Factors Associated With Pathogenesis Of Endometiral Polyp

Objectives:To identify the prevalence of endometrial polyp in our department, to identify the factorsassociated with the pathogenesis of endometrial polyp and to examine the relationship betweenendometrial polyp and the underlying endometrium.Background:Hysteroscopic surgeries have been used tremendously by gynecological specialists in recentyears. However, this technology has made it more easier for diagnosis and treatment of manygynecological conditions.Endometrial polyp (EP) is a common pathology, occurring in morethan25%of the general population, most frequently in perimenopausal and postmenopausalwomen, often in association with abnormal uterine bleeding.Endometrial polyps are biphasic benign endometrial neoplasms that classically have beendefined as ‘‘benign nodular protrusions above the endometrial surface, consisting of irregularlydistributed endometrial glands and stroma’’.They are characterized with locally abnormalgrowing of endometrial tissue, may be single or multiple in different sizes (0.5-4.0cm),benignstructures which may be glandular, stromal or vascular tissues.It is estimated that about50%ofwomen with EP presents with abnormal uterine bleeding. The polyps may be an incidentalasymptomatic finding diagnosed during routine vaginal sonography or infertility investigations.Most women with symptomatic endometrial polyps present with abnormal uterine bleeding(AUB), and this has been recently classified as AUB-P for premenopausal women as endorsedby FIGO.In symptomatic women, undergoing hysteroscopic surgery to diagnose the cause ofAUB, pelvic pain or infertility, more than50%of these patients were diagnosed as EPs.Asymptomatic women whose diagnosis was made performing transvaginal ultrasongraphy(TVUS) as EPs and who undergone hysteroscopic surgery were also found to have EPs onhistopathological examination. Based on the hypothesis that a polyp is a circumscribed pathology of the endometrium or apolypoid expression of endometrial hyperplasia,several studies have found the relationshipbetween EPs and the underlying endometrium. It has been suggested that the presence of EPscould be a marker of a greater risk of the patient’s endometrium undergoing proliferative andneoplastic transformations.Hysteroscopy and curettage under general anaesthesia is the "goldstandard " investigation to diagnose endometrial polyp that enables direct visualization of thepolyp. It is a minimally invasive procedure which can also be used in outpatient clinics.Transvaginal ultrasonography (TVUS) should be the first-line diagnostic modality whenevaluating disorders of the myometrium and endometrium. TVUS is best performed inpremenopausal women before day10of the cycle when the endometrium is minimally thin.About25percent of polyps disappear spontaneously without treatment over the course of12months. Polyps less than1cm in size, are most likely to regress because they don’t have a centralfeeding blood vessel. Only observation should be done in asymptomatic postmenopausal womenwith small polyps because they are unlikely to be malignant. However, those with a familyhistory of endometrial cancer should consider polyp removal.Treatment of endometrial polypcomprises of natural regression, medical treatment and surgical treatment.Recurrence rate isbetween2and5percent for the polyp to recur and is likely to reoccur within the first year.Hysterectomy(complete removal of the uterus) is considered in women with completed familyand if polyps remain persistent and symptomatic.Materials and methods:We did a retrospective data analysis of the cases recruited from Department I of Gynecology ofFirst hospital of Jilin University. All these patients had undergone either diagnostic ortherapeutics hysteroscopy to access the cause of abnormal uterine bleeding,infertility, pelvicpain or asymptomatic women but have abnormal sonographic findings. Hysteroscopic removalof endometrial lesion was done which was then followed by curettage of endometrium to accessthe underlying endometrium. The diagnosis of endometrial polyp were confirmed pathologically.Criteria for inclusion:Patients from Department I of Gynecology were only included.The age ofthe patients was ranging from20-75years.Only admitted patients were included in ourstudy.Women who had underwent either diagnostic or therapeutics hysteroscopy wereincluded.Criteria for exclusion:Outpatient hysteroscopy was not included in our study.Patients from other gynecological departments were not collected.Patients with cancer or on anti-cancermedication were not included in our study.Women in whom resection of lesion was not possibleor no histological confirmation report available are excluded.A questionnaire was made including clinical characteristics with possible relationship to polypswere considered: age, weight, BMI, parity, gravidity, menstrual history, menopausal status,medical history(diabetes,HTN, thyroid disease, cancer, endometriosis, STDs, HPV infection,cervical infections, cervical polyp, history