· ,
1. What are endometrial polyps? What is its
definition? Ans: Endometrial polyps are localized
overgrowths of
endometrial glands and stroma around vascular core that protrude from
the surface of the endometrium into the uterine cavity.
Q, 2: How a pathologist
classify Endo Polyps? Ans; Polyps may be f three kinds:-They can be A) hyperplastic
(similar to endometrial hyperplasia), B) atrophic (cystically dilated atrophic
glands), or C) functional (undergo cyclical changes). Polyps may be single or
multiple polyps (20% of the times, )
Q 3: What may
be sizes?? Ans:- Polyps
can occur that range from a few
millimetres to several centimetres in size. They can be sessile or pdunculated
they are found in the uterine fundus midwall cornua and cervix. Polyps may be
large (>2 cm), multiple in number .
Q.4: What is the age group? Endometrial polyps are rare among women
younger than 20 years of age. The incidence rises steadily with increasing age,
peaks in the fifth decade of life, and
gradually declines after menopause.
Q,4: What is the
prevalence ?? Ans: The
prevalenceof polyps can range from 10 to 24 % among women undergoing endometrial biopsy or
hysterectomy to 8 to 36 % in postmenopausal women on tamoxifen therapy.
.,
Q. 6: Etiology : Who are more
subjected to polyp formations? 1) PCOS women as a delayed squeal. 2)
Women who are on Tamoxifen therapy in postmenopausal tears and 3) women with Lynch syndrome may have an increased incidence of
endometrial polyps compared to the general population.
Q7: Theories of endometrial hyperplasia? There are several theories on the molecular
mechanisms playing a role in the development of endomaterial polyps: A) monoclonal
endomaterial hyperplasia B) gene mutations c) overexpression of endometrial aromatase.
Further like growth of myomas D) cytogenetic rearrangements and rearrangements
in the family of transcription factors
Q. 9: What % of so
called AUB are related to polyps? Ans: Although
endometrial polyps are responsible for approximately one-fourth of cases of
abnormal genital bleeding (monorrhagia, postmenopausal bleeding, or breakthrough bleeding during hormonal therapy) in both
premenopausal and postmenopausal women . Polyp can prolapse out through the
cervical os. But many polyp are
asymptomatic .
Q 11: Important message for clinicians : If a woman
is on treatment for so called AUB and there s poor response in absence of Sytemic
disease and pregancy then one should seriously consider the possibility of endometrial polyp for which Crina NCR/
Duoluton-L or ovral G are not working .WE have to think in that way.
Q. 12 : Natural
course : Most cases have spontaneous regression of their polyps at the second scan
without any form of therapy whatsoever , but a few women may
progress to new polyp formation over the
couple of yrs. It has been observed that polyps which were larger than 1 cm at
initial diag à were least
likely to regrees, and hormone use do not
appear to affect the natural history of the polyps. The problem is that the natural
course of polyps (I mean if ignored & left untreated) is variable.
Q. 13: Chance of recurrence after hysteroscopic
removal ? In rare cases, endometrial polyps continue to recur
multiple times after removal. There are no data regarding management of this
clinical situation. However , If polyps continue to recur, one option is an Option A : empiric trial
of progestin treatment (oral progestin such as medroxyprogesterone acetate 10
mg daily for 3-6 months, Option
B a levonorgestrel releasing device), and another option is Option C : endometrial
ablation for women who have completed their childbearing.
Q. 14: Malignancy rate ?
Malignant transformation appears to occur more
frequently in women on tamoxifen (3-11 %) than in other women
Regardless of polyp size or duration of tamoxifen
therapy. The overall chance of malignant transformation is 1-5% .
Q. 15: There two Q which remain controversial?? Query 1: Is there any benefit of using progestogen for treatment
of endometrial hyperplasia Query
2 : Can women treated with
Tamoxifene reduce the occurrence of de novo endometrial polyps if concurrently treated
with tamoxifen? .
Q. 16:-How to treat
Cervical polyp?? -For patients with cervical polyps, as many as 25 % of them will also have concomitant
endomaterial polyps, making hysteroscopy a worthwhile process for their
treatment, in contrast to insufficient D&C or blind endomaterial biopsies.
Q 17:
How to diagnose endometrial polyp?
