Endometrial polyps are localized overgrowths of endometrial tissue that protrude into the uterine cavity, representing a significant concern in gynecological health due to their association with abnormal uterine bleeding (AUB), infertility, and, in some cases, malignant transformation. While these lesions are predominantly benign, their pathogenesis is complex, involving a multifactorial interplay of hormonal imbalances, genetic predispositions, and inflammatory processes. The prevalence of endometrial polyps increases with age and exposure to exogenous estrogen, particularly in postmenopausal women. Furthermore, they are frequently observed in patients with metabolic disorders such as obesity, insulin resistance, and polycystic ovary syndrome (PCOS), suggesting a broader systemic influence on their development. Given the potential for symptomatic burden and oncologic implications, a thorough understanding of the pathophysiology, risk stratification, and contemporary therapeutic strategies is essential for improving clinical management and patient outcomes. Advances in diagnostic imaging and minimally invasive interventions, such as hysteroscopic resection, have significantly enhanced the ability to address these lesions while minimizing patient morbidity. Nevertheless, ongoing research into molecular and histopathological markers of malignant transformation remains crucial to refining treatment algorithms and preventing recurrence.
Pathophysiology and Etiology
Endometrial polyps arise from focal hyperplastic proliferation of endometrial glands and stroma. Their development is largely driven by estrogenic stimulation, which promotes endometrial proliferation, with insufficient counteraction by progesterone. Key etiological factors include:
- Hormonal Imbalances: Unopposed estrogen exposure, as seen in anovulatory cycles and hormone replacement therapy, increases polyp formation risk.
- Chronic Inflammation: Persistent endometrial irritation may contribute to aberrant tissue proliferation.
- Metabolic Disorders: Conditions such as obesity and insulin resistance elevate estrogen levels, fostering a pro-proliferative uterine environment.
- Genetic and Molecular Mechanisms: Mutations in the PTEN gene and aberrant expression of aromatase enzymes have been implicated in polyp pathogenesis.
- Medication Use: Tamoxifen, an estrogen receptor modulator, is associated with an increased prevalence of endometrial polyps, particularly in postmenopausal women.
Clinical Manifestations
Endometrial polyps may be asymptomatic or present with varying degrees of symptomatology. Common clinical manifestations include:
- Abnormal Uterine Bleeding (AUB): Intermenstrual bleeding, menorrhagia, or postmenopausal bleeding.
- Reproductive Dysfunction: Infertility and recurrent pregnancy loss due to implantation failure or endometrial receptivity disruption.
- Pelvic Discomfort: Some patients report pressure-like symptoms or non-specific pelvic pain.
- Vaginal Discharge: Excessive or mucoid discharge in cases of large or necrotic polyps.
Diagnostic Modalities
Accurate diagnosis of endometrial polyps requires a combination of clinical assessment and imaging techniques:
- Transvaginal Ultrasound (TVUS): First-line imaging modality, often enhanced with saline infusion sonohysterography (SIS) for improved visualization.
- Hysteroscopy: Gold standard for direct visualization and targeted biopsy.
- Endometrial Biopsy: Utilized to exclude hyperplasia or malignancy, particularly in postmenopausal patients or those with persistent AUB.
- Magnetic Resonance Imaging (MRI): Occasionally employed for complex cases requiring detailed anatomical assessment.
Therapeutic Approaches
Management strategies for endometrial polyps depend on patient symptoms, reproductive goals, and oncologic risk. Available interventions include:
Conservative Management
- Observation: Small, asymptomatic polyps, particularly in premenopausal women, may regress spontaneously.
- Medical Therapy: Hormonal treatments, including progestins and gonadotropin-releasing hormone (GnRH) analogs, may reduce polyp size but have limited efficacy in complete resolution.
Surgical Interventions
- Hysteroscopic Polypectomy: The preferred method for symptomatic or suspicious polyps, offering minimal invasiveness and high success rates.
- Dilation and Curettage (D&C): Less commonly performed as a standalone procedure due to lower diagnostic yield compared to hysteroscopy.
- Hysterectomy: Reserved for recurrent polyps in patients with additional gynecologic pathology or malignancy concerns.
Prevention and Risk Reduction Strategies
While definitive prevention is challenging, certain lifestyle modifications and medical interventions may mitigate risk:
- Weight Management: Reducing obesity-related estrogen excess.
- Hormonal Regulation: Cyclic progestin therapy or oral contraceptives may reduce recurrence in susceptible individuals.
- Regular Gynecologic Surveillance: Particularly in high-risk populations such as postmenopausal women or those with persistent AUB.
Complications and Long-Term Considerations
Although generally benign, endometrial polyps pose potential complications:
- Malignant Transformation: Occurs in approximately 0.5% to 3% of cases, with higher risk in postmenopausal women or those with atypical histology.
- Anemia: Chronic blood loss may lead to iron-deficiency anemia requiring supplementation or intervention.
- Impaired Fertility: Surgical removal is often recommended in infertile patients prior to assisted reproductive treatments.
- Psychological Impact: Persistent symptoms such as abnormal bleeding and reproductive challenges can contribute to anxiety and stress, necessitating supportive counseling and mental health interventions.
Conclusion
Endometrial polyps represent a prevalent yet clinically significant gynecologic condition with profound implications for reproductive health, endometrial function, and oncologic safety. These localized overgrowths of endometrial tissue, while predominantly benign, demand careful evaluation due to their association with abnormal uterine bleeding, subfertility, and potential malignant transformation. Advances in diagnostic imaging, particularly high-resolution transvaginal ultrasound and hysteroscopic techniques, have enhanced early detection and characterization, leading to more precise risk stratification. Furthermore, minimally invasive surgical interventions, such as hysteroscopic polypectomy, have significantly improved patient outcomes by reducing morbidity, recurrence rates, and long-term reproductive complications. Future research should prioritize the elucidation of molecular pathways governing polyp formation, including the role of estrogenic stimulation, inflammatory mediators, and genetic alterations such as PTEN mutations, with the goal of developing targeted pharmacological therapies. For patients experiencing symptoms or fertility concerns, early intervention, tailored therapeutic strategies, and comprehensive long-term surveillance remain paramount in optimizing gynecologic health and overall well-being.
