O&G · Gynaecological health — menstrual disorders
Endometrial polyps: prevalence, malignant potential, PPP framework & hysteroscopic management (the P of PALM-COEIN)
Also known as Endometrial polyp · Uterine polyp · AUB-P · Tamoxifen-related polyp · Endometrial polypectomy
Exam-exhaustive FRANZCOG fellowship topic on endometrial polyps — the P of FIGO PALM-COEIN. Covers prevalence and the malignant-potential risk factors (age, postmenopausal bleeding, tamoxifen), the imaging ladder from TVUS to saline-infusion sonohysterography, the PPP (polyp, pregnancy, pathology) framework for triaging a focal intracavitary lesion, the hysteroscopic polypectomy technique, indications for histology, the conservative-management evidence for small asymptomatic polyps (up to a quarter regress; under 10 mm), and tamoxifen-related polyp surveillance. RANZCOG-primary, globally tagged to MRCOG, ABOG, FRCSC and MRCPI.
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Target exams
Red flags
- Postmenopausal bleeding with a polyp — excise and send for histology; malignancy exclusion is the priority, never watch and wait
- Every resected polyp goes for histology — no threshold above which 'benign-only' is presumed
- Atypical hyperplastic polyp — around 5.6% concurrent endometrial cancer risk; discuss hysterectomy and staging
- Pregnancy must be excluded before labelling a focal lesion a 'polyp' — retained products can mimic one
- A thick endometrial echo in an asymptomatic postmenopausal woman is common (10–17%) and does not by itself trigger invasive sampling
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]
Why this matters — the burden in numbers
References14ShowHide
- [1]Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet, 2011.PMID 21345435
- [2]Jain V, Munro MG, Critchley HOD Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2. Int J Gynaecol Obstet, 2023.PMID 37538019
- [3]American Association of Gynecologic Laparoscopists AAGL practice report: practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol, 2012.PMID 22196255
- [4]Sasaki LMP, Andrade KRC, Figueiredo ACMG, Wanderley MDS, Pereira MG Factors Associated with Malignancy in Hysteroscopically Resected Endometrial Polyps: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol, 2018.PMID 29454147
- [5]de Rijk SR, Steenbergen ME, Nieboer TE, Coppus SF Atypical Endometrial Polyps and Concurrent Endometrial Cancer: A Systematic Review. Obstet Gynecol, 2016.PMID 27500332
- [6]DeWaay DJ, Syrop CH, Nygaard IE, Davis WA, Van Voorhis BJ Natural history of uterine polyps and leiomyomata. Obstet Gynecol, 2002.PMID 12100797
- [7]Kaveh M, Sadegi K, Salarzaei M, Parooei F Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in evaluating the endometrial polyps in women with abnormal uterine bleeding: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne, 2020.PMID 32904526
- [8]Goldstein SR Modern evaluation of the endometrium. Obstet Gynecol, 2010.PMID 20567184
- [9]Shi Q, Li J, Li M, Wu J, Yao Q, Xing A The role of levonorgestrel-releasing intrauterine system for endometrial protection in women with breast cancer taking tamoxifen. Eur J Gynaecol Oncol, 2014.PMID 25423691
- [10]Berceanu C, Cernea N, Căpitănescu RG, et al. Endometrial polyps. Rom J Morphol Embryol, 2022.PMID 36374138
- [11]Guo T, Zhou H, Yang J, et al. Identifying the superior surgical procedure for endometrial polypectomy: A network meta-analysis. Int J Surg, 2019.PMID 30654144
- [12]Su D, Li L, Zhong M, Xia Y Capacity of endometrial thickness measurement to diagnose endometrial carcinoma in asymptomatic postmenopausal women: a systematic review and meta-analysis. Ann Palliat Med, 2021.PMID 34763445
- [13]Ghoubara A, Price MJ, Fahmy MSE, Ait-Allah AS, Ewies A Prevalence of hyperplasia and cancer in endometrial polyps in women with postmenopausal bleeding: A systematic review and meta-analysis. Post Reprod Health, 2019.PMID 30845879
- [14]Van den Bosch T, Dueholm M, Leone FP, et al. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol, 2015.PMID 25652685