospital under general anaesthesia.

MAIN OUTCOME MEASURES

The primary outcome was successful treatment at 6 months, determined by the woman's assessment of her bleeding. Secondary outcomes included quality of life, procedure feasibility, acceptability and cost per quality-adjusted life-year (QALY) gained.

RESULTS

At 6 months, 73% (166/228) of women who underwent outpatient polypectomy were successfully treated compared with 80% (168/211) following inpatient polypectomy [relative risk (RR) 0.91, 95% confidence interval (CI) 0.82 to 1.02]. The lower end of the CIs showed that outpatient polypectomy was at most 18% worse, in relative terms, than inpatient treatment, within the 25% margin of non-inferiority set at the outset of the study. By 1 and 2 years the corresponding proportions were similar producing RRs close to unity. There was no evidence that the treatment effect differed according to any of the predefined subgroups when treatments by variable interaction parameters were examined. Failure to completely remove polyps was higher (19% vs. 7%; RR 2.5, 95% CI 1.5 to 4.1) with outpatient polypectomy. Procedure acceptability was reduced with outpatient compared with inpatient polyp treatment (83% vs. 92%; RR 0.90, 95% CI 0.84 to 0.97). There were no significant differences in quality of life. The incremental cost-effectiveness ratios at 6 and 12 months for inpatient treatment were £1,099,167 and £668,800 per additional QALY, respectively.

CONCLUSIONS

When treating women with AUB associated with uterine polyps, outpatient polypectomy was non-inferior to inpatient polypectomy at 6 and 12 months, and relatively cost-effective. However, patients need to be aware that failure to remove a polyp is more likely with outpatient polypectomy and procedure acceptability lower.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 65868569.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 61. See the NIHR Journals Library website for further project information.

Treatment of Women With an Endometrial Polyp and Heavy Menstrual Bleeding: A Levonorgestrel-Releasing Intrauterine Device or Hysteroscopic Polypectomy?

We performed a literature review of reports comparing a levonorgestrel-releasing intrauterine device (LNG-IUD) with transcervical polyp resection (TCRP) as a treatment for heavy menstrual bleeding (HMB). Our second objective was to investigate the effectiveness of LNG-IUD and TCRP in reducing menstrual bleeding and the patient satisfaction with each technique. No previously reported studies have compared TCRP and LNG-IUD as treatment for HMB in premenopausal women with an endometrial polyp. Likewise, no studies are available on LNG-IUD as a treatment for HMB in the presence of an endometrial polyp. Several studies have found the LNG-IUD to be an effective treatment option for HMB, with high patient satisfaction rates. Evidence of the effectiveness of TCRP as treatment of HMB is scarce. Patient satisfaction is reported relatively good, although persistent or recurrent symptoms appear to be frequent. We conclude that no evidence is available on LNG-IUD as treatment for HMB in women with an endometrial polyp. We hypothesize that LNG-IUD could be a good alternative to TCRP for treating HMB in premenopausal women with a polyp; however, further evidence is needed, and a randomized controlled trial should be performed.

Outpatient versus inpatient uterine polyp treatment for abnormal uterine bleeding: randomised controlled non-inferiority study

OBJECTIVE

To compare the effectiveness and acceptability of outpatient polypectomy with inpatient polypectomy.

DESIGN

Pragmatic multicentre randomised controlled non-inferiority study.

SETTING

Outpatient hysteroscopy clinics in 31 UK National Health Service hospitals.

PARTICIPANTS

507 women who attended as outpatients for diagnostic hysteroscopy because of abnormal uterine bleeding and were found to have uterine polyps.

INTERVENTIONS

Participants were randomly assigned to either outpatient uterine polypectomy under local anaesthetic or inpatient uterine polypectomy under general anaesthesia. Data were collected on women's self reported bleeding symptoms at baseline and at 6, 12, and 24 months. Data were also collected on pain and acceptability of the procedure at the time of polypectomy.

