TJARKS, MARY MD; VAN VOORHIS, BRADLEY J. MD
Department of Obstetrics and Gynecology, University of Iowa College of Medicine, Iowa City, Iowa.
Address reprint requests to: Bradley J. Van Voorhis, MD, University of Iowa Hospitals and Clinics, Department of Obstetrics and Gynecology, 200 Hawkins Drive, Iowa City, IA 52242-1080, E-mail: firstname.lastname@example.org
Received April 20, 2000. Received in revised form June 27, 2000. Accepted August 17, 2000.
Objective: To determine the effectiveness of different treatments for abnormal uterine bleeding in women with known endometrial polyps.
Methods: We retrospectively assessed the effectiveness of polypectomy and other treatments of women with abnormal uterine bleeding who had benign polyps detected by sonohysterography. Women with endometrial polyps diagnosed by sonohysterography between January 1997 and July 1998 were sent questionnaires on pretreatment and posttreatment uterine bleeding and satisfaction with their treatments. Charts were reviewed to validate questionnaire responses and determine treatments administered.
Results: Seventy-eight women had endometrial polyps by sonohysterography, and 60 of them (77%) responded to the questionnaire. Two with endometrial adenocarcinoma were excluded. The average age of the remaining 58 was 49 years; 37 (64%) were premenopausal and 21 (36%) postmenopausal. The average time from treatment to follow-up was 13 months (range 5–24 months). Participants were grouped according to the following treatments: polypectomy, polypectomy plus endometrial ablation, polypectomy plus hysteroscopic myomectomy, hysterectomy, D&C, and non-surgical treatment. The most frequent treatment was polypectomy (n = 26). Polypectomy, polypectomy plus endometrial ablation, polypectomy plus myomectomy, and hysterectomy each resulted in at least a twofold decrease in the number of bleeding days per month and led to high satisfaction rates.
Conclusion: Our results showed that simple polypectomy and more invasive surgical procedures led to subjective improvement in symptoms of menorrhagia and metrorrhagia and a high satisfaction rate in women with endometrial polyps.
Endometrial polyps are benign, localized overgrowths of endometrial tissue that are covered by epithelium and contain variable amounts of glands, stroma, and blood vessels.1 They are now diagnosed easily and painlessly by sonohysterography in women with abnormal uterine bleeding. The prevalence of polyps in women with abnormal uterine bleeding has been reported to range from 13–50%.1–12 Despite the high prevalence of polyps in women with abnormal uterine bleeding, there are few reports on efficacy of polypectomy for treating them. Outcome research is needed to guide clinical decision making for those patients. Although it is intuitive that polypectomy should be effective for treating women with abnormal bleeding, polyps frequently are associated with uterine myomas that can cause abnormal bleeding and are left behind after simple polypectomies.1,8 Polyps also can be asymptomatic. In a recent study, we found small polyps in 10% of asymptomatic, premenopausal women over age 30 years8; therefore, the causative role of polyps in abnormal uterine bleeding can be questioned. Our purpose was to study a group of women with polyps diagnosed by sonohysterography and determine the effectiveness of polypectomy and other treatments with respect to symptom reduction and patient satisfaction.
Materials and Methods
Approval for this study was granted by the University of Iowa Human Subjects Committee. All sonohysterography studies at our gynecologic ultrasound unit from January 1997 to July 1998 were reviewed, and 78 women with endometrial polyps were identified. Each was sent a letter that outlined the purpose of the study and a questionnaire to be used during telephone follow-up. The women subsequently were contacted by telephone and their answers transcribed by one of the investigators (MT).
The questionnaire included subjective information about pretreatment and posttreatment symptoms of menorrhagia, dysmenorrhea, and metrorrhagia. Menorrhagia and dysmenorrhea were rated as none, mild, moderate, or severe. Metrorrhagia was assessed by average days of bleeding per month. Women also were asked to rate their satisfaction with the results of treatment as very satisfied, satisfied, neither satisfied nor dissatisfied or not sure, dissatisfied, or very dissatisfied. Charts were reviewed to relate recorded pretreatment symptomatology with questionnaire results. Ultrasound results including size of endometrial polyps and concomitant uterine myomas were recorded. Treatments and pathology results also were recorded. Treatment decisions had been made independently by individual staff gynecologists and patients.
Treatment was categorized as polypectomy, polypectomy plus endometrial ablation, myomectomy with polypectomy (women who had polyps and myomas seen by sonohysterography), D&C only, hysterectomy, and no surgical treatment. To assess the differences between groups, the Kruskal Wallis nonparametric analysis of variance test was used. To assess the differences between pretreatment and posttreatment scores within the same treatment group, the Wilcoxon signed-rank test was used. P < .05 was considered statistically significant.
Fifty-eight (74%) of 78 women found by sonohysterography to have polyps were included. Six women refused participation for unspecified reasons; 12 women were lost to follow-up (phone disconnected, no forwarding number, or not available after repeated attempts to contact them); and two women had endometrial adenocarcinoma on concomitant endometrial biopsies and were excluded. No statistical differences were noted between participants and nonparticipants in age, menopausal status, and time to follow-up. Seven women had polyps less than 10 mm in diameter; 51 had polyps 10 mm or more in diameter. The range of polyp diameters was 8–31 mm. Many women (88%) had a single polyp, but some had multiple polyps.
The average age of study subjects was 49 years (range 28–74 years). Thirty-seven participants (64%) were pre-menopausal and 21 (36%) were postmenopausal. The average time from treatment to follow-up was 13.3 months (range 5–24 months). The most common pre-treatment symptoms of women with polyps were metrorrhagia and menorrhagia, with women reporting an average of 13 days of bleeding per month and “moderate” menorrhagia. Dysmenorrhea was less of a complaint, with the average dysmenorrhea score being “mild.” Symptoms reported less often included back pain and vaginal discharge.
