Search:
Menopause Live - IMS Updates
InFocus

Date of release: 07 September, 2009

Malignancy in endometrial polyps


Endometrial polyps are usually benign, localized overgrowths of endometrial tissue that are covered by epithelium and contain variable amounts of glands, stroma and blood vessels. They are most commonly found in perimenopausal women, with a prevalence among the general symptomatic female population of up to 50% and even higher if asymptomatic women are included. Hormone exposure is likely to play a crucial role as an over-expression of steroid receptors has been found in the glandular epithelium of polyps, and both tamoxifen and hormone replacement therapy (HRT) are often associated with the development of polyps. Abnormal uterine bleeding is the common presenting symptom, but polyps are often asymptomatic and may be found coincidentally during a routine pelvic ultrasound examination, when their management can present some dilemmas, particularly in the elderly or in those in whom cervical stenosis prevents safe access to the endometrial cavity. Fortunately, the incidence of carcinoma is low and varies between 0 and 4.8%, depending on the selection of patients and diagnostic methods used. A study by Baiocchi and colleagues [1] from Perugia University in Italy aimed to evaluate the risk of premalignant and malignant changes in endometrial polyps and to investigate whether some clinical parameters could predict the histopathological features of these lesions. This could be helpful for the clinician and the patient in deciding whether conservative management is appropriate, especially if the lesion is asymptomatic and when removal could present technical or medical difficulties.


 


This was a retrospective study of 1242 women with endometrial polyps presenting over a period of 12 years. The median age was 55 years (range 23–78 years) and 49% of the women were postmenopause. Abnormal bleeding was present in only 29%; HRT was used by 4.4% of the women and tamoxifen by 10.3%. The polyps were benign in 1182 cases (95.2%); hyperplasia with atypia was present in 15 (1.3%) and cancer in 45 (3.5%). Of those with premalignant or malignant polyps, 38 of 60 patients were older than 60 years (66.7%) and only 11 of 417 women (2.6%) younger than 50 years had cancerous polyps. For menopausal status, 49 of the 60 patients (81.6%) with malignant polyps were menopausal and only 11 (18.4%) were premenopausal patients (p < 0.05). Similarly, 32 of 45 patients with cancer (71.1%) had hypertension (p < 0.05). Of the 60 patients with malignant polyps, 39 had abnormal bleeding.

Comment

This study has confirmed many previous reports, but has the merit of being much larger than most and so the proportion of those with malignant or premalignant changes may be more accurate. The conclusion that patients with hypertension are more likely to have such changes is of interest, but is not really strong enough to be used as an indicator of who can be managed conservatively. Although the aim of this study was to find clinical parameters that might identify those most likely to have a pathological polyp, surprisingly no other means of assessment were mentioned in the discussion, of which more detailed ultrasound and Doppler blood flow studies would seem to have some promise, although, as always, larger studies are still needed [2,3]. So, for elderly or infirm women or a patient with a stenosed cervix that will not allow safe access to the uterine cavity, and presenting with an asymptomatic endometrial polyp, there is as yet no clear discriminator for conservative management, and malignancy can still only be excluded by histopathological examination of the removed specimen.

Comentario

David Sturdee
Solihull Hospital, Heart of England NHS Foundation Trust, Birmingham, UK

    References

  1. Baiocchi G, Manci N, Pazzaglia M, et al. Malignancy in endometrial polyps: a 12-year experience. Am J Obstet Gynecol 2009; July 25. E-pub ahead of print.
    http://www.ncbi.nlm.nih.gov/pubmed/19632664

  2. Goldstein SR, Monteagudo A, Popiolek D, Mayberry P, Timor-Tritsch I. Evaluation of endometrial polyps. Am J Obstet Gynecol 2002;186:669-74.
    http://www.ncbi.nlm.nih.gov/pubmed/11967489

  3. Lieng M, Qvigstad E, Dahl GF, Istre O. Flow differences between endometrial polyps and cancer: a prospective study using intravenous contrast-enhanced transvaginal color flow Doppler and three-dimensional power Doppler ultrasound. Ultrasound Obstet Gynecol 2008;32:935-40.
    http://www.ncbi.nlm.nih.gov/pubmed/19035544