Endometrial polyps

Introduction

Endometrial polyps are small, often benign growths that protrude from the inner lining of the uterus (the endometrium). Although many women never notice them, they can cause irregular bleeding, pelvic discomfort, or fertility challenges. Endometrial polyps affect up to 10% of women in their reproductive years and become more common around menopause. In this article, we’ll explore what these polyps are, how they form, what symptoms they cause, and what treatments are available plus a peek at long-term outlook.

Definition and Classification

Medically, an endometrial polyp is a localized overgrowth of endometrial glands and stroma attached to the uterine wall by a thin stalk or broad base. Classified as benign in most cases, they range from a few millimeters to several centimeters in size. Polyps can be:

• Pedunculated – hanging by a stalk into the uterine cavity.
• Sessile – broad-based and flat against the uterine lining.

They’re not typically considered malignant, but atypical or hyperplastic subtypes may carry a slight risk of progression to endometrial cancer. Polyps primarily involve the endometrium but can sometimes extend into the cervix. Clinically, we differentiate:

• Pre-menopausal
• Post-menopausal (higher malignancy risk)

Causes and Risk Factors

The exact cause of endometrial polyps isn’t fully understood, but several factors seem to contribute. Hormonal influences play a major role, especially estrogens both endogenous and from hormone therapies that stimulate endometrial cell growth. It’s like the lining gets hyper-sensitive to proliferative signals.

Key risk factors include:

• Age: More common in women aged 40–50, peaking near menopause.
• Hormonal imbalance: Conditions like polycystic ovary syndrome (PCOS) or unopposed estrogen therapy increase risk.
• Obesity: Adipose tissue converts androgens into estrogen, raising endometrial exposure.
• Hypertension and diabetes: Chronic metabolic issues may alter uterine blood flow and tissue growth factors.
• Tamoxifen therapy: Used in breast cancer, paradoxically linked to polyp formation.
• Genetic predispositions: Rarely, familial syndromes or specific gene variants might play a part.
• Inflammation: Chronic endometritis (uterine inflammation) may trigger localized overgrowth.

Non‐modifiable factors: age, family history, genetics. Modifiable: weight, insulin resistance, exposure to certain medications. Infectious or autoimmune triggers have been proposed but remain under study. Importantly, most polyps occur sporadically rather than from a single known cause.

Pathophysiology (Mechanisms of Disease)

Under normal conditions, the endometrium undergoes cyclic proliferation and shedding regulated by estrogen and progesterone. In endometrial polyps, this balance tips toward unregulated proliferation. Estrogen stimulates glandular and stromal cells, leading to localized hyperplasia. Meanwhile, inadequate progesterone response may prevent normal shedding and remodeling.

On a cellular level, polyps exhibit:

• Increased expression of growth factors (EGF, VEGF) promoting angiogenesis.
• Altered apoptotic signaling—cells fail to undergo normal programmed death.
• Stromal cell overgrowth creating the fibrous core of the polyp.
• Reduced responsiveness to anti-proliferative signals.

Vascular changes are also key: spiral arteries within the endometrium may enlarge irregularly, supplying the polyp with blood and giving it that characteristic red appearance. Immunohistochemical studies reveal variable expression of estrogen and progesterone receptors within the polyp tissue, but often a higher ratio of ER to PR, shifting toward unopposed estrogenic effect.

Symptoms and Clinical Presentation

Many women with endometrial polyps are asymptomatic, and polyps are found incidentally during imaging or procedures. When symptoms occur, they can vary widely:

• Abnormal uterine bleeding: The hallmark symptom includes menorrhagia (heavy periods), metrorrhagia (irregular spotting), or post-menopausal bleeding.
• Intermenstrual spotting: Light to moderate spotting between cycles, often scant but frequent.
• Infertility or subfertility: Polyps can impair embryo implantation or distort the uterine cavity.
• Pelvic pain or pressure: Rare in small polyps but possible with larger growths or torsion of pedunculated polyps.
• Dyspareunia: Pain during intercourse if a polyp prolapses into the vaginal canal.

