Endometrial polyps: prevalence, malignant potential, PPP framework & hysteroscopic management (the P of PALM-COEIN)

A 58-year-old woman, three years past the menopause, has had two episodes of postmenopausal bleeding. Her transvaginal ultrasound shows a focal echogenic mass in the cavity. Your job is not to reassure her with "it's probably just a polyp" — it is to image it properly with saline-infusion sonohysterography, resect it hysteroscopically, send it for histology, and exclude endometrial cancer. This topic is the structured answer to "a focal lesion in the cavity" — and the PPP framework that triages it.[2][8]

Overview and definition

An endometrial polyp is a localised overgrowth of endometrial glands and stroma that projects into the uterine cavity, usually attached by a pedicle. They are one of the four structural causes of AUB in the FIGO PALM-COEIN classification — AUB-P.[1][3]

The histological spectrum matters because it determines management:[3][5]

• Benign — the majority.
• Hyperplastic without atypia — oestrogen-driven; usually resected.
• Atypical hyperplastic — premalignant; concurrent endometrial cancer risk warrants dedicated workup.[5]
• Malignant (carcinoma within a polyp) — uncommon, but the central concern in the older or postmenopausal woman.[3][4]