MAIN OUTCOME MEASURES

The primary outcome was successful treatment, determined by the women's assessment of bleeding at six months, with a prespecified non-inferiority margin of 25%. Secondary outcomes included generic (EQ-5D) and disease specific (menorrhagia multi-attribute scale) quality of life, and feasibility and acceptability of the procedure.

RESULTS

73% (166/228) of women in the outpatient group and 80% (168/211) in the inpatient group reported successful treatment at six months (intention to treat relative risk 0.91, 95% confidence interval 0.82 to 1.02; per protocol relative risk 0.92, 0.82 to 1.02). Failure to remove polyps was higher (19% v 7%; relative risk 2.5, 1.5 to 4.1) and acceptability of the procedure was lower (83% v 92%; 0.90, 0.84 to 0.97) in the outpatient group Quality of life did not differ significantly between the groups. Four uterine perforations, one of which necessitated bowel resection, all occurred in the inpatient group.

CONCLUSIONS

Outpatient polypectomy was non-inferior to inpatient polypectomy. Failure to remove a uterine polyp was, however, more likely with outpatient polypectomy and acceptability of the procedure was slightly lower.

TRIAL REGISTRATION

International Clinical Trials Registry 65868569.

Effectiveness of transcervical hysteroscopic endometrial resection based on the prevention of the recurrence of endometrial polyps in post-menopausal women

BACKGROUND

The objectives of this study were to determine the effectiveness the effectiveness of post-polypectomy hysteroscopic endometrial resection in preventing the recurrence of endometrial polyps in post-menopausal patients and analyse the complications and necessity of additional surgery in patients, in addition to their degree of satisfaction.

METHODS

A prospective longitudinal study of post-menopausal patients diagnosed with endometrial polyps was conducted including polypectomy and hysteroscopic endometrial resection following the therapeutic purposes (endometrial polyp removal) and prevention of recurrence of endometrial polyps. We evaluated the general condition and characteristics of the patients, including age, BMI, smoking habits, medical, surgical, and obstetrics history and menstrual status. The results were analysed at several time points, 6, 18, 42 and 60 months by hysteroscopy, including the presence of vaginal bleeding and/or possible intracavitary pathology.

RESULTS

A total of 89.5% (n = 355) of our patients had profile factors associated with the increased incidence of endometrial polyps and hyperestrogenism (diabetes mellitus, hypertension and overweight); 89.5% (n = 355) of patients were overweight; 34% had grade I obesity. The surgical procedure was safe, with a 90% (n = 357) success rate without complications, which was higher than the 95-99.5% at the beginning and end time points of the study. Patient acceptance and satisfaction was 90 and 84%, respectively.

CONCLUSIONS

Endometrial resection proved effective in preventing the recurrence of endometrial polyps. It is a safe and effective method. Post-menopausal bleeding reduces the presence of endometrial polyps. Patients reported satisfaction and acceptance of the procedure.

New mini-resectoscope: analysis of preliminary quality results in outpatient hysteroscopic polypectomy

PURPOSE

We investigated the feasibility and acceptability of office hysteroscopic polypectomy using a new continuous-flow operative 16 Fr Gubbini's mini-resectoscope. This is a prospective clinical study (Canadian Task Force classification III).

METHODS

The office hysteroscopic polypectomy was performed with a mini-resectoscope without analgesia or anesthesia. We evaluated the polyp size and the number, the effectiveness of resection, the operating time, the pelvic pain and complications.

RESULTS

The office hysteroscopic polypectomy was successfully performed in all 33 patients. The polyps ranged in size from 5 to 50 mm with a mean of 18.15 ± 11.45 mm. We analyzed the operating time with a mean of 11.45 ± 4.71 min: 29 procedures took less than 15 min from the start of vaginoscopy to the end of surgery. Overall mean visual analog scale (VAS) calculated was 2.48 ± 1.37 (range 0-6). The correlation between the size of the polyps and operating time was statistically significant (p < 0.001). No major complications were recorded.

