Endometrial polyps — structured oral station (12 minutes)

Opening prompt — "What is your framework for triaging this focal cavity lesion?"

Model response — the PPP framework: ^[1]

• "I triage a focal intracavitary lesion with the PPP framework — Polyp, Pregnancy, Pathology."
• "Polyp is the default — but I first exclude pregnancy, because a gestational sac, retained products or trophoblastic disease can mimic a polyp. And I keep Pathology — endometrial hyperplasia or carcinoma — on the board, especially in a 58-year-old with postmenopausal bleeding."
• "Endometrial polyps are the P of FIGO PALM-COEIN (AUB-P)."^[1]

Probe 1 — "What is your imaging strategy?"

• "Transvaginal ultrasound first to assess the endometrial echo and identify focal lesions. If the cavity is indistinct or a polyp is suspected, I add saline-infusion sonohysterography — it distends the cavity and significantly improves detection."
• "The Kaveh 2020 meta-analysis gives the accuracy ladder: TVUS sens 0.62 / spec 0.73; SIS sens 0.87 / spec 0.86; hysteroscopy sens 0.92 / spec 0.85."
• "Hysteroscopy is the gold standard because it both confirms and treats."^[2]

Probe 2 — "What is the risk that this polyp is malignant?"

• "In a 58-year-old with postmenopausal bleeding, the risk is materially higher than the pooled 3.4 percent premalignant/malignant rate in clinically-recognised polyps (Sasaki 2018). Her risk factors — postmenopausal bleeding, age — place her firmly in the higher-risk group."
• "Other independent risk factors from the Sasaki meta-analysis are age over 60, diabetes, hypertension, obesity and tamoxifen."
• "If atypia is found in a polyp, the concurrent endometrial cancer risk is 5.6 percent (de Rijk)."^[3]

Probe 3 — "What is your management?"

• "Hysteroscopy with directed polypectomy and histology — malignancy exclusion is the priority. I never watch-and-wait a postmenopausal bleeder with a polyp."
• "Every resected polyp goes for histology — there is no threshold above which benign-only is presumed."
• "If histology shows atypical hyperplasia within the polyp, I discuss hysterectomy and staging in shared decision-making."^[3]

Probe 4 — "She asks if she will need cancer treatment. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[3]

• Move to her eye level, use her name, acknowledge the fear: "Most polyps are benign, but at 58 with postmenopausal bleeding we must rule out cancer properly — that means a small day-case procedure to remove the polyp and send it to the lab. The result will give us a clear answer in about a week. I will explain every step as we go."
• Offer a clear plan and timeline, and a named contact for between visits.^[3]

Probe 5 — "She also has breast cancer and is on tamoxifen. Does that change anything?"

• "Tamoxifen is a known risk factor for polyp formation and for malignancy within polyps. She still needs excision and histology for this polyp."
• "For prevention going forward, the LNG-IUS reduces polyp formation (OR about 0.22) and hyperplasia (OR about 0.13) in tamoxifen users (Shi 2014)."
• "She should have structured endometrial surveillance with TVUS/SIS while on tamoxifen."^[4]