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Endometrial Polyps
Silvina M. Bocca
1 1
Introduction
Endometrial polyps are localized overgrowths of
endometrial glands and stroma around a vascular
core that protrude from the surface of the endometrium into the uterine cavity. They can be
hyperplastic (similar to endometrial hyperplasia),
atrophic (cystically dilated atrophic glands), or
functional (undergo cyclical changes). Single or
multiple polyps (20 % of the times, Fig. 11.1 ) can
occur that range from a few millimeters to several centimeters in size. They can be sessile or
pedunculated (Fig. 11.2 ). They are found in the
uterine fundus (Fig. 11.3 ), midwall (Figs. 11.1
and 11.2 ), cornua (Fig. 11.4 ), and cervix.
Endometrial polyps are rare among women
younger than 20 years of age. The incidence
rises steadily with increasing age, peaks in the
fi fth decade of life, and gradually declines after
menopause. The prevalence of polyps can range
from 10 to 24 % among women undergoing
endometrial biopsy or hysterectomy [ 1 ] to 8 to
36 % in postmenopausal women on tamoxifen
therapy [
large (>2 cm), multiple, or show molecular
alterations [
drome may have an increased incidence of
S. M. Bocca , MD, PhD
Department of Obstetrics and Gynecology ,
The Jones Institute for Reproductive Medicine ,
601 Colley Ave , Norfolk , VA 23507 , USA
e-mail: boccas@ems.edu
2 ]. Polyps in these women may be
2 – 5 ]. Also women with Lynch syn-
endometrial polyps compared to the general
population [ 6 ]. There are several theories on the
molecular mechanisms playing a role in the
development of endometrial polyps: monoclonal endometrial hyperplasia [ 7 ], gene mutations
[ 8 ], overexpression of endometrial aromatase
[ 9 , 10 ], and, like in leiomyomas, cytogenetic
rearrangements and rearrangements in the HMG
family of transcription factors [ 3 , 11 , 12 ].
Although endometrial polyps are responsible for approximately one-fourth of cases of
abnormal genital bleeding (menorrhagia, postmenopausal bleeding, prolapse through the cervical os, and breakthrough bleeding during
hormonal therapy) in both premenopausal and
postmenopausal women [ 1 ], many polyps are
asymptomatic [ 13 ].
The natural course of polyps is variable.
A prospective study [ 14 ] to evaluate this per-
formed two saline infusion sonograms 2.5 years
apart on 64 initially asymptomatic women (mean
age 44 years). Seven women had polyps on the
fi rst examination. Four of these women had spontaneous regression of their polyps at the second
scan, while seven women developed new polyps
over the 2.5-year interval. Polyps larger than
1 cm were least likely to regress, and hormone
use did not appear to affect the natural history of
the polyps. In rare cases, endometrial polyps continue to recur multiple times after removal. There
are no data regarding management of this clinical
situation. If polyps continue to recur, one option
is an empiric trial of progestin treatment (oral
progestin such as medroxyprogesterone acetate
L.A. Stadtmauer, I. Tur-Kaspa (eds.), Ultrasound Imaging in Reproductive Medicine,
DOI 10.1007/978-1-4614-9182-8_11, © Springer Science+Business Media New York 2014
133
134
S.M. Bocca
ab
c
d
Fig. 11.1 Endometrial polyps. A single polyp located in
a lateral wall at midcorpus, shown in two dimensional
transvaginal ultrasonographic view ( a ) and in 3D imaging
ab
Fig. 11.2 ( a ) Sessile polyps ( arrow ) shown in a transverse 2D view of the uterus distended by saline infusion.
