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To Determine the Frequency of Endometrial Polyps in Patients Presenting with Irregular per Vaginal Bleeding

Article Information

Anum Malik1, Laila Zeb2

Obstetrics and gynaecology department, Lady reading hospital, Peshawar, Pakistan

*Corresponding author: Laila Zeb, Obstetrics and gynaecology department Lady reading hospital Peshawar Pakistan

Received: 05 March 2022; Accepted: 11 March 2022; Published: 29 March 2022

Citation: Anum Malik, Laila Zeb. To Determine the Frequency of Endometrial Polyps in Patients Presenting with Irregular per Vaginal Bleeding. Fortune Journal of Health Sciences 5 (2022): 198-294

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Abstract

Introduction: Endometrial polyp is a focal hyperplastic growth of endometrial glands and stroma and is commonly benign lesion, which can rarely become malignant. Abnormal Uterine Bleeding (AUB) is the commonest presentation in the reproductive age group as well as postmenopausal age group.

Objective: To determine the frequency of endometrial polyps in patients presenting with irregular per vaginal bleeding. This Descriptive Cross-Sectional Study was conducted at Department of Obstetrics and Gynecology, Khyber Teaching Hospital Peshawar for a Period of 6 Months From 1st January 2021 till 30th June 2021.

Material & Methods: Total of 249 patients were observed in this study. In women with abnormal uterine bleeding or in women in whom the endometrium was abnormally thick (>4 mm), as determined by routine vaginal sonography, a diagnostic outpatient hysteroscopy was performed with a Gynaecare, Ethicon, and disposable 3 mm hysteroscope with 30o. The hysteroscope was gently introduced through the cervix into the uterine cavity. Normal saline was used to distend the uterine cavity. Hysteroscopy was considered successful if an adequate view over the whole uterine cavity was obtained. A Pipelle device was used to obtain tissue for histology.

Results: In this study mean age was 33 years with SD± 9.749. Fifteen percent patients were primi para while 85% patients were multi para. More over 30% patients had endometrial polyp and 70% patients didn’t have endometrial polyp.

Conclusion: Our study concludes that the frequency of endometrial polyps was 30% in patients presenting with irregular per vaginal bleeding.

Keywords

hysteroscope, Gyneacology, tamoxifen, sonography

Article Details

1. Introduction

Endometrial polyp commonly benign lesion, which can rarely become malignant, is a focal hyperplastic growth of endometrial glands and stroma. The commonest presentation is the abnormal uterine bleeding in the reproductive age group as well as postmenopausal age group. Endometrial polyps especially at cornua can be attributed as a cause of infertility also. Sometimes patients will be entirely asymptomatic. With the advent of high-resolution pelvic ultrasound and hysteroscopic diagnosis, it has become clear that AUB in women’s life is associated with endometrial polyp more often than suspected earlier. Depending on the population studied [1]. The prevalence of endometrial polyp ranges from 7.8% to 34.9% in the general population the prevalence of endometrial polyps ranges from 6 to 38%, and rarely are they present before menarche. Between 40 and 50 years of age they are more frequent, with a gradual increase before this age and a decrease thereafter [2].

Endometrial polyps can cause symptoms, and might be associated with endometrial cancer. In association with the polyps, or even within them the percentage of malignant lesions, is ∼ 2.5 to 3%, and can be higher in some populations. Advanced age, menopausal status, size of the lesion, hypertension, obesity and the presence of postmenopausal bleeding are the risk factors for malignancy. Selective modulators of estrogenic receptors, such as tamoxifen, also play a role in the increased risk of endometrial cancer [3].

The use of transvaginal ultrasound is inevitably entailing a significant increase in the number of women diagnosed with endometrial polyps. Hysteroscopic polypectomy remains the gold standard for treatment, is effective and safe both as a diagnostic and therapeutic intervention [4]. The most common indication for performing operative hysteroscopy was abnormal uterine bleeding 82.2% (n=83) [5]. In a study comprised of 101 cases of endometrial polyps diagnosed by diagnostic hysteroscopy, transvaginal ultrasonography and saline contrast sonohysterography.The results of another study that was conducted to find out the histopathological pattern of endometrium in abnormal uterine bleeding (AUB) showed that one cause of abnormal uterine bleeding was endometrial polyp and the proportion of endometrial polyp was (1.79%) [6].

