Apr 26, 2011

Are Endometrial Polyps Overtreated?

A metaanalysis of women who have had polypectomies suggests that postmenopausal status and abnormal bleeding are negatively associated with endometrial neoplasia. However, a second prospective analysis of patients diagnosed with polyps who were referred for follow-up rather than immediate intervention suggests that “watch and wait” might be the most prudent course in a majority of cases. Both studies were reported here at the American Institute of Ultrasound in Medicine (AIUM) 2011 Annual Convention.

“Everyone in this room knows that with the advent of high-resolution, unenhanced transvaginal sonography, as well as saline infusion sonography and hysteroscopy, we’re diagnosing a lot more polyps then we have in the past,” said Andrew Kaunitz, MD, from the Department of Pathology, University of Florida College of Medicine, Jacksonville.

The majority of these polyps are benign. However, the small number of polyps that are malignant might be influencing how the majority of diagnosed polyps are being treated. “We are often asked by a patient or referring colleague: What’s the chance this given polyp is cancerous? And the related question: Is removal necessary?”

In an attempt to answer these questions by determining a stratified risk profile for this patient population, Dr. Kaunitz and lead investigator Stephanie Lee, MD, performed a metaanalysis of reports published from 1980 to 2010. Articles for this analysis were selected on the basis of the inclusion of women who had undergone polypectomy and who had tissue analysis. The primary end point of the metaanalysis was to compare the prevalence of endometrial neoplasia among pre- and postmenopausal women; the secondary end point compared the prevalence of neoplasias in women who had abnormal bleeding with the prevalence in women who were asymptomatic at the time of their procedure.

A total of 17 articles were selected for review, representing a patient population of 10,572 women. Metaanalysis revealed that 377 women were identified as having endometrial neoplasia. Of these, 5.4% were postmenopausal and 1.7% were premenopausal; 4.2% of these women had experienced symptoms of bleeding, whereas 2.2% were asymptomatic. “Women who were menopausal with polyps had an almost 4-fold higher likelihood of that polyp being malignant than when polyps were diagnosed in reproductive-aged women,” said Dr. Kaunitz. Correspondingly, a polyp was 2-fold more likely to be malignant in women with bleeding than in those who were asymptomatic.

The authors hope that there is now a bit more clarity about which polyps can wait and which might require immediate attention.

What Happens When You Watch and Wait?

In a second presentation here, Alex Hartman, MD, from True North Imaging in Thornhill, Ontario, Canada, reported on a study that looked at women who had been diagnosed with endometrial polyps and who received no intervention at the time of diagnosis but who were referred for follow-up.

From January to July of 2010, Dr. Hartman examined 300 women who had been diagnosed with endometrial polyps in the previous 2 to 43 months. The women ranged in age from 22 to 78 years. Factors considered in this analysis were location of polyp, time interval between studies, menopausal status, abnormal bleeding, blood flow, endometrial thickness, and patient age.

Results of these examinations showed that in 41 (13.7%) of these women, the polyp had naturally resolved; in 125 (41.7%), there was no change in polyp size; in 61 (20.3%), there was a decrease of at least 1 mm; in 49 (16.3%), there was an increase of greater than 50% of the originally measured polyp diameter; and in 24 (8.0%), there was a greater than 50% increase in polyp diameter.

Change in polyp size was significantly associated with menopausal status and blood flow, but not with polyp location or abnormal bleeding. Further, there was no statistical association between polyp progression and patient age, time between scans, or endometrial thickness. Although Dr. Hartman acknowledged that his patient cohort was effectively chosen by the treatment preferences of his referring doctors, he concluded that “automatic treatment of benign-appearing endometrial polyps is a practice that at least should be reevaluated.”

Dr. Hartman, Dr. Lee, and Dr. Kaunitz have disclosed no relevant financial relationships.

American Institute of Ultrasound in Medicine (AIUM) 2011 Annual Convention: Abstracts 939528 and 981597. Presented April 15, 2011.

— Neil Canavan

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