CONCLUSION

Our preliminary data demonstrated that can be possible to remove endometrial polyps by hysteroscopy, using the mini-resectoscope, in an office setting. All procedures were completed successfully and well tolerated with a little discomfort permitting the removal also of big sized polyps without a statistical correlation between VAS and size of polyps or operating time. The outpatient polypectomy is a less-costing procedure and represents an acceptable and effective alternative to inpatient resectoscopic polypectomy, leading to a complete polyp excision in nearly all patients.

Endoloop ligation technique for prolapsed pedunculated submucous uterine myoma: utility and reliability

PURPOSE

We use a non-surgical endoloop snare technique to remove prolapsed pedunculated submucous uterine myomas under the concept that ligating the pedicle causes tumor necrosis and natural elimination of the tumor. We evaluated our method on the basis of clinical outcomes.

METHODS

For pertinent clinical data, we reviewed the hospital records of 11 patients treated by our new method between July 2009 and 2010 and followed up for 22-31 months.

RESULTS

Patients' mean age was 40.9 years, and the mean hemoglobin level was 10.6 g/dl. None required urgent hospitalization, blood transfusion, or laparotomy. The tumors were eliminated naturally or removed by cutting necrotic pedicle within 4-11 days. One patient required a second endoloop application. Another one patient required follow-up surgery for a second submucous myoma, adenomyosis, and persistent hypermenorrhea.

CONCLUSIONS

Endoloop ligation is feasible for eliminating prolapsed pedunculated submucous myoma. It is simple and safe and can be performed in the outpatient setting.

Prevalence, 1-year regression rate, and clinical significance of asymptomatic endometrial polyps: cross-sectional study

STUDY OBJECTIVE

To estimate the prevalence, 1-year regression rate, and clinical significance of endometrial polyps in women aged 45 to 50 years.

DESIGN

Cross-sectional study (Canadian Task Force II-2).

SETTING

University teaching hospital.

PATIENTS

Two hundred fifty-seven of 1000 randomly selected women aged 45 to 50 years.

INTERVENTIONS

Transvaginal ultrasonography and saline infusion sonography were performed in all study participants and were repeated in women with endometrial polyps after 12 months. Polyps present at follow-up were removed by hysteroscopic polyp resection.

MEASUREMENTS AND MAIN RESULTS

Endometrial polyps were diagnosed in 31 women (12.1%). At 1 year, the polyp regression rate was 27%. Myomas occurred more often in women with endometrial polyps, and women with polyps experienced significantly heavier periodic bleeding compared with women without polyps.

CONCLUSION

Our study findings suggest that endometrial polyps are common in women aged 45 to 50 years and that women with such polyps experience heavier periodic bleeding. Although some polyps seem to regress spontaneously during 1-year follow-up, most seem to persist.

Flow differences between endometrial polyps and cancer: a prospective study using intravenous contrast-enhanced transvaginal color flow Doppler and three-dimensional power Doppler ultrasound

OBJECTIVES

To evaluate whether assessment of blood flow by transvaginal color Doppler and three-dimensional power Doppler imaging, enhanced by intravenous contrast, may be useful in the differentiation between benign endometrial polyps and endometrial cancer.

METHODS

A prospective study was performed comparing 17 women with benign endometrial polyps and 17 women with endometrial cancer. Transvaginal color Doppler and three-dimensional power Doppler angiography were performed before and after injection of intravenous contrast. The pulsatility index (PI) and the resistance index (RI) of the polyp feeding vessel or central vessel in malignant lesions, as well as the power Doppler endometrial flow indices vascularization index (VI), flow index (FI) and vascularization flow index (VFI), were calculated before and after enhancement by contrast, and compared between the two groups of women.

RESULTS

PI (mean difference +/- SD, 0.68 +/- 0.22; 95% CI, 0.23-1.13; P = 0.004) and RI (mean difference +/- SD, 0.16 +/- 0.08; 95% CI, 0.00-0.32; P = 0.045) were significantly lower in vessels of malignant tumors than in those of benign endometrial polyps after enhancement by intravenous contrast. No significant differences in PI, RI, VI, FI or VFI before enhancement by contrast, or in VI, FI or VFI after enhancement by contrast, were detected between women with endometrial polyps and those with endometrial cancer.