( b ) Coronal view (3D) of the uterus showing a pedunculated polyp ( arrow )
( b ). Multiple polyps and submucosal fi broids (by
Pathology) shown by 2D US ( c ) and by 3D US ( d )
11 Endometrial Polyps
a
Fig. 11.3 Large polyp ( arrows ) occupying the entire fundal area shown in a sagittal 2D view ( a ), in an HSG view ( b )
giving a globular appearance of the uterus, and in a hysteroscopic view ( c )
b c
135
a
b
cd
Fig. 11.4 Cornual polyps ( arrows ) clearly seen in HSG ( a ) and hysteroscopy ( b , c ) but not visualized in 2D US ( d )
10 mg daily for 3–6 months, a levonorgestrelreleasing device), and another option is endometrial ablation for women who have completed
their childbearing.
The great majority of endometrial polyps are
benign, but malignancy occurs in some women.
A systematic review of 17 observational studies
including over 10,000 women reported that the
136
S.M. Bocca
incidence of malignant or premalignant (simple
hyperplasia and atypia, endometrial polyps with
complex hyperplasia and atypia) polyps was signifi cantly higher in postmenopausal compared
with premenopausal women (5.4 versus 1.7 %;
RR 3.86; 95 % CI 2.905.1) and those with bleeding compared to those without bleeding (4.2 %
versus 2.2 %, RR 2.0; 95 % CI 1.2–3.1) [ 15 ].
Data were inconsistent regarding whether large
polyp size was associated with malignancy.
Malignant transformation appears to occur more
frequently in women on tamoxifen (3–11 %) than
in other women [ 2 ] regardless of polyp size or
duration of tamoxifen therapy. The benefi t of
using progestagens for treatment of endometrial
hyperplasia as well as to reduce the occurrence of
de novo endometrial polyps in women treated
with tamoxifen has been demonstrated by Chan
et al. [ 16 ].
For patients with cervical polyps, Stamatellos
et al. [ 17 ] reported that 25 % of them will also
have concomitant endometrial polyps, making
hysteroscopy a worthwhile process for their treatment, in contrast to insuffi cient D&C or blind
endometrial biopsies.
a
b
Fig. 11.5 Transvaginal ultrasonographic view of an
endometrial polyp ( a , cursor ) appearing as an echogenic
ovoid structure containing a feeding vessel visualized by
Doppler ( b )
Diagnosis
Abnormal uterine bleeding occurs in 9–14 % of
women between menarche and menopause, signifi cantly impacting quality of life and imposing
fi nancial burden. The American College of
Obstetrics and Gynecology (ACOG) [ 18 ] recom-
mends endometrial tissue assessment to rule out
cancer in adolescents and in women younger than
35 years or older with suspected anovulatory
bleeding and women unresponsive to medical
therapy. Neither ultrasonography nor hysteroscopy can reliably distinguish between benign and
malignant polyps [ 19 , 20 ].
Transvaginal ultrasound (TVUS) is the initial imaging of choice, with MRI reserved for
indeterminate cases or where sampling is diffi cult [ 21 ]. On US, endometrial polyps appear
as ovoid echogenic masses that project into the
endometrial lumen with Doppler US showing
a feeding vessel (Figs. 11.1 and 11.5 ). The fol-
lowing guidelines have been proposed in 2012
by the American Association of Gynecologic
Laparoscopists (AAGL) [ 22 ] for the diagnosis
of endometrial polyps: (1) TVUS provides reliable information for the detection of endometrial
polyps and should be the investigation of choice
where available; (2) the addition of color or
power Doppler increases the capacity of TVUS
to diagnose endometrial polyps; (3) adding intrauterine contrast sonography (with or without
3D imaging) improves the diagnostic capacity
for endometrial polyps; (4) blind dilatation and
curettage or biopsy should not be used for diagnosis of endometrial polyps.
