Menopausal status and endometrial polyp diagnosis

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Hysteroscopy is significantly more accurate than transvaginal ultrasonography (TVUS) for diagnosing endometrial polyps in postmenopausal women than in premenopausal women, according to new research by Israeli investigators. The findings, the authors said, may be useful in counseling patients. 

Results of the retrospective study, conducted at two tertiary medical centers in Israel, were published in the Journal of Obstetrics and Gynaecology Canada (JOGC). 

The authors reviewed records from 2010 to 2014 from 694 women who had a suspected endometrial polyp diagnosed with TVUS and then underwent hysteroscopy to more fully visualize the entire uterine cavity. The study included TVUS performed in different locations and by different health care providers. The average age of patients was 49 and the majority of the premenopausal patients included had abnormal uterine bleeding (AUB), which can complicate timing of the procedure. 

The patients were divided into two groups, one premenopausal (395 patients) and the other postmenopausal (299 patients), and compared.  Hysteroscopy confirmed the TVUS diagnosis in 212 (71%) postmenopausal patients versus 212 (53%) premenopausal patients (P< 0.001). Of the excised polyps observed by hysteroscopy, 95% were confirmed with histology in the postmenopausal patients, versus 85% in the premenopausal patients (P= 0.004). 

In postmenopausal women, the size of an endometrial polyp did not change the accuracy of TVUS diagnosis. However, in premenopausal women whose polyps were smaller than 10 mm, the procedure was significantly less accurate (P= 0.029). 

AUB was the most common presenting symptom in the premenopausal patients (69%), whereas the majority of the postmenopausal women (61%) were asymptomatic. 

Endometrial polyps can be caused by estrogen-related factors in premenopause and perimenopause or by non−estrogen-related factors that are not completely understood. Therefore, risk of malignancy and optional monitoring and treatment are different in the two patient populations. 

Although TVUS is considered the first choice for diagnosis of uterine cavity disorders, some doctors and researchers question use of it to screen for endometrial disease in patients without symptoms. Treatment of asymptomatic polyps, the authors noted, is controversial, because early diagnosis of asymptomatic endometrial cancer has not been proven to increase survival rates.  

The researchers found that in women with abnormal bleeding especially, the most appropriate time for TVUS and hysteroscopy to be scheduled is before menopause, as this is when the diagnostic value for polyps is at its highest. Limitations of the study they noted were the retrospective design, use of two-dimensional TVUS, and difficulty associated with timing of TVUS and hysteroscopy in the premenopausal patients who had AUB.