Outpatient versus inpatient uterine polyp treatment for abnormal uterine bleeding: randomised controlled non-inferiority study

In the last years, endometrial polyps are increasingly detected in symptomatic and asymptomatic women due to the extended use of TVS both in evaluating AUB and in routine examination of asymptomatic women (1). Hysteroscopy is often the next step, after a polyp is suspected. Recently, as instruments have reduced in size, office hysteroscopy for diagnostic purposes has begun to replace operating room procedures, so , in Italy we had a rapid increase of hysteroscopies , since it became an office procedure considered of little discomfort by gynaecologists. In the Department of Obstetrics and Gynaecology of Institute of Maternal and Child Health IRCCS Burlo Garofolo, Trieste (Italy), we have an outpatient hysteroscopic service. Recently, in order to assess the appropriateness of hysteroscopic examinations performed in our service between January 2012 and June 2014, we retrospectively analyzed the records of 1070 patients at low risk for endometrial cancer. So, we excluded women with a BMI > 30, with a family history of endometrial, ovarian and/or intestinal cancer, and women undergoing tamoxifen treatment. The patients were divided in two groups: women in reproductive age and less than 50 years old and women in postmenopause, after at least 1 year of amenorrhea and over 50 years old.

Polyps were the most common indication for sending patients to our hysteroscopic service, we found them in 43% of our reproductive-aged women and in 52% of postmenopausal group.

No neoplastic or preneoplastic lesions were present in polyps in fertile women and in postmenopausal women with asymptomatic polyps of diameter < 10 mm. The only woman with carcinoma that did not bleed showed a sonographic and hysteroscopic picture of endometrial polyp with a diameter greater than 18 mm, as reported also by Ferrazzi et al. (1).

We ignore if removal of asymptomatic small polyps may modify their natural history. As stated by Glasziou (2), some newly diagnosed and treated patients will benefit, but others will experience the adverse effects of unneeded treatment: infections, pain, anxiety, risks associated to local analgesia and, although rarely uterine perforation.

Hoff and colleagues (3) discuss a similar question regarding colorectal screening programmes that increased the number of benign lesions being detected. The authors suggest the need for more evidence about their malignant potential to be sure that the risks of their removal do not outweigh the benefits of screening.

In our experience outpatient uterine polyp treatment with a “see and treat” approach is an interesting and acceptable procedure but could induce an overtreatment. Implementation of outpatient hysteroscopic services needs a rigorous attention to scientific evidences and to guidelines of main medical societies (4,5,6,7).

In Italy, the great majority of hysteroscopic training courses are financed by the companies that produce the instruments. In these courses, more attention is being payed to learning technologies than to the guidelines concerning the indications for hysteroscopy.

Scientific societies should point out the risks of overinvestigation, overdiagnosis and related overtreatment in their guidelines and systematic review articles to better identify thresholds where benefits are likely to outweigh harms.

The question if it is appropriate to remove all polyps “when malignancy is not suspected”, as suggested by your study, is fundamental, since it can modify up to 50% of the accesses to our services of office hysteroscopy.

References
1. Ferrazzi E, Zupi E, Leone FP, Savelli L, Omodei U, Moscarini M, et al. How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study. Am J Obstet Gynecol 2009; 200 (3):p235.e1–6.
2. Glasziou P, Moynihan R. Too much medicine; too little care. BMJ 2013; 346:f4247.
3. Hoff G, Bretthauer M, Garborg K, Eide TJ. New polyps , old tricks : controversy about removing. BMJ 2013; 5843:8–11.
4. Levens ED, Decherney AH. ACOG Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 2012 ;120(1):197–206.
5. Singh S, Best C, Dunn S, Leyland N, Wolfman WL. Abnormal uterine bleeding in pre-menopausal women. J Obstet Gynaecol Canada 2013; 35(5):473-9.
6. Renaud MC, Le T, Bentley J, Farrell S, Fortier MP, et al. Epidemiology and investigations for suspected endometrial cancer. J Obstet Gynaecol Can. 2013 Apr;35(4):380-3.
7. Dreisler E, Poulsen LG, Antonsen SL, Ceausu I, Depypere H et al. EMAS clinical guide: assessment of the endometrium in peri and postmenopausal women. Maturitas 2013; 75(2): 181–90.