CONCLUSIONS

Transvaginal color Doppler examination enhanced by intravenous contrast may help to discriminate between benign endometrial polyps and cancer. Larger studies are required to confirm these findings.

Clinical utility of liquid-based cytology for the characterization and management of endometrial polyps in postmenopausal age

The proper management of endometrial polyps still represents a clinical ongoing challenge, especially when they are asymptomatic and occasionally discovered. The aim of this study was to evaluate liquid-based endometrial cytology to manage endometrial polyps in postmenopausal age by its ability to exclude hidden premalignant and malignant changes within polyps. Three hundred fifty-nine consecutive postmenopausal patients who underwent hysteroscopic diagnosis of endometrial polyp over a 3-year period and who were scheduled for surgical removal within the three subsequent months were retrospectively evaluated. Histologic results after resection during operative hysteroscopy or during hysterectomy were compared with liquid-based cytology and endometrial biopsy obtained at the time of diagnostic hysteroscopy. Eight of 359 patients (2.2%) had malignant or premalignant polyps interpreted as benign finding at hysteroscopy. Unsatisfactory samples were higher for endometrial biopsy compared to liquid-based cytology in the whole series and in the subgroup of low-risk asymptomatic patients (P< 0.001). Endometrial biopsy and liquid-based cytology revealed a sensitivity of 62% and 87.5%, respectively and a 100% specificity. Considering the subgroup of low-risk asymptomatic patients, liquid-based cytology disclosed all the five pathologic lesions with a 100% sensitivity and specificity. In conclusion, liquid-based cytology proved to be a useful tool to establish the nature of endometrial polyps in postmenopausal patients. Complete removal of the lesion should be offered to all symptomatic patients and those with established risk factors for endometrial cancer. Conversely, a wait and see attitude should be considered in case of asymptomatic low-risk polyps with typical appearance on hysteroscopy and negative liquid-based cytology.

Current treatment options for abnormal uterine bleeding: an evidence-based approach

Heavy menstrual bleeding is the predominant complaint in women with abnormal uterine bleeding. Treatment options are drug therapy, and first- and second-generation endometrial resection. Many women will subsequently have a hysterectomy. Uterine fibroids are the most common solid pelvic tumours in women, and although many fibroids seem to cause no symptoms, they can have serious adverse effects and impact on quality of life. As women postpone having children, gynaecologists will have to manage fibroids and polyps in a conservative manner. The past decade has witnessed the development of highly sophisticated diagnostic and therapeutic technology for women suffering from menorrhagia, fibroids and polyps, including minimally invasive uterine therapy. The tools currently at our disposal permit greater management flexibility, which must be tailored to the individual clinical situation. This chapter reviews the evidence-based approach and minimally invasive therapy.

Hysteroscopic resection of symptomatic and asymptomatic endometrial polyps

STUDY OBJECTIVE

To estimate the occurrence of malignancy and atypical hyperplasia in endometrial polyps in patients with and without symptoms.

DESIGN

Retrospective registration of all patients who underwent hysteroscopic resection of endometrial polyps. Age, menopausal status, presence or absence of symptoms, any use of hormonal medication, as well as histologic diagnosis, complications, and eventual repeated surgery were documented (Canadian Task Force classification II-3).

SETTING

Ullevaal University Hospital, Department of Gynecology.

PATIENTS

All patients who underwent hysteroscopic resection of an endometrial polyp in our department from January 1, 2001 through March 1, 2005.

INTERVENTIONS

Hysteroscopic resection of endometrial polyps.

MEASUREMENTS AND MAIN RESULTS

Four hundred eleven patients were included. One hundred twenty-nine patients (31.4%) had no symptoms. The prevalence of malignancy or atypical hyperplasia was 3.2% in women with symptoms and 3.9% in those without symptoms.