Early in development, polyps are usually silent. As they grow, you might notice changes in your menstrual pattern say you normally spot lightly for 2 days but suddenly it turns into a week of unpredictable bleeding. Advanced cases aren’t common, but very large polyps can lead to significant blood loss and anemia. Keep in mind, any new post-menopausal bleeding warrants prompt evaluation.

Diagnosis and Medical Evaluation

Diagnosing endometrial polyps typically starts with a detailed history and physical exam, including a pelvic exam. Key steps in evaluation:

• Transvaginal ultrasound (TVUS): First-line imaging. Polyps appear as echogenic masses within the endometrial cavity. Doppler may show a feeding vessel.
• Saline infusion sonohysterography (SIS): Saline distends the cavity for better visualization—polyps look like filling defects.
• Hysteroscopy: Direct visualization of the uterine cavity; allows targeted biopsy or removal.
• Endometrial biopsy: Tissue sampling to rule out hyperplasia or malignancy, especially in high-risk women.

Laboratory tests are generally supportive complete blood count if you have heavy bleeding to check for anemia. Differential diagnoses include submucosal fibroids, retained products of conception, hyperplasia, or malignancy. In some emergencies like acute heavy bleeding urgent imaging or even dilation and curettage (D&C) might be needed.

Which Doctor Should You See for Endometrial Polyps?

If you suspect endometrial polyps due to abnormal bleeding or fertility issues your first stop is often a gynecologist or an obstetrician-gynecologist (OB-GYN). They’re equipped to perform pelvic exams, order ultrasounds, and discuss treatment options. For initial guidance or second opinions, telemedicine visits can help you interpret ultrasound reports or clarify symptoms without the waiting room. But remember, online consults can’t replace hands-on procedures like hysteroscopy.

In urgent situations (e.g., severe bleeding, signs of infection), head to the nearest emergency department or an urgent care clinic with OB-GYN coverage. A reproductive endocrinologist may be involved if polyps are linked to fertility problems. Pathologists play a role in analyzing biopsy specimens to rule out precancerous changes.

Treatment Options and Management

Management depends on symptoms, polyp size, and patient goals (e.g., fertility preservation). Key approaches:

• Watchful waiting: Small, asymptomatic polyps in pre-menopausal women can be monitored with periodic ultrasound.
• Hysteroscopic polypectomy: Gold standard minimally invasive removal under direct vision. Often done as an outpatient.
• Dilation and curettage (D&C): Scraping of the lining; less targeted than hysteroscopy, higher chance of missed lesions.
• Hormonal therapies: Progestins or GnRH agonists can shrink polyps temporarily, but high recurrence rates if used alone.
• Follow-up: Repeat imaging at 6–12 months, especially if risk factors for malignancy are present.

Side effects of hysteroscopy are usually mild cramps, spotting, or a day of fatigue. Hormonal meds may cause mood swings or hot flashes. Really large or atypical polyps might require more extensive sampling or even hysterectomy if fertility isn’t desired.

Prognosis and Possible Complications

Overall prognosis is excellent when polyps are benign and removed promptly. Recurrence rates vary up to 15–20% at 2 years so follow-up is recommended. Potential complications include:

• Anemia: From chronic heavy bleeding.
• Infertility: Particularly if polyps disrupt implantation.
• Infection: Rare after polypectomy but possible.
• Malignancy: Uncommon (<1–2%); slightly higher in post-menopausal women or those with atypical histology.

Factors influencing outlook include patient age, symptom severity, polyp size, and histological subtype. Timely removal and histologic examination reduce long-term risks.