Transvaginal Ultrasonography
Salim et al. [ 23 ] performed a review of the litera-
ture on the diagnosis and management of endometrial polyps. On TVUS, an endometrial polyp
11 Endometrial Polyps
a1 b1
c1
c2
137
d
a2
Fig. 11.6 Examples of different endometrial pathologies
presenting as endometrial thickening in TVUS. ( a )
Endometrial polyp ( a1 2D US, a2 3D SIS); ( b ) complex
hyperplasia without atypia ( b1 2D US, b2 fl at lesions in
b2
typically appears as a hyperechoic lesion with
regular contours within the uterine lumen surrounded by a thin hyperechoic halo [ 24 ], occa-
sionally cystic spaces corresponding to dilated
glands fi lled with proteinaceous fl uid may be
seen within the polyp [ 25 ], or the polyp may
appear as a nonspecifi c endometrial thickening or
focal mass within the endometrial cavity [ 26 ].
None of these fi ndings can reliably distinguish
among polyps, submucous fi broids, adenomyosis, and neoplastic change.
In premenopausal women, the TVUS examination should be performed early in the proliferative phase when the endometrium is at its thinnest
(4–8 mm) [ 27 , 28 ] to minimize false-positive and
negative fi ndings [ 29 ]. Endometrial thickness
is associated with risk of endometrial cancer in
menopausal women but not in premenopausal
women [ 30 , 31 ]. Endometrial thickening
(Fig. 11.6 ) is a nonspecifi c fi nding of endome-
trial hyperplasia as well as other causes such
as polyp, endometrial cancer, trophoblastic disease (Fig. 11.6 ), retained products of conception
c3
hysteroscopy); ( c ) retained products of conception ( c1
HSG, c2 3D US, c3 3D SIS); ( d ) trophoblastic disease
(multivessel signal)
(Fig. 11.6 ), or submucosal leiomyoma (Fig. 11.1 )
[ 21 ]. If structural abnormalities are suspected on
ultrasound examination, then these abnormalities can be further evaluated by saline infusion
sonography or hysteroscopy. In a retrospective
review of multiple studies, Salim and his group
[ 23 ] report that for TVUS the sensitivity var-
ies between 19 and 96 %, specifi city of 53 and
100 %, positive predictive value (PPV) of 75 and
100 %, and negative predictive value (NPV) of
87 and 97 %, when compared with hysteroscopy
with guided biopsy. The ranges were tighter in
a single-large prospective study evaluating the
causes of menorrhagia: 86 % sensitivity, 94 %
specifi city, 91 % PPV, and 90 % NPV [ 32 ].
There are limited data to support color-fl ow or
power Doppler aiding in the differentiation of hyperplasia and malignancy in polyps [ 33 – 35 ]. Color-
fl ow Doppler scanning identifi es a single feeding
vessel (Fig. 11.5 ) [ 11 ]. The use of power Doppler
sonography with identifi cation of a single- vessel
pattern improves diagnostic sensitivity to 89 % and
specifi city to 87 % for an endometrial polyp [ 36 ], in
138
S.M. Bocca
Fig. 11.7 3D-rendered view of the uterus during sonohysterography. The arrow points to an endometrial polyp in the
left midcorpus
comparison to the multivessel (Fig. 11.6 ) or scat-
tered pattern seen in malignant lesions or endometrial hyperplasia [ 34 ]. At this time, sonographic
examination either with or without color-fl ow or
power Doppler sonography is not a substitute for
pathologic evaluation after surgical removal.
outlined by fl uid [ 26 ]. Differentiating endome-
trial polyps from submucosal fi broids can be diffi cult (Fig. 11.1 ), but examination of lesion
echotexture and identifi cation of overlying echogenic endometrium are useful features to distinguish the two [ 39 ]. SIS has relatively minor
disadvantages: it cannot provide defi nitive diagnosis of endometrial disease [ 40 ], a longer learn-
Sonohysterography
ing curve compared with non-contrast TVUS
[ 41 ], and patient discomfort caused by fl uid leak-
The use of saline infusion sonography (SIS),
sonohysterography, or hydrosonogram involves
injection of sterile saline into the endometrial
cavity followed by a transvaginal ultrasound
examination (Figs. 11.2 and 11.7 ). This tech-
nique increases sonographic contrast of the endometrial cavity, enabling delineation of the size,
number, and location of polyps that could have
been missed on gray-scale TVUS, and is likely to
improve diagnostic accuracy [ 37 , 38 ]. With SIS,
polyps appear as echogenic, smooth, intracavitary masses with either broad bases or thin stalks
age or pain with the use of a balloon catheter
[ 42 ]. Bingol et al. [ 43 ] selected a total of 346
patients for operative hysteroscopy, following
SIS after TVUS. SIS seems to be superior to
TVS, for uterine pathologies, with respect to hysteroscopy as the gold standard.
