Hysteroscopic polypectomy is an effective method to remove them. The postoperative polyp recurrence might result in the reappearance of abnormal uterine bleeding or infertility. There is limited data on the factors that influence postoperative recurrence.
Progesterone appears to be a valid therapeutic alternative for the management of recurrent endometrial polyps.
Levonorgestrel intrauterine device is endometrial cancer before menopause an option for women who want to conceive. Infertile women should be counseled to achieve a pregnancy in the next couple of months after hysteroscopic polypectomy, endometrial cancer before menopause as soon endometrial cancer before menopause possible before polyp recurrence.
Keywords recurrent endometrial polyps, infertility, hysteroscopy Rezumat Polipii endometriali PE sunt frecvent întâlniţi în practica ginecologică, motivele prezentării la medic fiind cel mai adesea infertilitatea şi sângerarea uterină anormală.
Polipectomia histeroscopică este considerată standardul de aur pentru tratamentul PE. Recurenţa postoperatorie determină reapariţia simptomatologiei. Factorii care influenţează recurenţa PE sunt puţin cunoscuţi. Progesteronul este o metodă terapeutică eficientă de prevenire a reapariţiei PE.
Steriletul cu levonorgestrel nu este o metodă utilă în cazul pacientelor infertile care îşi doresc o sarcină.
Femeile cu infertilitate trebuie consiliate să obţină o sarcină în următoarele luni după polipectomia histeroscopică. Cuvinte cheie recurenţa polipilor endometriali infertilitate histeroscopie Introduction When talking about the evaluation of the uterine cavity, hysteroscopy is considered endometrial cancer before menopause be the gold standard 1.
Hysteroscopy is a diagnostic and an operative procedure and evaluates the intrauterine pathology in premenopausal and postmenopausal women. Hysteroscopy is indicated in the workup of infertile patients with suspected uterine abnormalities and in patients complaining of abnormal uterine bleeding 2,3.
Millions of women present each year to gynecologists accusing abnormal uterine bleeding. Abnormal uterine bleeding can be caused by structural abnormalities such as endometrial polypsovulatory dysfunctions coagulopathies or due to iatrogenic causes Endometrial polyps are one of the most common causes of abnormal uterine bleeding and infertility, but they can also be asymptomatic 7. Endometrial polyps EP are epithelial proliferations that comprise a variable vascular, glandular, fibromuscular and connective tissue components.
Recurenţa polipilor endometriali – factori de risc şi tratament
They are hyperplastic overgrowths of endometrial glands and stroma that form a projection from the surface of the endometrium Endometrial polyps can be diagnosed by ultrasound, sonohysterography, hysteroscopy and uterine curettage. Among them, hysteroscopy is superior to the other three methods, because it is able to detect the number, the type and the location of endometrial polyps. After diagnosis, hysteroscopic polypectomy is now the gold standard for treatment.
Histeroscopy allows the direct visualization and the complete excision of the polyp and keeps the adjacent endometrium intact. For infertile women with no other reason to explain their infertility, hysteroscopic polypectomy improves fertility and increases pregnancy rates The postoperative polyp recurrence might determine the reappearance of abnormal uterine bleeding or infertility.
What can we do when facing a woman with recurrent endometrial polyps? Histopathology Single or multiple polyps may occur and range in diameter from a few millimeters to several centimeters.
Polyps can develop anywhere in the uterine cavity. Endometrial polyps may be hyperplastic, functional, atrophic or mixed endocervical-endometrial. Endometrial polyps share some histologic characteristics: a polypoid configuration with surface epithelium on at least three sides, a central usually fibrotic core that occasionally contains smooth muscle, irregular glandular architecture often dyssynchronous with adjacent normal endometrium and thick-walled vessels.
Hyperplastic polyps endometrial cancer before menopause most likely related to hormonal imbalances and are composed of proliferating, irregularly-shaped glands resembling endometrial hyperplasia. Atrophic polyps have a glandular architecture and are typically seen in postmenopausal women. In functional polyps, the glands are in synchrony with those of the endometrium.
Tamoxifen-related endometrial polyps are usually multiple and their microscopic features usually include hyperplastic glands Etiology, incidence and presentation of endometrial polyps The etiology of endometrial polyps is not exactly known. The close relationship with the background endometrium suggests a similar way in which they proliferate and express apoptosis-regulating endometrial cancer before menopause during the menstrual cycle Endometrial polyps overexpress estrogen and progesterone receptors, while dropping their apoptotic regulation.