of infertility), surgical history (previous caesareansection or hysteroscopy or removal of polyp,), contraceptive history (use of IUD, oralcontraceptives or permanent contraception), use of anti cancer medicine or use of any health careproducts. Also the endoscopic results including size of polyp, locationand pathological outcomeswere reviewed using the computer database of hospital.Statistical analysis was evaluated by using Chi-Square test and ANOVA test wherever suitablewith significance of p<0.05.Results:The total number of women had undergone hysteroscopic surgery were568. Among them,total542histopathological reports were collected and analysed. Endometrial polyps were foundin240women (44.3%), endometrial hyperplasia in118women (21.8%), submucosalleiomyoma in26patients (4.8%), cevical polyp in10patients (1.8%) and38(7.01%) patientshad normal secretory or proliferative endometrium. Endometrial polyp were seen in associationwith endometrial hyperplasia, with cervical polyp and with adenomyoma. There was no patientswho was diagnosed as cancer as it was in exclusion criteria. The prevalence of endometrial polypis high (44.3%) in patients undergoing hysteroscopic surgery, the second being endometrialhyperplasia (21.8%). As the prevalence of endometrial polyp undergoing hysteroscopic surgeriesare more, our study is focused to access the factors associated with endometrial polyp.Also, wecan see the presence of endometrial polyp with endometrial hyperplasia and cervical polyp so wewant to know whether the presence of endometrial polyp is associated with the occurrence ofendometrial hyperplasia. In our study we included230patients with EP as case group and234control group who do nothave EP. Age of patients with EP ranges from25-73years with average age of43.38yrs;36.5%were less than40years of age at the time of diagnosis. Majority of women with EPs were among40-59years age group. EP were found to be more in women with low BMI i.e. BMI <25(62.6%),commonly seen in premenopausal age group and multiparous women with the incidence of79.1%and87.8%respectively. Half of the patients with EP had vaginal bleeding whereas halfof them were asymptomatic,diagnosed from physical examination. Hypertension was found in38women, only10women had diabetes. The total number of patients with EP with EH whichwas43. Among them,37(86%) had benign hyperplasia and the rest14%waspremalignant/malignant. We could not find out whether there is association of EH in patientswith EP but studies had shown association between number and weight of polyps and patientsage with AEH for premenopausal and post menopausal women.The mean age and BMI ofwomen in EP case group was43.38±10.186and23.88±3.68respectively. Whereas the mean ageand BMI of women in control group was found to be39.26±9.334and24.71±3.54respectively.As age and body mass could be the associated factors that can lead to other diseases that couldaffect our analysis result, first,we compare the means of age,BMI and presence of EP using theindependent sample t-test using SPSS which shows that age and BMI is not significantlyassociated with the presence of EP(P-value.665and.743respectively).Our analysis shows that hypertension(P=0.0050), parity(P=0.052), menopausal status(P=0.00246) and use of intrauterine device(P=0.0001) was significantly associated with presenceof endometrial polyp. Our study shows no association between diabetes, weight, past history ofuterine surgery,use of any health care products and endometrial thickness.Univariate analysis (1covariate at a time) revealed that age, menopause, past history of EP anduse of IUD are statistically significant in association with the presence of EP whereas HTN,diabetes, overweight and other factors lost their significance (p value>0.05). Whereas inmultivariate analysis adjusting for the confounding effects of age, menopause, overweight, HTN,diabetes,past surgery and use of IUD showed that only the past h/o EP and use of IUD issignificant on occurence of polyp with P-value of0.004and0.001respectively.Before performing a binary logistic analysis, a correlation matrix was built, which showedsignificant collinearity(-6) between age and menopausal status. As the prevalence of otherdisease as well as menopause increases with age, both age and menopausal status was excluded in binary logistic analysis.The use of IUD was strongly associated with EP (OR-2.552, P-value=0.009) and also HTN was associated with EP (P-value=0.045), All other independentvariables lost their significance.Conclusion:Use of IUD and hypertension was positively associated with the pathogenesis of EP, so oneshould consider the endometrial cavity in hypertensive patients and those who are using IUDwho presents with abnormal uterine bleeding. However, our study rejects the hypothesis thatobesity is the risk factor for endometrial polyp. In addition, histopathologic evaluation ofendometrium should be combined with polypectomy in patients with EP those who are at highrisk of malignancy, especially in elderly and menopausal women.