A meta-analysis showed that in women with postmenopausal bleeding endometrial Polyps reported up to 40% 7. This study will help in establishing local statistics in our population on frequency of endometrial polyps with irregular per vaginal bleeding as different studies have reported different results and also no single study has been conducted in our hospital on this topic. This will help us in reducing the effect of the disease.

2. Materials and Methods

This descriptive cross sectional study was conducted at Department of Obstetrics and Gyneacology, Khyber Teaching Hospital Peshawar for a period of 6 months from 1st January 2021 till 30th June 2021.Data was collected by Consecutive non probability sampling technique from 249 patients. The sample size was calculated by WHO sample size calculation formula. After getting approval from institutional review board all pre and postmenopausal women with age between 19-52 years with abnormal uterine bleeding were included in the study. Women taking hormonal contraception, HRT or tamoxifen or presenting with vaginal bleeding due to obvious causes other than endometrial polyp as diagnosed by hysteroscopic examination were excluded from the study. From the participants of the study, written informed consent was taken both for inclusion in the study and for the hysteroscopic procedure.

Diagnostic hysteroscopy was performed in women with abnormal uterine bleeding or in women in whom the endometrium was abnormally thick (>4 mm), as determined by routine vaginal sonography. As pre-operative preparation, mefenamic acid 500-1000 mg tablets were given to every patient two hours before the procedure. Out-patient hysteroscopy was performed with a Gyneacare, Ethicon, and disposable 3 mm hysteroscope with 30o. The patient was placed in lithotomy position, Sim's speculum was inserted and the cervix was grasped using a tenaculum. The hysteroscope was then gently introduced through the cervix into the uterine cavity. Normal saline was used to distend the uterine cavity. By a Storz cold light source via a fibre-optic cable illumination was provided. If an adequate view over the whole uterine cavity was obtained, outpatient hysteroscopy was considered successful. A Pipelle device was used to obtain tissue for histology. The hysteroscopic findings were recorded in a standardized way. All the information was recorded on a predesigned proforma. Data was analyzed in SPSS ver 22. Mean and standard deviation was computed for continuous variables like age, parity, duration of per vaginal bleeding, polyp diameter, number of polyps. Frequency and percentages were computed for categorical variables like marital status, endometrial polyps. Endometrial polyp was stratified with age, parity, marital status, duration of per vaginal bleeding. Post stratification chi square test was applied in which P value ≤0.05 was considered as significant value.

3. Result

In this study age distribution among 249 patients was analyzed, in age group 18-30 years there were 55(22%) patients, in age group 31-45 years there were 194(78%) patients. Mean age was 33 years with SD±9.749. (Table no 1) Parity distribution among 249 patients was analyzed, primi para were 37(15%) of patients, multi para were 212(85%) of patients. (Table no 2). Duration of per vaginal bleed among 249 patients was analyzed, duration ≤2 months was observed in 147(59%) patients , 102(41%) patients had duration of per vaginal bleed >2 months. Mean duration was 2 months with SD ± 2.143. (Table no 3)

Marital status among 249 patients was analyzed, unmarried were 12(5%) women, while 237(95%) women were married. (Table No 4). Among 249 patients status of endometrial polyp was analyzed, 75(30%) patients had endometrial polyp while 174(70%) patients didn’t have endometrial polyp. (Table No 5). Stratification of endometrial polyp with respect to age, parity, marital status, duration of per vaginal bleeding is given in table 6,7,8,9.

Table 1: Age Distribution (n=249)

AGE

FREQUENCY

PERCENTAGE

18-30 years

55

22%

31-50 years

194

78%

Total

249

100%

Mean age was 33 with SD± 9.74

Table 2:  Parity (n=249)

PARITY

FREQUENCY

PERCENTAGE

Primi para

37

15%

Multi para

212

85%

Total

249

100%

Table 3: Duration of per Vaginal Bleeding (n=249)

DURATION

FREQUENCY

PERCENTAGE

≤2 months

147

59%

>2 months

102

41%

Total

249

100%

Mean duration was 2 months with SD ± 2.143

Table 4:  Marital Status (n=249)

MARITAL STATUS

FREQUENCY

PERCENTAGE

Un married

12

5%

Married

237

95%

Total

249

100%

Table 5: Endometrial Polyp (n=249)

ENDOMETRIAL POLYP

FREQUENCY

PERCENTAGE

Yes

75

30%

No

174

70%

Total

249

100%

Mean number of polyps were 2 with SD ± 1.29

Table 6: Stratification of Endometrial Polyp W.R.T Age Distribution (n=249)

