Presented in the ESGE Annual Congress, Antalya 2017

1. Endometrial polyps in
postmenopausal women
Do we have to remove them?
Ayman Ewies
MBChB, MSc, FRCOG, MD
Consultant Gynaecologist, SWBH, UK
Honorary Senior Lecturer, University of Birmingham, UK
Sandwell and West
Birmingham Hospitals
NHS Trust
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3. Sandwell and West Birmingham Hospitals
NHS Trust
Uncertainties!
1- The Prevalence
o The exact prevalence is unknown because many polyps are
asymptomatic
o Most studies included a mixture of pre- and postmenopausal
women both symptomatic and asymptomatic
o In women of all age groups investigated for a variety of
reasons: 8-10%
o In women with PMB: 5-33%
o In asymptomatic postmenopausal women: 13-38%
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4. Sandwell and West Birmingham Hospitals
NHS Trust
Uncertainties!
2- The Prevalence of hyperplasia & cancer
o Varied in various studies depending on the population
studied:
✓ Hyperplasia: 0.24%-24%
✓ Cancer: 1.3%-13%
o Most studies reported a mixture of pre- and
postmenopausal women both symptomatic and
asymptomatic
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5. Sandwell and West Birmingham Hospitals
NHS Trust
Uncertainties!
3- Predictors (independent risk factors) for hyperplasia & cancer
o Given the high prevalence of hyperplasia and cancer, it would
be helpful to have non-invasive diagnostic tools and/or clinical
characteristics as reliable predictors for malignancy
✓ American Association of Gynecologic Laparoscopists,
2012: increasing age, hypertension, obesity, tamoxifen use
✓ Lieng et al, 2010: increasing age, menopausal status, PMB
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6. Sandwell and West Birmingham Hospitals
NHS Trust
Uncertainties!
4- Remove or not to remove
o No consensus amongst gynaecologists!
o No universal algorithm exists to guide
management!
o No evidence could be produced from a RCT and
2 systematic reviews!
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7. Sandwell and West Birmingham Hospitals
NHS Trust
Uncertainties!
4- Remove or not to remove
o RCT (Timmermans et al, 2009) - evaluating the efficacy of
polyp removal in women with PMB
o Immediate office hysteroscopic removal v expectant
management
o The trial was discontinued after 26 months because of lack of
recruitment to the expectant management arm:
1. Doctors were reluctance to seek for informed consent
2. Women were unwilling to participate since most opted for
allocation on the hysteroscopic polypectomy arm
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8. Sandwell and West Birmingham Hospitals
NHS Trust
Uncertainties!
4- Remove or not to remove
o Two systematic reviews by Lee et al, 2010 (17 studies, n=10572) and Lieng
et al, 2010 (35 studies, n=9266) could not produce evidence:
1. Heterogeneity in population and outcome measures -
Most studies included a mixture of pre- and postmenopausal women &
symptomatic and asymptomatic
precluded generalization of the results + prevented subgroup analyses
2. Poor quality of most of the included studies - small & retrospective
3. Lieng et al could even not perform meta-analysis since pooling of data
was not possible
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9. Background
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10. Sandwell and West Birmingham Hospitals
NHS Trust
Aim
In postmenopausal women
To produce data that help inform clinical practice
as whether:
It is safer to remove endometrial polyps
when first diagnosed
Or
Women could have the option of adopting
expectant management
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11. Sandwell and West Birmingham Hospitals
NHS Trust
Objectives
In postmenopausal women
1. Estimate the prevalence of endometrial polyps
2. Quantify the prevalence of hyperplasia and cancer in
polyps
3. Identify the clinical predictors for hyperplasia and
cancer in polyps
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12. Sandwell and West Birmingham Hospitals
NHS Trust
Objectives
1. Estimate the prevalence of endometrial polyps
2. Quantify the prevalence of hyperplasia and cancer in
polyps
3. Identify the clinical predictors for hyperplasia and
cancer in polyps
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13. Sandwell and West Birmingham Hospitals
NHS Trust
What have we done?!
o Design: Prospectively collected the data
o Sample size: 2625 consecutive women
o Setting: PMB clinic
o Institute: SWBH, UK
o Duration: 60 months - 1 January 2011 – 31 December 2015
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14. Sandwell and West Birmingham Hospitals
NHS Trust
What have we done?!