CONCLUSION

The prevalence of malignancy and atypical hyperplasia was found to be relatively high, indicating that symptomatic, as well as asymptomatic, endometrial polyps should be removed.

Polypectomy in premenopausal women with abnormal uterine bleeding: effectiveness of hysteroscopic removal

STUDY OBJECTIVE

To estimate the effectiveness of hysteroscopic polypectomy in premenopausal women with abnormal uterine bleeding and to identify prognostic factors for persistence or recurrence of symptoms after polypectomy.

DESIGN

Retrospective study (Canadian Task Force classification II-3).

SETTING

University teaching hospital.

PATIENTS

Premenopausal women with abnormal uterine bleeding.

INTERVENTION

Hysteroscopic polypectomy, regardless of whether combined with endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device.

MEASUREMENTS AND MAIN RESULTS

Seventy-eight consecutive patients met the inclusion criteria and were followed over time. Data were retrieved from medical records or from additional questionnaires sent to the patients. Failure of treatment was defined as persistence or recurrence of abnormal uterine bleeding after polypectomy, requiring further treatment. The mean age was 44.2 years (SD 5.2, 95% CI 33.9-54.4 years). Intervention-free survival after polypectomy, as calculated by Kaplan-Meier survival analysis, was 41.1% (SE 8.3%, 95% CI 24.8%-57.4%) after 4 years for patients who underwent only hysteroscopic polypectomy and 54.7% (SE 13.6%, 95% CI 28.0%-81.4%) for patients who underwent a polypectomy combined with endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device (p = .08). Cox regression analyses revealed no statistically significant predictors for persistence or recurrence of symptoms after polypectomy.

CONCLUSION

Nearly 60% of patients required further treatment for persistence or recurrence of abnormal uterine bleeding 4 years after hysteroscopic polypectomy. Although not significant, outcome of treatment tended to improve by combining polypectomy with either an endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device.

Uterine polypectomy in the management of abnormal uterine bleeding: A systematic review

In order to assess the efficacy of uterine polypectomy in the treatment of abnormal uterine bleeding (AUB), we conducted a systematic review of the published literature. Relevant papers were identified through electronic scanning of MEDLINE (1966-2004), EMBASE (1980-2004), and the Cochrane Library, and manual searching of bibliographies of known primary and review articles. Studies were selected if the efficacy of uterine polypectomy in treating women with AUB (menstrual dysfunction, postmenopausal bleeding with or without hormone replacement/tamoxifen therapy) was estimated. Study selection, quality assessment, and data abstraction were performed independently and in duplicate. The main outcomes measured were relief of AUB symptoms measured in general terms (improvement from baseline, normalization of bleeding patterns) and patient satisfaction. Secondary outcomes included technical feasibility and complications. Ten uncontrolled observational studies with 617 women were identified. No randomized trials were found. The methodologic quality of included studies was poor. Hysteroscopic resection under general anesthesia was used to remove intrauterine polyps in all studies, although outpatient approaches with local anesthetic also were employed in three of these case series. No technical failures were reported, but three complications including one uterine perforation were described. All studies reported an improvement in symptoms of AUB after polypectomy (range 75%-100%) at follow-up intervals of between 2 and 52 months. A single study compared outpatient polyp removal under local anesthesia with inpatient, general anesthetic treatment and detected no significant difference in treatment outcomes (p = 0.7). It was only possible to stratify treatment outcome according to type of AUB in one small study, which detected no significant difference between polypectomy for menstrual dysfunction or postmenopausal bleeding (p = 0.2). In conclusion, there is a lack of high-quality evidence to reliably inform clinical practice regarding the efficacy of intrauterine polypectomy in women with AUB. The limited available evidence suggests that hysteroscopic polypectomy is a technically successful procedure that improves AUB symptoms. Further research in the form of a multicenter, randomized, controlled trial, stratified by technique, setting, and pattern of AUB, is required to assess the short- and long-term effects of this commonly practiced intervention.