Ans: Though TVS can pick up almost all cases of polyps but the limitation
is that
neither ultrasonography nor hysteroscopy can reliably
distinguish between benign and malignant polyps for which an endometrial biopsy
is warranted. Transvaginal ultrasound (TVS) is the initial imaging of choice, with MRI reserved for indeterminate cases or where sampling is
difficult. On TVS , endometrial polyps appear as ovoid echogenic masses
that project into the endometrial lumen with Doppler US showing a feeding vessel.
Q
18: How best to improve the imaging quality in TVS?? : the tips are as follows
:
The following guidelines have been proposed in 2012 by the American Association
of Gynecologic Laparoscopists (AAGL) for the diagnosis of endometrial polyps
(1) TVS provides reliable information for the detection of endometrial polyps
and should be first investigation of
choice where available; (2) the addition of colour
or power Doppler increases the capacity of TVS to diagnose endometrial polyps; (3)
adding intrauterine contrast sonography (with or without 3D imaging) improves
the diagnostic capacity for endometrial polyps
Caution for practioner: A blind dilatation and curettage or biopsy should not be
used for diagnosis of endometrial polyps as it often misses the small polyps
or other polyps are not removed
Q 19: Can USG miss a polyp ? Can there be False-Positive , False-Negative,
or say Artifacts ?
Reasoning and answer: There is not a single imaging
technique that can accurately diagnose all possible intrauterine pathologies.
Ultrasonography may not pick up very small polyps, flat endometrial anomalies,
cornual polyps, or thin bands of synechiae even when combined with saline
infusion sonography.
Q, 20 : What are the artifacts?? : Uterus
undergoes contractions and relaxations which are more frequent in proliferative
phase. Therefore there could be
transient endometrial changes (apparent thickening) which may confuse a
sonologist more so if she/ he is in a hurry. Moreover if USG is done first time
in her life and uterus has a structural
defect then took the said cong defect (like very small septum) may be confused
as polyp. Similarly an intrauterine
blood clot or presence of mucus especially in hyperestrogenic states such as
during controlled ovarian hyperstimulation for IVF may mimic polyp but follow
up scan at basal scan day 4-5 of cycle will speak the truth. .Therefore to conclude ,followings may confuse
a clinician as a polyp such are a) intrauterine cystic loculation b) endometrial irregularities b) possible localized
mucus accumulations..
Q. 21 : What
are the impact of Polyps on Fertility??
It is controversial whether endometrial polyps
contribute to infertility or miscarriages and because there is no uterine
abnormality that is always associated with poor reproductive performance,
automatic surgical correction is not indicated when a uterine abnormality is found.
But, surgical correction should be considered when a submucous fibroid,
endometrial polyp, septate uterus, or uterine synechiae are discovered in the
setting of failure to conceive or recurrent pregnancy loss, science there may
be a casual association. But many believe that endometrial
polyps to be the most common of the intrauterine lesions interfering with the
endometrial cavity.
Q. 22. How presences
of Polyp cause subfertility? Ans: The exact mechanism by which endometrial
polyps cause infertility is not known, but some proposed mechanisms are
induction of an a) low grade inflammatory process similar to an intrauterine
device , b) mechanical interference with sperm and embryo transport, c) impairment
of embryo implantation, or d) altered endometrial receptivity such as abnormalities in the
expression of molecular markers such as HOXA 10 and HOXA 11
Regardless of the mechanism of endometrial
disturbance, uterine polyps have been associated with decreased pregnancy rate
both in natural conceptions and in intrauterine insemination (IUI) cycles./
How helpful
is polypectomy in improving conception rate?? Following
polypectomy, menstrual pattern is normalized in about 90% cases and spontaneous
pregnancy and delivery at term rates, increased after the procedure and were 60% and 55% respectively. But one things which
have been observed by many authors that there was no statistical difference in
fertility rates between patients having polyps ≤1 cm
and patients having >1 cm polyps or multiple polyps. Spontaneous
abortion rate in the first trimester of pregnancy was 6 %, and there was no
statistical difference between patients with small or bigger/multiple polyps. Researchers
therefore concluded that hysteroscopic polypectomy appeared to improve
fertility and increase pregnancy rates in previous infertile women with no
other reason to explain their infertility, irrespective of the size or number
of the polyps.
