Hysteroscopic Polypectomy - An Overview

What Is Hysteroscopic Polypectomy?

It is the gold standard for the surgical treatment of endometrial polyps. It involves two components:

1. Hysteroscopy - It is a surgical method to look at the womb lining with the help of a hysteroscope.

2. Polypectomy - Surgical removal of the endometrial polyps.

An endometrial polyp is an abnormal localized growth (or tumor) within the uterus lining. It contains glands, stroma, and blood vessels. The growth can be small or large enough to occupy the uterine cavity.

They are common findings, both in women with and without gynecological symptoms. Most endometrial polyps are asymptomatic but occasionally become symptomatic, especially in premenopausal women.

Symptoms typically include uterine bleeding and infertility. It is not known exactly what causes endometrial polyps, but women with underlying risk factors are predisposed toward them. The risk factors include age, obesity, use of Tamoxifen, hypertension, and other gynecological conditions like fibroids and cervical polyps.

Endometrial polyps can be diagnosed with transvaginal ultrasound or histological examination. Less popular but effective methods include color-flow or power doppler and sonohysterography (saline-infused sonography). Treatment options include conservative surgery (hysteroscopic polypectomy), radical surgery, and conservative non-surgical management. Women with postmenopausal bleeding must be examined within four weeks because of the relatively high risk for endometrial cancer. The treatment modality depends on the symptoms, risk of malignancy, and fertility issues.

How Is Hysteroscopic Polypectomy Performed?

The procedure is done under general anesthesia. Once sufficiently anesthetizes the patient is, a hysteroscope (narrow telescope) is inserted through the vagina and cervix and into the uterus. The camera attached to the hysteroscope facilitates visualization of the uterine cavity on a monitor during the surgery.

The uterus is then filled with sterile saline to give a better view; once the polyp is located, the surgeon will use the electrosurgical wire loop of the hysteroscope and wrap it around it and remove it. Post-surgery the patient will be prescribed antibiotics and nonsteroidal antiinflammatory medication to prevent infection and manage the pain.

How Effective Is Hysteroscopic Polypectomy?

It is considered the gold standard for the surgical treatment of endometrial polyps because of the following reasons:

1. Removal of the polyps through this method prevents recurrence.

2. The procedure's outcomes remain the same regardless of menopausal status, size, and the number of polyps.

3. Resection of polyps through this method has been known to reduce symptoms like uterine bleeding and infertility.

4. Hysteroscopic polypectomy has a low complication and recurrence rate.

5. It is cost-effective and does not require complicated training.

What Are the Complications of Hysteroscopic Polypectomy?

Hysteroscopic polypectomy has very few complications when compared to other surgical procedures; some of them are:

1. Puncture of the Uterus - The hysteroscope can puncture the uterus. This rare complication can happen in 2 for every 100 surgeries. However, if it does happen, the surgery must be postponed until the uterus is healed completely. On very rare occasions, damage to the bowel, like a puncture, may occur, in which case, the patient will need additional surgery, like a laparoscopy, to correct the problem.

2. Bleeding - Excessive bleeding during and after surgery happens in 1 for every 400 cases and can be managed with coagulation devices or electrocauterization.

3. Infection - The procedure can cause uterine infection and can be managed with pre and post-surgical antibiotics.

Apart from the abovementioned complications, general anesthesia can cause complications like paresthesia (burning or pricking sensation) and breathing problems, which are common for all surgeries under its influence.

What Are the Alternative Treatments for Endometrial Polyps?

The different treatment options for endometrial polyps other than hysteroscopic polypectomy are:

1. Dilation and Curettage (D&C) - Another surgical option for endometrial polyps, but it is generally used for investigating the abnormality rather than removing them. This procedure is known as a blind procedure because there is no visual guidance for the procedure, and as a result, the potential to miss the polys due to their mobility is around 50% to 80% of the cases.

The complications associated with D&C include risks with anesthesia, adverse reaction to the medication, hemorrhage, infection, laceration or weakening of the cervix, and perforation or puncture of the uterus.

The alternative treatments mentioned below are the non-surgical approach to managing endometrial polyps. These are preferred in women with small polyps (<10 mm) and are free from symptoms. The polyps in these women have a regression rate over one year and a low chance of malignancy. The symptoms in these women can be managed with observation alone, but it is preferable to treat them with hormone-combined therapy to prevent further development of the polyps.

2. Levonorgestrel Intrauterine System (LNG-IUS) - It is a hormone delivery system that can prevent endometrial polyps and hyperplasia in women who are on estrogen replacement therapy and Tamoxifen. The system delivers an oral contraceptive (OC) directly into the uterus, which is believed to prevent the development of polyps. The OC can be levonorgestrel or Progesterone. The regression observed due to the system is due to the following factors:

1. The oral contraceptive delivered by the system causes endometrial apoptosis. (cell death) and decrease in cell proliferation in the epithelial and stromal cells.

2. Antiinflammatory effects of progesterone.

3. Endometrial quiescence (increased contractility) was established due to steady levels of estrogen and progesterone.

3. Hormone Replacement Therapy (HRT) - HRT is known to reduce the development of endometrial polyps by reducing the endometrium's thickness, which happens through estrogen suppression.

4. Dienogest and Danazol - These medications are extensively used for the treatment of endometriosis, but in individuals with endometrial polyps, they are used as a preoperative endometrial preparation before hysteroscopic polypectomy.

Dienogest reduces the side effects and complications of hysteroscopic polypectomy by reducing the thickness of the endometrium and inducing endometrial atrophy. The latter will reduce the severity of the bleeding and improve the operative time, all of which reduces complications compared to other pharmacological preparations or no preparation. Danazol can also be used for endometrial preparation, but when compared to Dienogest, it is less effective.

It is important that the patient is informed about her options and is made aware of the side effects and complications of the chosen procedure. The treatment method is arrived at based on the patient's willingness to pursue a particular therapeutic course and the health condition.

Conclusion

Endometrial polyps are often overlooked due to insufficient knowledge about their etiology and pathogenesis. But it is important to note that they could be possible precursors for malignancy and should be addressed immediately after diagnosis.