Inclusion criteria
We included endometrial polyps which were:
1. Confirmed on hysteroscopic examination,
2. Benign-looking,
3. Associated with benign endometrial biopsy and/or atrophic-looking
endometrium on hysteroscopic examination,
4. Diagnosed in postmenopausal women referred with PMB or
incidental finding of thickened endometrium
5. No HRT
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15. Sandwell and West Birmingham Hospitals
NHS Trust
How did we pick polyps up?!
Hysteroscopy
1. Recurrent PMB
2. Focal lesion on TVS
3. Tamoxifen use
4. ET>10mm
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16. Sandwell and West Birmingham Hospitals
NHS Trust
Outcome Groups
Group 1: benign endometrial polyps
Group 2: Hyperplasia or cancer in endometrial polyps
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NHS Trust 17

18. Sandwell and West Birmingham Hospitals
NHS Trust
Prevalence of Polyps
n = 2625
448 (17%)
2177 (83%)
Polyps with normal background
endometrium
No polyps
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19. Sandwell and West Birmingham Hospitals
NHS Trust
Symptoms of women diagnosed with polyps
n = 448
27 (6%)
421 (94%)
PMB
Incidental Finding – No PMB
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20. Sandwell and West Birmingham Hospitals
NHS Trust
Prevalence of Hyperplasia & Cancer
n = 448
35 (7.8%)
413 (92.2%)
Benign polyps
Polyps with hyperplasia and cancer
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21. Sandwell and West Birmingham Hospitals
NHS Trust
Predictors for hyperplasia and cancer
The univariate analysis
o Women in group 2 had significantly:
1. Higher rate of recurrent PMB (p=0.025)
2. Higher BMI (p=0.001)
3. Thicker endometrium (p=0.005)
o Age, ethnic origin, years since LMP, diabetes, hypertension, and the
use of Tamoxifen did not differ between the outcome groups
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22. Sandwell and West Birmingham Hospitals
NHS Trust
Predictors for hyperplasia and cancer
MVLRA
o The independent predictors for hyperplasia and cancer:
1. BMI: p=0.002, OR (95% CI) = 1.07 (1.02-1.12)
2. ET: p=0.025, OR (95% CI) = 1.07 (1.01-1.13)
o This means that for every 1 kg/m2 ↑ in BMI and 1mm ↑ in ET
and, there is a 7% ↑ in the odds of hyperplasia and cancer
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23. Sandwell and West Birmingham Hospitals
NHS Trust
Predictors for hyperplasia and cancer
Receiver operator characteristic (ROC)
o Women with BMI ≥32.5 had OR of 3.2 (95% CI=1.5-7.1) to have
polyps with hyperplasia or cancer, p=0.008
o Women with ET ≥10.8mm had OR 4.5 (95% CI=2-9.8) to have
polyps with hyperplasia or cancer, p=0.001
o Women with both BMI ≥32.5 and ET ≥10.8mm had OR of 6.3 (95%
CI=3.1-13.1) to have polyps with hyperplasia or cancer, p<0.001
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24. Sandwell and West Birmingham Hospitals
NHS Trust
Predictors for hyperplasia and cancer
PMB V Asymptomatic
Being asymptomatic ↓ the odds of hyperplasia and cancer
in polyps; however, the difference was insignificant
OR (95% CI) = 0.44 (0.06-3.3), p= 0.7
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NHS Trust 25

26. Sandwell and West Birmingham Hospitals
NHS Trust
Take Home Messages
1. The prevalence of benign-looking endometrial polyps with
normal background endometrium in women referred to the PMB
clinic: 17%
2. The prevalence of hyperplasia or cancer in these polyps: 7.8%
3. Women with polyps showing hyperplasia or cancer were more
likely to have higher BMI and/or thicker endometrium
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27. Sandwell and West Birmingham Hospitals
NHS Trust
Take Home Messages
4. Other variables were not found to be independent predictors
for hyperplasia and cancer in polyps
5. Being asymptomatic (with incidental finding of thickened
endometrium) insignificantly ↓ the odds of hyperplasia and
cancer in polyps
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28. Sandwell and West Birmingham Hospitals
NHS Trust
Take Home Messages
The advocates: Benign-looking endometrial polyps (with normal background
endometrium) should be removed at first presentation in women referred to
PMB clinic
The opponents: Routine polypectomy may be subjecting women to
unnecessary interventions and wasting valuable health-care resources
Based on our data: what do you think?