Twenty-six women had polypectomies alone (Table 1); 24 of those had hysteroscopies with polypectomies under general anesthesia, and two had clinic polypectomies for endometrial polyps protruding through their cervices. Polypoid lesions were viewed hysteroscopically in all women, and there was pathologic confirmation of polyps in 24 of 26. This discrepancy was not surprising because polyps might not be diagnosed pathologically if they arrive fragmented. The other two women had benign secretory endometrium as their pathologic diagnosis. The average age of that group was 52 years (range 28–74). Twelve women (46%) were premenopausal and 14 (54%) were postmenopausal. After polypectomy, there was a statistically significant improvement in menorrhagia scores and metrorrhagia scores measured by average number of days of bleeding per month (Table 1). Dysmenorrhea scores were unchanged when pretreatment and posttreatment scores were compared (median pretreatment score 0 [range 0–3], median posttreatment score 0 [range 0–3]). Sixty-five percent of women described themselves as satisfied or very satisfied after polypectomy, 23% were neither satisfied nor dissatisfied, and 12% were dissatisfied or very dissatisfied (Table 2). The reason for dissatisfaction was continued abnormal bleeding after the procedure. Satisfaction rates did not vary depending on women's menopausal statuses, the size of the polyp removed (under 1 cm, at least 1 cm), or concomitant uterine myomas.
Treatments other than polypectomy were used less commonly (Table 1). There were no differences in age, menopausal status, or length of follow-up when comparing women who received different treatments. However, there were differences in women's perceptions of severity of menorrhagia between groups (Table 1, P = .001 by the Kruskal-Wallis test). Women treated by polypectomy plus endometrial ablation and by myomectomy plus polypectomy had higher pretreatment menorrhagia scores.
Statistically significant improvements in menorrhagia scores or average number of days of bleeding per month were noted for women who had polypectomy plus endometrial ablation, myomectomy combined with polypectomy, and hysterectomy. Although the numbers were small, nonsurgical treatment did not result in significant improvements in those symptoms (Table 1). Medical treatment typically consisted of progestins and nonsteroidal anti-inflammatory agents. Only two women were treated with D&Cs only; both were very dissatisfied with the outcome of treatment and required further surgery. Most women were satisfied with surgical results after ablation, myomectomy, and hysterectomy. Few were satisfied after nonsurgical treatment or D&C alone (Table 2). Continued abnormal bleeding after treatment was the most common reason stated for dissatisfaction.
Endometrial polyps are likely to be diagnosed with increasing frequency as sonohysterography is used for evaluating women with abnormal uterine bleeding. We and others have shown that endometrial polyps are found commonly in women with abnormal uterine bleeding.1–9 The purpose of this study was to determine the effectiveness of treating endometrial polyps by different means. We found that surgical treatments that removed the polyps resulted in an improvement in patients' bleeding symptoms and high satisfaction rates. When comparing only women treated by polypectomy, the outcomes were the same regardless of their menopausal status. The size of the polyps removed and concomitant intramural myomas did not seem to influence satisfaction rates. However, many polyps treated were larger than 1 cm in diameter, so it is not known whether removal of very small polyps results in the same satisfaction rates.
Individual patient factors led to different treatment decisions. For instance, those treated with polypectomy plus myomectomy or polypectomy plus endometrial ablation more often self-reported menorrhagia. Several women also had endometrial biopsies at the same time as sonohysterography, so different treatments might have been selected because of differences in symptomatology and pathologic findings based on biopsies. Therefore, treatment groups and outcomes are not directly comparable. For these reasons, plus the non-random assignments to treatments, comparing the different treatment groups might be misleading. However, attempts at medical treatment of abnormal uterine bleeding in women with polyps are not likely to be successful.
Several weaknesses of this study need to be acknowledged. This was a retrospective study and subject to recall bias of the women. The outcomes of treatment were subjective and not measured accurately. Clinical evaluations of menorrhagia and metrorrhagia are often subjective, and surgical decisions commonly are made on patients' perceptions of symptoms. Ultimately, the patient's satisfaction with the treatment is the most important outcome. Finally, our follow-up time was relatively short. Satisfaction with surgical treatments such as polypectomy might decrease over time, particularly if polyps recur and symptoms return. Nevertheless, an average of 1 year after therapy, most women were satisfied with the results of surgical polyp removal. Our high response rate to the questionnaire and similarity between participants and nonparticipants makes selection bias an unlikely explanation for that finding. Further study of the recurrence rate and long-term satisfaction rate after polypectomy is needed.
Despite the high incidence of uterine polyps and the frequency of polypectomies in these patients, there are few studies that evaluated outcomes in them. Our findings agree with those of Cravello et al2 who reported an 88% success rate an average of 3 years after polypectomy in 51 postmenopausal women. Loffer13 reported on the 1-year outcomes of 45 women treated with hysteroscopic resection of large uterine masses and found that excessive bleeding was controlled in 93% of them. That series included ten women with large polyps, but no separate analysis of outcomes was done.13 Our data suggest that polypectomy is an effective treatment.
In 1953, Roger Scott14 noted that little attention had been given to the endometrial polyp in the medical literature. He further questioned whether the discovered polyp was the real reason for abnormal uterine bleeding or only an incidental finding. Although polyps can be asymptomatic, our study suggests that in women who present with abnormal uterine bleeding and have polyps, the polyps are most often the cause of the bleeding. Removal of the polyp is usually curative and probably should be done before further surgery is suggested.
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