Are the site, diameter, and number of endometrial polyps related with symptomatology?

OBJECTIVE

The objective of the study was to evaluate the relationship among polyp site, number, diameter, and symptomatology in endometrial polyps in reproductive and postmenopausal women.

STUDY DESIGN

One hundred fifty-five subjects with endometrial polyps were evaluated retrospectively. Sociodemographic characteristics, endometrial thickness, polyp number, diameter, and site were reviewed, and their relations with abnormal uterine bleeding were tested.

RESULTS

A total of 36.1% of the patients in the postmenopausal group and 44.4% of the patients in the reproductive-aged group were asymptomatic. In addition, 37.3% of polyps in the reproductive-aged and 29.2% in the postmenopausal group were multiple. Polyp number, diameter, and site were not different among the 2 groups (P = .282, P = .469, and P = .485, respectively). When patients were evaluated as a whole, symptomatology was not related with polyp number, diameter, and site (P = .677, P = .334, and P = .699, respectively).

CONCLUSION

Many endometrial polyps are asymptomatic and multiple in nature. Polyp site, number, and diameter do not correlate with symptomatology.

Résultats à long terme de la résection des polypes endométriaux chez 367 patientes. Place de l'endométrectomie associée

OBJECTIVE

To assess the results of hysteroscopic resection of endometrial polyps and the eventual role of associated endometrial resection.

PATIENTS AND METHODS

Retrospective study. Between 1998 and 2001, 367 patients had hysteroscopic resection of endometrial polyps, which were initially confirmed by diagnostic hysteroscopy. Fifty-four percent of these had associated endometrial resection.

RESULTS

Five intraoperative complications and/or incidents were noted, but there was no major complication. 83% of patients were followed up and the median follow-up period was 40 months (range 17-66 months). The success rate in this study was 96.4%. This is higher in the group of patients that had associated endometrial resection: 98.3 vs 93.7%.

DISCUSSION AND CONCLUSION

Hysteroscopic resection is the optimal method for treatment of benign endometrial polyps. Associated endometrial resection in older patients or in patients not desiring to conserve their fertility potential improves the success rate and decreases the rate of recurrences.

Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women

OBJECTIVE

To ascertain the therapeutic efficacy and safety of hysteroscopic polypectomy in 240 premenopausal and postmenopausal patients.

DESIGN

Retrospective study.

SETTING

Tertiary university hospital.

PATIENT(S)

Two hundred forty patients with intrauterine endometrial polyps, who mostly suffered from abnormal uterine bleeding and infertility.

INTERVENTION(S)

Hysteroscopic polypectomy using various instruments including microscissors, grasping forceps, or electrosurgery either with a monopolar probe or a resectoscope.

MAIN OUTCOME MEASURE(S)

Operating time, amount of glycine absorption, complications, resumption of normal menstruation, cumulative pregnancy rate, and recurrent rate of polyps after hysteroscopic surgery.

RESULT(S)

Resectoscopic polypectomy needed more operating time, had more glycine absorption and complications, but less recurrence than other hysteroscopic techniques. The resectoscope had a 0% recurrence rate and that grasping forceps had a 15% recurrence rate. A total of 21 (8.7%) complications occurred, but no major complications were noted. After long-term follow-up of 9 years and 2 months, those with abnormal uterine bleeding resumed normal menstruation in 93.1% and those with infertility had a cumulative pregnancy rate of 42.3%. There was no statistical difference in reproductive outcome between patients having polyps < or = 2.5 cm and >2.5 cm.

CONCLUSION(S)

We found hysteroscopic polypectomy to be effective, safe, minimally invasive procedure with low rate and mild complications. Restoration of reproductive ability did not depend on the size of the removed lesion. Resectoscopic surgery is more preferable to prevent recurrence of polyps.

Outpatient Hysteroscopic Polypectomy in 237 Patients: Feasibility of a One-Stop “See-and-Treat” Procedure

STUDY OBJECTIVE

To evaluate the feasibility of a "see-and-treat" office polyp resection, using a 5-mm sheathed operative hysteroscope.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

Public hospital.

