Endometrial polyps — structured SAQ (15 marks)

(a) Classification and the PPP framework (3 marks)

One mark per point, maximum three. ^[1][6]

• Endometrial polyps are the P of FIGO PALM-COEIN — a structural cause (AUB-P).
• PPP framework — triage a focal intracavitary lesion as:
  • P — Polyp: the default focal lesion; manage by hysteroscopic polypectomy with histology.
  • P — Pregnancy: exclude pregnancy first — a gestational sac, retained products or trophoblastic disease can mimic a polyp.
  • P — Pathology: endometrial hyperplasia or carcinoma — especially in the older, postmenopausal or risk-factor-laden woman; every resected polyp goes for histology.^[1][6]

(b) Imaging ladder and accuracy (4 marks)

One mark per point. ^[2]

• Transvaginal ultrasound (TVUS) first-line: assesses the endometrial echo and focal lesions; sensitivity about 0.62, specificity about 0.73.
• Saline-infusion sonohysterography (SIS): for cavity lesions; sensitivity about 0.87, specificity about 0.86.
• Hysteroscopy with directed biopsy: the gold standard, also treats; sensitivity about 0.92, specificity about 0.85.
• Rank: hysteroscopy greater than SIS greater than TVUS. SIS is the cost-accuracy sweet spot; hysteroscopy both confirms and treats.^[2]

(c) Malignancy rates and risk factors (4 marks)

One mark per point, maximum four. ^[3][4]

• Pooled prevalence of premalignant/malignant lesions in clinically-recognised polyps is 3.4 percent (Sasaki 2018 meta-analysis of 21,057 polyps).
• Independent risk factors: abnormal uterine bleeding, menopausal status, age over 60 years, diabetes mellitus, hypertension, obesity, tamoxifen use.
• Atypical hyperplastic polyp carries a pooled concurrent endometrial cancer risk of 5.6 percent (de Rijk 2016).
• Three of every 100 women with clinically-recognised polyps will harbour premalignant or malignant lesions — the rate drives investigation in older and risk-factor-laden women.^[3][4]

(d) Management and tamoxifen (4 marks)

One mark per point, maximum four. ^[5][6]

• This 58-year-old: postmenopausal bleeding with a polyp is a red flag — hysteroscopy with directed polypectomy and histology; malignancy exclusion is the priority.
• Threshold for histology: every resected polyp goes for histology; particular vigilance for postmenopausal women, older women with risk factors, and any polyp with atypia.
• Tamoxifen user: excise symptomatic polyps for histology; surveillance with TVUS/SIS for asymptomatic users; LNG-IUS reduces polyp formation (OR about 0.22) and hyperplasia (OR about 0.13).
• Conservative management is reserved for small asymptomatic polyps under 10 mm in women without malignancy risk factors — up to 25 percent regress.^[5][6]