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29. Sandwell and West Birmingham Hospitals
NHS Trust
Research Needed
o We need established hysteroscopic morphological criteria to
identify polyps with hyperplasia and cancer
o This could be related to the polyp size, surface irregularity,
vascularity, etc.
o Difficult to achieve objectivity: Inter- and intrapersonal
variations!!
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30. Sandwell and West Birmingham Hospitals
NHS Trust
Research Needed
o A retrospective study included a mixture of symptomatic (n=20) and asymptomatic
(n=40) postmenopausal women:
✓ Hysteroscopic appearance could not discriminate polyps with hyperplasia and
cancer from benign ones
✓ All polyps appeared benign, but histological assessment showed 3 cases with
atypical hyperplasia or cancer. These 3 cases were asymptomatic and had
normal endometrium (de Almeida et al, 2001)
o 7.5% of endometrial carcinoma has polypoid appearance (Sugimoto, 1975)
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31. Sandwell and West Birmingham Hospitals
NHS Trust
Gratitude
o I would to thank my collaborators:
1. Dr Sudha Sundar, Senior Lecturer and Consultant,
University of Birmingham and SWBH, UK
2. Dr Ahmed Ghoubara, Research Fellow, University of
Birmingham and SWBH, UK and Assistant Lecturer,
Aswan University, Egypt
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34. Sandwell and West Birmingham Hospitals
NHS Trust
Endometrial Polyps
o Localized endometrial overgrowth covered by epithelium
o Overexpression of steroid receptors in their glandular
epithelium suggests a crucial role for hormonal exposure
o Found on investigating women with unscheduled uterine
bleeding, and also found incidentally in asymptomatic
women investigated for other indications
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35. Sandwell and West Birmingham Hospitals
NHS Trust
Uncertainties!
3- Predictors (independent risk factors) for hyperplasia & cancer
o Obesity: 4 studies → only one found a statistically significant
correlation
o Diabetes: 6 studies → only one found a statistically significant
correlation
o Hypertension: 5 studies → only 2 found a statistically significant
correlation
o Tamoxifen usage: 1 study found a statistically significant correlation
o HRT usage: 2 studies found no correlation
o Polyp size >15mm: 2 found a statistically significant correlation
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36. Sandwell and West Birmingham Hospitals
NHS Trust
Why did we group hyperplasia and
cancer together?
o For atypical hyperplasia: high rate of concurrent cancer (42.6%)
or progression to cancer (28%)
o For hyperplasia without cytological atypia: despite the low
progression rate of <5% over 20 years, the Green Top Guidelines of
the RCOG, 2016 recommend at least progestogenic therapy and
surveillance i.e. these women cannot be categorized as having
negative investigations or benign pathology
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37. Sandwell and West Birmingham Hospitals
NHS Trust
Histopathology Results
Variable n (%)
Group 1 413 (92.2%)
Group 2 35 (7.8%)
Hyperplasia without atypia 10 (2.2 %)
Hyperplasia with atypia 20 (4.5%)
Cancer 5 (1.1%)
Total 448 (100%)
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