ENDOMETRIAL POLYP

18-30 years

18-30 years

Total

Yes

17

58

75

No

38

136

174

Total

55

194

249

chi square test was applied in which P value was 0.8851

Table 7: Stratification of Endometrial Polyp W.R.T Parity Distribution (n=249)

ENDOMETRIAL POLYP

Primi para

Multi para

Total

Yes

11

64

75

No

26

148

174

Total

37

212

249

chi square test was applied in which P value was 0.9552

Table 8: Stratification of Endometrial Polyp W.R.T Marital Status (n=249)

ENDOMETRIAL POLYP

Unmarried

Married

Total

Yes

4

71

75

No

8

166

174

Total

12

237

249

chi square test was applied in which P value was 0.8036

Table 9: Stratification of Endometrial Polyp W.R.T Duration Of Per Vaginal Bleeding (n=249)

ENDOMETRIAL POLYP

≤2 months

>2 months

Total

Yes

44

31

75

No

103

71

174

Total

147

102

249

chi square test was applied in which P value was 0.9379

5. Discussion

Endometrial polyp, commonly benign lesion, which can rarely become malignant is a focal hyperplastic growth of endometrial glands and stroma. The commonest presentation is the abnormal uterine bleeding in the reproductive age group as well as postmenopausal age group. Endometrial polyps especially at cornua can be attributed as a cause of infertility also. Sometimes patients will be entirely asymptomatic. With the advent of high-resolution pelvic ultrasound and hysteroscopic diagnosis, it has become clear that AUB in women’s life is associated with endometrial polyp more often than suspected earlier. Depending on the population studied [1] the prevalence of endometrial polyp ranges from 7.8% to 34.9%. Our study shows that mean age was 33 years with SD± 9.749. Primi para were fifteen percent while 85% patients were multi para. More over 30% patients had endometrial polyp and 70% patients didn’t have endometrial polyp.

Similar results were observed in another study conducted by Saroj A et al [8] to find out the histopathological pattern of endometrium in abnormal uterine bleeding (AUB), showed that one cause of abnormal uterine bleeding was endometrial polyp and the proportion of endometrial polyp was (1.79%) [6]. Similar results were observed in another study conducted by Vroom AJ et al9 in women with postmenopausal bleeding in which endometrial Polyp was reported up to 40%.

Similar results were observed in another study conducted by Kanthi JM et al10 in which the age group of 40-49 years, the prevalence of polyp among women who underwent diagnostic hysteroscopy and blind polypectomy was more common. Polyps manifested as AUB in 45.6% of our study population. Between premenopausal and postmenopausal women and single and multiple polyps, the mean size of the polyp was not significantly different. In our study population histopathological study of the polyp showed two malignant polyps. In 33 women premalignant lesions i.e., endometrial hyperplasia without atypia and with atypia was found. There was one cervical tear;one uterine perforation ,one false passage and one patient had mild bleeding after the procedure. In our study, 3.9% (7 women) had recurrence in the mean follow-up period of 37.57±28.12 months. In the follow-up period of 16.56±18.96 months, 78.9% women didn’t have recurrence.

In another study conducted by Yousaf S et al [11], similar results were observed   in total number of 50 consecutive patients who met inclusion criteria were enrolled in the study. Ages of the patients who presented with PMB ranged between 48 years and 80 years with a mean age of 59 years. In 18 out of 50 cases (36%) malignancy was found. Endometrial CA constituted about 14 out of 50 cases (28%) and CA cervix constituted 4 out of 50 cases (8%). Benign pathology was more frequent (64%). 13 of 50 cases (26%) had hyperplasia out of which 1 case (2%) was of atypical hyperplasia. In 4 of 50 cases (8%) endometrial polyp was found. 3 of 50 cases (6%) had chronic endometritis. 5 of 50 cases (10%) had chronic cervicitis. While 7 cases (14%) had postmenopausal bleeding due to decubitus ulcer of uterovaginal prolapse. Among malignancies (36%), the most frequent malignancy in women with postmenopausal bleeding with mean age of 65 years was endometrial cancer.

6. Conclusion

Our study concludes that in patients presenting with irregular per vaginal bleeding the frequency of endometrial polyps was 30%.

Funding sources:

There was no funding agency involved for financial support.

Conflict of interest:

No conflict of interest.

References

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