Kamel et al. [ 44 ] reported on 106 women with
menometrorrhagia where sonohysterography
was signifi cantly more accurate than ultrasound
alone in making a diagnosis, with a higher sensitivity (93 % versus 65 %) and specifi city (94 %
versus 76 %) than transvaginal ultrasonography.
11 Endometrial Polyps
a1
b1
a2
c1 c2
139
b2 b3
Fig. 11.8 Intrauterine lesions that may not be easily
detected by TVUS. ( a1 ) Apparently normal 2D sagittal
view of the uterus. ( a2 ) Same uterus as in (a1), containing
fl at hyperemic lesions visualized directly by hysteroscopy
(benign polyp on Pathology). ( b1 ) Apparently normal 3D
Three-Dimensional TVUS and Three- Dimensional SIS
Three-dimensional ultrasonography (3D US) is a
noninvasive imaging technique with the ability to
generate multiplanar reconstructed images
(Fig. 11.8 ) through the uterus and its external
contours. Coronal views of the uterus allow more
accurate visualization between the endometrium
and myometrium at the fundus and cornual
angles, providing superior diagnostic accuracy in
detecting endometrial polyps compared to 2D
TVUS (Figs. 11.1 , 11.2 , and 11.7 ).
coronal view of the uterus. ( b2 ) Thin, though multiple,
bands of synechiae seen on 3D SIS and hysteroscopy
( b3 ). ( c1 ) Synechiae not clearly visualized on 3D-SIS but
more clearly identifi ed upon evaluation of the multiplanar
views ( c2 ) of the uterus
In a study of 3,850 consecutive, Kupesic et al.
[ 45 ] reported 3D US to have sensitivity of 100 %,
specifi city of 99 %, PPV of 99 %, and NPV of
100 % in diagnosing endometrial polyps when
compared to hysteroscopy with biopsy. Adding
saline solution contrast into the endometrial cavity to perform 3D SIS may provide additional
information in the diagnosis of endometrial polyps (Figs. 11.6 and 11.7 ). However, studies report
only slightly higher specifi city (88–99 %) and
PPV (97–100 %) for endometrial polyps than
those of 3D US, with sensitivity of 92–95 % and
NPV of 97 % [ 46 , 47 ].
140
S.M. Bocca
Three-dimensional sonography is simple,
quick, and noninvasive for detecting most congenital and acquired uterine anomalies. We
demonstrated that physicians who learn the
Z technique [ 48 ] are able to retrieve the mid-
coronal plane of the uterus faster and improve
its image quality in volume sonography. In a
prospective blinded study to evaluate the costs,
accuracy, risks, and benefi ts of 3D TV sonography compared to hysterosalpingography [ 49 ],
we enrolled 101 women aged 26–44 years with
evidence of uterine anomalies (congenital and
acquired). We concluded that 3D TV sonography provides visualization and evaluation of the
uterine cavity with similar or better accuracy
than standard hysterosalpingography (HSG) in
the offi ce setting, without radiation exposure,
with lower cost and morbidity. Despite the multiple advantages of performing 3D US, including
having diagnostic accuracy comparable to MRI
or combined laparoscopy and hysteroscopy, it is
still not widely available and accepted as a diagnostic tool, and multiple insurance carriers deny
its reimbursement.