PATIENTS

Two hundred thirty-seven patients suffering from endometrial polyps who underwent outpatient hysteroscopy.

INTERVENTIONS

Office polypectomy with anesthetic paracervical block (120 patients) or without (117 patients) using either mechanical (104 patients) or bipolar coaxial electrosurgical (107 patients) instrumentation. In 26 patients, we stopped the procedure before surgery because of intervening adverse events or polyps judged unresectable with an office-based procedure. A 10-cm visual analog scale (VAS) was used to rate patients' pelvic pain perception.

MEASUREMENTS AND MAIN RESULTS

Overall effective polyp resection rate was 81.2% (191 of 235 evaluable patients). An inverse, although not significant (r = -.44) correlation was found between accomplished polypectomies and polyp size, ranging from 96.0% to 18.7% when the diameter of polyps was below 1 cm and above 4 cm, respectively (50 of 52 and 3 of 16 successfully accomplished procedures, respectively). No significant differences were found between successful resection rates (83.3% and 80.2%, respectively; p = .10) and VAS scores (2.2 +/- 2.6 and 3.6 +/- 2.9, respectively; p = .30) obtained in 79 premenopausal and 156 postmenopausal patients. Paracervical block administration (118 evaluable patients) matched with no anesthetic support (117 patients) was not associated either with an improved rate of resection (85.5% and 76.9%, respectively; p = .10) or with pelvic pain perception (VAS scores 3.3 +/- 2.9 and 3.0 +/- 2.8, respectively; p = .94). Visual analog scale scores were significantly lower (2.8 +/- 2.5 and 4.7 +/- 3.6, respectively; p = .001) and polyp resection rates were significantly higher (84.3% and 67.4%, respectively; p = .01) in 192 parous versus 43 nulliparous patients. Polypectomy failed in 44 of 235 patients (18.7%); the leading causes of failure were intolerable pelvic pain in 18 patients (7.6%) and polyp size in 17 patients (7.2%). Other than pelvic pain, the only adverse event we observed was clinical vasovagal reaction in four patients (1.7%).

CONCLUSION

One-stop outpatient hysteroscopic polypectomy is effective in about 80% of patients. With proper preoperative selection, it can be offered as a reliable option to avoid general anesthesia and resectoscopic surgery.

Is outpatient diagnostic hysteroscopy more useful than endometrial biopsy alone for the investigation of abnormal uterine bleeding in unselected premenopausal women? A randomised comparison

OBJECTIVE

To formally evaluate the clinical benefit of additional outpatient hysteroscopy over traditional vaginal examination and endometrial biopsy.

DESIGN

A prospective randomised controlled trial.

SETTING

A large teaching hospital in the northeast of Scotland. SAMPLE Premenopausal women with abnormal uterine bleeding referred to the general gynaecologic clinic and requiring endometrial biopsy. METHODS Women were randomised to either outpatient hysteroscopy and endometrial biopsy or endometrial biopsy alone.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

initial surgical intervention rates.

SECONDARY OUTCOMES

procedural success and acceptability, intrauterine pathology identified and changes in management.

RESULTS

Three hundred and seventy women were recruited to the study. Initial trends in clinical management were comparable in both groups. No woman was advised to have removal of a localised lesion found at outpatient hysteroscopy and a normal uterine cavity at hysteroscopy did not influence the hysterectomy rate, which was similar in both groups. Outpatient hysteroscopy was found to be as acceptable as an outpatient endometrial biopsy and successfully completed in 85% compared with 91% of women who underwent endometrial biopsy alone. No cases of endometrial malignancy were identified.

CONCLUSIONS

Outpatient diagnostic hysteroscopy is an acceptable procedure and may give more reassurance. It did not influence clinical management, especially with respect to hysterectomy rate. Outpatient hysteroscopy may be useful in selected cases, but when performed in a non-selective manner, it has little influence on clinical management and increases costs.