Hysteroscopic removal of endometrial polyps appears to
improve spontaneous pregnancy rates in women with otherwise unexplained
infertility. Additionally most of the data for polypectomy in subfertile
patients suggests that removal improves fertility, with reported pregnancy rates varying between
43 and 90 % .
It is also observed that both spontaneous pregnancy
rates and those associated with assisted reproductive technology increased
after polypectomy. Localization of the polyp (upper, middle, or lower third of
the uterine cavity) or polyp size (4-14 mm) did not seem to affect pregnancy
rates.
Researchers concluded that endometrial
polyps <1.4 cm detected during
ovarian stimulation did not affect pregnancy rates, miscarriage rates, and live
birth rates in ICSI cycles and that patients with an endometrial polyp detected
before ICSI treatment and resected by hysteroscopy had similar pregnancy rates
compared with patients with no endometrial polyps.
Q 23: What are
the requisite for normal pregancy?? Ans: Normal endometrial thickness, structure,
and texture are crucial for uterine receptivity, and any structural pathology
in the uterine cavity may lead to subfertility or implantation
failure
Q. 24: How to remove polyp/ polyps in
hysteroscopy?? Ans: Hysteroscopically guided polypectomy
(with grasping forceps, suction curette, microscissors, a small electrosurgical
hook, i.e., resectoscope, mechanical morcellation, or a bipolar electric probe are the
most effective method of removal since small polyps and other structural
abnormalities can be missed by blind curettage .
Warning for clinicians: In modern
times with the popularization of hysteroscopy one should refrain from
traditional D& C procedure for removal of polyp.
Q. 25: What is the chance of having endometrial ca in
hyperplastic endometrium?? Ans: All hyperplasia taken together the progression
is as follows A) Remains stable= 18% B) regresses of its own = 74% C) Turns
into endometrial Ca= 8%.of all cases taken together.
But it all depends
on initial histology and slide may be reviewed by another pathologist and block
is to be preserved by the patient carefully .There are three kinds of
histological classification of endometrial hyperplasia depending on the changes in 1) surface
epithelium, 2) glandular epithelium ,3) stroma and 4) pattern of blood vessels .The architecture of endometrium
is very important .
Q, 26: How to define Simple endometrial hyperplasia??
1)
Glands are dilated but no cellular atypia 2) increased
glandular/ stromal ratio 3) No gland crowding 4) no surface epithelial atypia ,However
the chance of having endometrial ca if left untreated will be about 1% if no
atypia is observed in microscopy and from block.
Q. 27: What is Complex
hyperplasia after removal of polyp and the polyp is subjected to histology? 1) Glands
are crowded, budding, infolding glands(usually such changes are designated by histologist
as adenomatous
hyperplasia without atypia ; 2) less stroma 3)
surface epithelium do not exhibit atypia. Tr by progesterone only and if no tr
is done then progression to endometrial cancer is 3% only.
Q. 28:-What do we mean by atypical
hyperplasia? Ans: Atypical hyperplasia may be of two types like a) Simple
cystic hyperplasia & 2) Complex atypical hyperplasia. The problem
with atypical hyperplasia is that though the bit of endometrium put for block
and microscopy may miss carcinoma site and of all atypical hyperplasia as many
as 25-43% may still harbour endometrial cancer (sampling error) .In caes of Complex
adenomatous hyperplasia with atypia we should be cautious not to miss
associated endocervical cancer which may
be associated as high as 30-40%. However if TAH is contemplated than at Theatre
the removed uterus should be cut and one should macroscopically observe any
myometrial invasion, If invasion seems likely
then Pel lymphadenectomy should be done
if anesthetist permits you.
Q. 29: What are the causes of PMB(Post meno
bleeding)? Ans 1) Atrophic endometrium (60-80% of all PMB)
2) iatrogenic: Post meno oestrogen therapy (15-25%) 3) Endometrial polyp (
2-12%) 4) Endometrial hyperplasia
including atypia-5-10% 5) genital trauma 2% and 6) Endometrial Ca 10% .
Another warning to clinicians: As many as 5% of all endometrial Ca are of less
than 40 yrs of age!!! So age should not be a bar for hysteroscopy if she is symptomatic
or USG reveal as peer site but thick ET on day 4. This is more relevant in PCO
& obese diabetics.
No comments:
Post a Comment