Hysteroscopy is an outpatient surgical
procedure usually requiring local or intravenous
anesthesia that provides direct visualization of
the endometrial cavity (Figs. 11.3 , 11.4 , 11.6 ,
11.8 , and 11.9 ), thereby allowing targeted biopsy
or excision of lesions identifi ed during the procedure [ 52 ]. Although considered the gold stan-
dard for the diagnosis of abnormal uterine
bleeding, hysteroscopy requires advanced training and is more costly and invasive than imaging
modalities for endometrial assessment [ 27 ].
Grimbizis et al. [ 53 ] studied a total of 105 con-
secutive women presenting in an outpatient
clinic with symptoms of menorrhagia, postmenopausal bleeding, and infertility. They found
diagnostic hysteroscopy to be the most accurate
diagnostic technique on any endometrial pathology compared with TVUS and SIS, whereas
there was no statistically signifi cant difference in
the diagnostic performances of SIS and TVUS.
False-Positive, False-Negative, and Artifacts
Other Imaging Modalities
Hysterosalpingography may defi ne an endome-
trial polyp as pedunculated (Fig. 11.4 ), or as a
nonspecifi c fi ling defects within the endometrial
cavity (Figs. 11.3 and 11.6 ), with high sensitivity
(98 %) but low specifi city (34.6 %) compared
with hysteroscopy [ 50 ]. It has the advantage of
allowing for assessment of tubal patency in infertile women, but due to the disadvantages of using
ionizing radiation, iodinated contrast materials,
and patient discomfort, routine use of HSG for
diagnosis of an endometrial polyp cannot be
recommended.
T2-weighted MRI and computed tomography
scanning are very high-cost, limited availability
techniques with limited advantages when compared with TVUS, even with contrast enhancement [ 51 ]. Appearance on MR is not diagnostic,
and endometrial polyp, secretory endometrium,
stage IA endometrial cancer, and endometrial
hyperplasia can demonstrate similar fi ndings.
There is not a single imaging technique that can
accurately diagnose all possible intrauterine
pathologies. Ultrasonography may not distinguish
very small polyps, fl at endometrial anomalies
(Figs. 11.6 and 11.8 ), cornual polyps (Fig. 11.4 ),
or thin bands of synechiae (Figs. 11.8 and 11.9 )
even when combined with saline infusion sonography [ 54 ].
To the contrary, there could be transient endometrial changes detected by ultrasonography as
a possible structural defect, such as an intrauterine blood clot (Fig. 11.6 ) or presence of mucus
especially in hyperestrogenic states such as during controlled ovarian hyperstimulation for IVF
(Fig. 11.10 ) that may spontaneously resolve. Our
group [ 55 ] reported on early postoperative intra-
uterine changes by 3D US in patients undergoing hysteroscopic correction of various uterine
anomalies. Postoperative changes 1 month after
hysteroscopy were detected by 3D US in 20 %
(6/30) of these patients. The changes detected
consisted of intrauterine cystic loculations
(Fig. 11.10 ) in three patients and endometrial
11 Endometrial Polyps
a b
c
141
Fig. 11.9 Nonspecifi c endometrial US fi ndings. An area of endometrial constrictions is shown by 2D US ( a ), by 3D
SIS ( b ), and by HSG ( c ). Arrows point to the area of narrowing representing synechiae
a1
b1
a2
c
d
b2
Fig. 11.10 Transient endometrial changes detected as
morphological anomalies by US. Endometrial clots and
fl uid seen on menstrual day 4 ( a1 ) that spontaneously dis-
appeared 1 day later ( a2 ). ( b1 ) Endometrial mucus seen
during ovarian stimulation for IVF. Notice lack of internal
blood fl ow in the hyperechoic mucus accumulation ( b2 ).
Monoloculated ( c ) and multiloculated ( d ) cystic lesions
observed by 3D US a few weeks after hysteroscopy that
spontaneously resolved within 2 months post op