This mechanism is similar in both pre- and postmenopausal women Several molecular mechanisms try to explain the development of endometrial polyps: monoclonal endometrial hyperplasia, overexpression of endometrial aromatase, and gene mutations The etiology and the pathogenesis of polyps in obese females appear to be associated with the progesterone receptor, the inhibition of apoptosis and cellular mechanisms linked with inflammation Endometrial polyps are one of the most common causes of abnormal uterine bleeding and infertility, but they can also be asymptomatic.
Endometrial polyps can be an incidental finding during pelvic ultrasonography. Other presentations include postmenopausal bleeding, polyp externalization through the cervical ostium, abnormal vaginal discharge, and incidental bleeding during hormonal therapy 27, The highest incidence of endometrial polyps is in the fifth decade of life and declines after menopause.
This pathology is rare under the age of Influencing factors 1. Hormone replacement therapy and tamoxifen A number of studies report an increased incidence of endometrial polyps in women on hormone replacement therapy HRT and tamoxifen.
Recurenţa polipilor endometriali – factori de risc şi tratament
Tamoxifen acts as a selective modulator receptor and estrogen agonist on the endometrium The influence on endometrial polyps seems to be through estrogen, of which endometrial polyps depend. However, endometrial polyp formation appears to be related to the type and dosage of the estrogen and progestogen in HRT; in particular, a progestogen with high anti-estrogenic activity may have an important role in preventing the development of endometrial polyps One endometrial cancer before menopause cohort study of consecutive patients confirmed tamoxifen as associated with endometrial polyps.
The same study rejects the hypothesis that hormone replacement therapy is a risk factor for endometrial polyps Older studies support that endometrial polyps are less common in women on continuous combined HRT, but their appearance has been reported. Rarely, women reporting incidental bleeding after having achieved prolonged amenorrhea on continuous combined HRT will be found to have an endometrial polyp.
Such cases always impose biopsy and histological evaluation, because adenocarcinoma can also occur 34, Endometrial polyp formation may be dependent on the type and dosage of the estrogen and progestogen. Especially a progestogen with high antiestrogenic activity may play an important preventive role in the development of endometrial endometrial cancer before menopause Diabetes, hypertension and obesity Some authors postulate that metabolic anomalies, such as diabetes, hypertension, dyslipidemia and obesity, are independent risk factors for the development of endometrial polyps.
The prevention and the treatment of obesity and diabetes is a key factor in treating recurrent endometrial polyps Dysregulations in the immune system and progesterone deficiency Recent studies indicate that dysregulations in the immune system participate in the development of a variety of symptoms, such as aging, obesity and hypertension, many of which are risk factors for endometrial polyps.
Based on these discoveries, Zhu Y et al. Kosei N et al.
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Micropolyps, as a macroscopic manifestation of an active inflammatory process in chronic endometritis, are characterized by focal infiltrates of leukocytes CD45macrophages CD68plasma cells CD and NK CD56 cells, whose activity leads to excess abnormal proliferation of the endometrium, even in the absence of hormone receptor disorders Other influencing factors One recent case-control study shows that the prevalence of endometrial polyps is higher in infertile patients with fallopian tube obstruction than in patients with fallopian tube patency Risk factors for recurrence and recurrence rate Hysteroscopic resection is a safe and simple procedure which effectively removes polyps, but endometrial polyps can recur.
Some studies suggest postoperative recurrence rates of the endometrial polyps to range from 2. Gu F et al. The authors concluded that a high number of EP, endometriosis, and previous polypectomy history are independent risk factors for recurrence The hyperplastic polyp without atypia endometrial cancer before menopause a higher risk of postoperative recurrence than that of benign polyps Infertile women are more likely to suffer from endometrial polyps, which suggests a causative relationship between endometrial polyps and infertility.
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However, it is difficult to explain why some women have a tendency to experience polyp recurrence and others do not. The recurrence of endometrial polyps might be due to the polypoid background in the endometrium, resulting from genetic aberrations. The factors influencing postoperative recurrence potential of benign endometrial polyps have limited data 41, One study analyzed women with endometrial polyps in both pre- and postmenopausal period It shows that after hysteroscopic polypectomy, the recurrence rate of endometrial polyps is Management of recurrent endometrial polyps The indications of treatment for women with endometrial polyps are: symptomatic endometrial polyps, obesity, infertility, the need to exclude malignancy.
Conservative management A endometrial cancer before menopause of 46 studies, including more than The prevalence of atypia and malignancy was 0. This low malignancy rate allows a conservative management. Metabolic anomalies play an important role in the development of benign endometrial pathologies.