Prevention and Risk Reduction

There’s no guaranteed way to prevent endometrial polyps, but risk can be reduced by addressing modifiable factors:

• Weight management: Maintaining healthy BMI lowers estrogen excess from adipose tissue.
• Control metabolic conditions: Treat hypertension and diabetes effectively; aim for balanced blood sugars.
• Avoid unopposed estrogen: If on hormone therapy, consider combined estrogen–progestin regimens.
• Regular check-ups: Yearly gynecologic exams can catch early changes, especially in perimenopausal women.
• Screening: No formal screening guidelines, but discuss any abnormal bleeding promptly.

Lifestyle measures such as a balanced diet, regular exercise, and stress management support overall hormonal balance. It’s not a foolproof prevention, but staying proactive helps reduce severity and catch issues early.

Myths and Realities

The internet is full of misconceptions about endometrial polyps. Let’s debunk a few:

• Myth: “Polyps always require a hysterectomy.”
  Reality: Most are removed hysteroscopically, preserving the uterus and fertility.
• Myth: “If you have heavy periods, it’s definitely polyps.”
  Reality: Heavy bleeding has many causes—fibroids, adenomyosis, bleeding disorders.
• Myth: “Herbal remedies cure polyps.”
  Reality: No solid evidence supports herbs alone; medical removal is standard.
• Myth: “No symptoms means no problem.”
  Reality: Asymptomatic polyps still carry a small risk of atypia, especially after menopause.

Media often oversimplify by suggesting all uterine growths are cancerous. In reality, benign polyps are common and highly treatable. Always verify online claims with peer-reviewed studies or trusted medical sources.

Conclusion

Endometrial polyps are generally benign, hormone-driven overgrowths of the uterine lining that can cause abnormal bleeding, discomfort, or fertility challenges. Accurate diagnosis relies on ultrasound and hysteroscopy, while hysteroscopic polypectomy offers definitive removal with low complication rates. Although recurrence can occur, timely treatment and regular follow-up minimize risks. Always consult a qualified healthcare professional if you notice new or unusual bleeding, as early evaluation leads to better outcomes. 

Frequently Asked Questions

1. What exactly are endometrial polyps?

Localized growths of uterine lining tissue, usually benign but sometimes causing bleeding or fertility issues.

2. What symptoms suggest I might have a polyp?

Irregular or heavy menstrual bleeding, spotting between periods, post-menopausal bleeding, or pelvic discomfort.

3. Are endometrial polyps common?

They affect about 10% of women, more in perimenopausal and postmenopausal age groups.

4. How are polyps diagnosed?

Primarily via transvaginal ultrasound, saline infusion sonohysterography, and confirmatory hysteroscopy with biopsy.

5. Can polyps turn cancerous?

Malignancy is rare (<2%), higher risk in postmenopausal women and those with atypical histology.

6. What treatments are available?

Hysteroscopic polypectomy is the gold standard; hormonal therapies offer temporary relief but may not prevent recurrence.

7. Is surgery always needed?

Not if polyps are small and asymptomatic in premenopausal women—but follow-up imaging is advised.

8. Can polyps affect fertility?

Yes, they may interfere with embryo implantation; removal often improves fertility outcomes.

9. Are there ways to prevent polyps?

No guaranteed prevention, but weight control, balanced hormones, and routine gynecologic exams help.

10. How often do polyps recur?

Recurrence rates are 15–20% within two years post-removal, so periodic monitoring is wise.

11. Which doctor should I consult?

Start with a gynecologist. Telemedicine can provide initial guidance, but procedures require in-person visits.

12. What complications can arise if untreated?

Chronic anemia, ongoing bleeding, infection risk, and very rarely malignant transformation.

13. How long is recovery from polypectomy?

Most women resume normal activities within a day or two; some spotting and cramping are common.

14. Can lifestyle changes help?

Healthy weight, blood sugar control, and avoiding unopposed estrogen therapies reduce risk factors.

15. When should I seek urgent care?

If you experience heavy bleeding soaking pads hourly, severe pain, or signs of infection (fever, foul discharge).