Diagnostic Ultrasound - Abdomen and Pelvis

Endometrial Polyp
Diagnoses: Female Pelvis
○ Positive pregnancy test
○ Often associated with hyperemesis
○ Beta human chorionic gonadotrophin levels may be
extremely high
○ 25% association with theca lutein cysts
• Retained products of conception
○ Associated with history of recent gestation
○ Often prominent feeding vessels from myometrium to
"mass"
○ May have positive pregnancy test
PATHOLOGY
General Features
• Etiology
○ Associated with Tamoxifen treatment in
postmenopausal women
– Premenopausal women taking Tamoxifen for breast
cancer are not at increased risk for endometrial cancer
○ Lynch syndrome (hereditary nonpolyposis colon cancer)
case report of EP containing cancer
Gross Pathologic & Surgical Features
• Circumscribed overgrowth of endometrial mucosa ±
stromal tissue
• Protrudes into cavity on fibrovascular stalk
Microscopic Features
• Foci of atypical hyperplasia may be seen within polyps
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Abnormal bleeding
– Intermenstrual
– Postcoital
– Postmenopausal
• Other signs/symptoms
○ Atypical glandular cells of endometrial origin on
Papanicolaou smear
– Indication for endometrial biopsy as 40% incidence of
significant pathology
Demographics
• Epidemiology
○ EP → 30% of postmenopausal bleeding
Natural History & Prognosis
• Polyp site/number/diameter do not correlate with
symptomatology
• Often asymptomatic
○ 36.1% of postmenopausal women
○ 44.4% of reproductive-aged women
• Frequent finding in infertile patients
○ Controversial if etiologic factor or if resection improves
outcome
○ Endometrial polyps < 1.5 cm diameter discovered during
ovarian stimulation do not negatively affect
pregnancy/implantation outcomes in intracytoplasmic
sperm injection (ICSI) cycles
Treatment
• Progestin therapy
• Polypectomy
○ Outpatient procedure is safe and better tolerated than
operating room hysteroscopic resection
• Hysterectomy if atypical pathology/carcinoma
• Observation, particularly in older asymptomatic patients
DIAGNOSTIC CHECKLIST
Consider
• SHG for endometrial thickening, particularly if no cysts or
feeding vessel
• MR/TVS/color Doppler may help to distinguish polyp from
carcinoma
○ Cancer may coexist with benign disease
Image Interpretation Pearls
• Focal or diffuse echogenic endometrial thickening with
"hyperechoic line" sign
• Single feeding vessel
• Intratumoral cysts suggestive of polyp, rare in carcinoma
• Benign polyps cannot be differentiated from polyps with
atypical hyperplasia; biopsy required
• Beware of endometrial "wrinkles," which can be mistaken
for sessile polyps
○ Uterine contraction is a response to cavitary distention →
"wrinkles"
SELECTED REFERENCES
1. Fang L et al: Value of 3-dimensional and power Doppler sonography for
diagnosis of endometrial polyps. J Ultrasound Med. 32(2):247-55, 2013
2. Van den Bosch T et al: Pre-sampling ultrasound evaluation and assessment
of the tissue yield during sampling improves the diagnostic reliability of
office endometrial biopsy. J Obstet Gynaecol. 32(2):173-6, 2012
3. Costa-Paiva L et al: Risk of malignancy in endometrial polyps in
premenopausal and postmenopausal women according to clinicopathologic
characteristics. Menopause. 18(12):1278-82, 2011
4. La Sala GB et al: Diagnostic accuracy of sonohysterography and transvaginal
sonography as compared with hysteroscopy and endometrial biopsy: a
prospective study. Minerva Ginecol. 63(5):421-7, 2011
5. Cil AP et al: Power Doppler properties of endometrial polyps and
submucosal fibroids: a preliminary observational study in women with
known intracavitary lesions. Ultrasound Obstet Gynecol. 35(2):233-7, 2010
6. Grimbizis GF et al: A prospective comparison of transvaginal ultrasound,
saline infusion sonohysterography, and diagnostic hysteroscopy in the
evaluation of endometrial pathology. Fertil Steril. 94(7):2720-5, 2010
7. Lee SC et al: The oncogenic potential of endometrial polyps: a systematic
review and meta-analysis. Obstet Gynecol. 116(5):1197-205, 2010
8. Tamura-Sadamori R et al: The sonohysterographic difference in submucosal
uterine fibroids and endometrial polyps treated by hysteroscopic surgery. J
Ultrasound Med. 26(7):941-6; quiz 947-8, 2007
9. American College of Obstetricians and Gynecologists Committee on
Gynecologic Practice: ACOG committee opinion. No. 336: Tamoxifen and
uterine cancer. Obstet Gynecol. 107(6):1475-8, 2006
10. Hassa H et al: Are the site, diameter, and number of endometrial polyps
related with symptomatology? Am J Obstet Gynecol. 194(3):718-21, 2006
11. Fong K et al: Transvaginal US and hysterosonography in postmenopausal
women with breast cancer receiving tamoxifen: correlation with
hysteroscopy and pathologic study. Radiographics. 23(1):137-50; discussion
151-5, 2003
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