The prevention and the treatment of obesity and diabetes are key factors in treating recurrent endometrial polyps Expectant management with no intervention is an option. Smaller polyps regress more likely than polyps with 10 mm in length. The conservative management of asymptomatic polyps is an option only after the discussion with the patient 30, Medical management The use of some types oxiuros sintomas ninos hormonal therapies may have a preventative role for polyp formation.
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The use crema pentru papiloame pe organele genitale levonorgestrel-releasing intrauterine device is reported to reduce the incidence of endometrial polyps 46, Wu Endometrial cancer before menopause et al.
They found that levonorgestrel intrauterine system may inhibit the recurrence and formation endometrial cancer before menopause endometrial polyp by lowering the expressions of estrogen icd 10 code for papilloma rll ERprogesterone receptor PR and insulin-like growth factor-1 IGF-1 Another study supports the levonorgestrel intrauterine system The effect of levonorgestrel intrauterine system is superior to that of oral progestin, conclude the authors A retrospective study aimed to investigate the effects of three cycles of subcutaneous progesterone administered during the luteal phase on the regression rate of symptomatic and asymptomatic endometrial polyps in premenopausal woman The regression rate of endometrial polyps in women treated with subcutaneous progesterone was compared with the wait-and-see patients.
The regression rate was Another study analyzed 98 patients who were confirmed with endometrial polyps and underwent hysteroscopyc polypectomy The patients were dividend in two groups: one group was treated with progesterone hormone drugs after hysteroscopic operation, and the other group was not treated with progesterone hormone after hysteroscopic operation.
The authors conclude that post-hysteroscopic progesterone hormone therapy have favorable clinical effect in treating endometrial polyps, as it can effectively prevent the recurrence of endometrial polyps, restore the level of hemoglobin, and reduce endometrial thickness GnRHa gonadotropin-releasing hormone antagonist can be used before hysteroscopic resection.
This option has many side endometrial cancer before menopause and is more expensive than excisional surgery alone. There are no data to support the use of GnRHa in this setting Hysteroscopic resection Postmenopausal symptomatic women have a higher risk of premalignant and malignant tissue changes 37 and many studies show that in infertile women hysteroscopic polypectomy improves fertility and increases pregnancy rates.
Hysteroscopic polypectomy is the gold standard regarding the surgical management of endometrial polyps. Histeroscopy has many advantages: direct vision that allows the complete removal of the polyps while preserving the adjacent endometrium Moreover, the levonorgestrel intrauterine device is not an option for women who want to conceive.
Infertile women should be counseled to achieve a pregnancy in the next couple of months after hysteroscopic polypectomy, and as soon as possible before polyp recurrence Radical surgical options Hysterectomy is the only way that proves no endometrial polyp recurrence and guarantees no potential for malignancy.
It should be taken in consideration that hysterectomy is a major surgical procedure with potential for morbidity. The patients should be counseled about its risks and implications.
There are hpv impfung jungen kkh comparative data for conservative and radical treatments. When atypical hyperplasia or malignancy is diagnosed by histopathological examination within an endometrial polyp, the woman should be treated in accordance with the guidelines for the treatment of atypical endometrial hyperplasia or endometrial cancer, respectively Conclusions Endometrial polyps are a common finding in gynecology, with low malignancy rate progression.
Limited data are available about the factors that influence postoperative recurrence. Some studies show that the number of endometrial polyps and the follow-up duration are major factors that determine the recurrence potential after hysteroscopic polypectomy.
A higher number of endometrial polyps and longer follow-up duration are associated with a greater potential of polyp recurrence. Correcting metabolic anomalies, such as diabetes, hypertension and dyslipidemia, decreases the risk of recurrence. Weight loss also plays an important role in polyps recurrence. When hysteroscopic treatment is available, blind curettage should not be used as a diagnostic or therapeutic intervention.
When an endometrial polyp is diagnosed or suspected and hysteroscopy is not available, the patient should be referred for appropriate treatment. Progesterone deficiency determines a local immune imbalance.
Progestogen with high antiestrogenic activity plays an important preventive role in the recurrence of endometrial polyps. Post-hysteroscopic progesterone hormone therapy has a favorable clinical effect in treating endometrial polyps, as it can effectively prevent the recurrence of endometrial polyps, restore the level of hemoglobin and reduce endometrial thickness. The levonorgestrel endometrial cancer before menopause device is not an option for women who want to conceive.
When atypical hyperplasia or malignancy is diagnosed by histopathological examination within an endometrial polyp, the woman should be treated in accordance with the guidelines for the treatment of atypical endometrial hyperplasia or endometrial cancer, respectively.
Conflict of interests: The authors declare no conflict of interests.
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