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New Treatments for Endometrial Polyps

Endometrial polyps are hyperplastic overgrowths of glands and stroma that are localized and that form a projection above the surface endometrial polyps. The prevalence of polyps has been estimated at 10% to 24% among women undergoing endometrial biopsy or hysterectomy. Endometrial polyps are rare among women younger than 20 years of age. The incidence of these polyps rises steadily with increasing age, peaks in the fifth decade of life.

The most common symptom in women with endometrial polyps is metrorrhagia, or irregular bleeding; it is reported in 50% of symptomatic patients. Postmenstrual spotting is also common. Less common symptoms include menorrhagia, postmenopausal bleeding, and breakthrough bleeding during hormonal therapy. Overall, endometrial polyps account for 25%.

Endometrial polyps can sometimes be seen prolapsing through the cervix. Often they are diagnosed by microscopic examination of a specimen obtained after dilatation and curettage (D & C) or after endometrial biopsy. As is the case with submucous fibroids, polyps can escape detection if the uterus is not distended. Increasingly these lesions are diagnosed by modalities such as ultrasonography.

Endometrial polyps usually are cured by thorough curettage. However, polyps or other structural abnormalities may be missed by blind curettage, and hysteroscopic-guided curettage.

Uterine anomalies may be congenital or they may be acquired after infection or mechanical trauma, and they may lead to reproductive or menstrual dysfunction.

The uterus is formed from the paired mullerian ducts during embryogenesis. Uterine anomalies result from their defective migration, fusion, or absorption during embryonic life. The incidence of anomalies is difficult to estimate because many congenital anomalies do not result in clinical manifestations (Rock and Jones, 1977). Patients with symptomatic mullerian anomalies usually have signs of menstrual outflow obstruction or reproductive dysfunction. Diagnostic methods for determining the exact nature of a mullerian anomaly have evolved from bimanual examination, postpartum manual exploration, and D & C, to the more sophisticated techniques of hysterography, laparoscopy, hysteroscopy, ultrasonography, and MRI. Increased capacity of the latter techniques to yield complete information will undoubtedly be reflected in a higher reported incidence.

Retrospective studies reveal that approximately 25% of women with congenital uterine anomalies encounter re- productive difficulties, although conception rates are not different than they are among women in control groups (Abramovici et al, 1983; Harger, 1983). Spontaneous abortions, premature births, and fetal malpresentations are common in women with congenital uterine anomalies.

Anomalies can be classified as problems with hypoplasia or agenesis (American Fertility Society [AFS] class I) or as fusion defects (AFS classes II-V). Class I anomalies, also referred to as mullerian anomalies, usually are diagnosed in women who seek treatment for primary amenorrhea or for an inability to have vaginal intercourse. These defects are thought to occur developmentally when the mullerian structures fail to join with the structures.

Fusion defects include unicornuate uterus (AFS class II), uterus didelphys (AFS class III), bicornuate uterus (AFS class IV), and septate uterus (class V). A unicornuate uterus has a single hemi-uterus that is attached to its fallopian tube. It may also be associated with a rudimentary cavity from the contralateral side. A didelphys uterus has two uterine cavities, and each has a separate cervix. The fundus of the uterus also has a deep cleft between the cavities.

Two clinically relevant points for fusion defects are:

  1. In a woman with a unicornuate uterus, a rudimentary horn can result in pain because of obstruction orretrograde flow, either of which may cause endometriosis or be a site of infection.
  2. Fusion defects may be associated with reproductive problems, from recurrent miscarriage to premature labor. The incidence of these problems is uncertain, however, because in women who have had only uncomplicated pregnancies, anomalies may never have been noted.

Among patients with AFS class I to IV uterine anomalies, there is an increased incidence of renal anomalies, usually renal agenesis ipsilateral to the associated hypoplastic mullerian defect. Therefore, a search for uterine anomalies should be conducted in patients.