Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women

Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women Sangchai Preutthipan, M.D., and Yongyoth Herabutya, F.R.C.O.G. Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Mahidol University, Bangkok, Thailand Objective: To ascertain the therapeutic efficacy and safety of hysteroscopic polypectomy in 240 premenopausal and postmenopausal patients. Design: Retrospective study. Setting: Tertiary university hospital. Patient(s): Two hundred forty patients with intrauterine endometrial polyps, who mostly suffered from abnormal uterine bleeding and infertility. Intervention(s): Hysteroscopic polypectomy using various instruments including microscissors, grasping forceps, or electrosurgery either with a monopolar probe or a resectoscope. Main Outcome Measure(s): Operating time, amount of glycine absorption, complications, resumption of normal menstruation, cumulative pregnancy rate, and recurrent rate of polyps after hysteroscopic surgery. Result(s): Resectoscopic polypectomy needed more operating time, had more glycine absorption and complications, but less recurrence than other hysteroscopic techniques. The resectoscope had a 0% recurrence rate and that grasping forceps had a 15% recurrence rate. A total of 21 (8.7%) complications occurred, but no major complications were noted. After long-term follow-up of 9 years and 2 months, those with abnormal uterine bleeding resumed normal menstruation in 93.1% and those with infertility had a cumulative pregnancy rate of 42.3%. There was no statistical difference in reproductive outcome between patients having polyps 2.5 cm and 2.5 cm. Conclusion(s): We found hysteroscopic polypectomy to be effective, safe, minimally invasive procedure with low rate and mild complications. Restoration of reproductive ability did not depend on the size of the removed lesion. Resectoscopic surgery is more preferable to prevent recurrence of polyps. (Fertil Steril 2005;83:705 9. 2005 by American Society for Reproductive Medicine.) Key Words: Abnormal uterine bleeding, endometrial polyps, hysteroscopic polypectomy, infertility, premenopausal and postmenopausal Endometrial polyps are hyperplastic overgrowths of glands and stroma that are localized and form a projection above the uterine surface. They may be sessile or pedunculated and rarely include foci of neoplastic growth (1). Patients having these intrauterine lesions may be totally asymptomatic. When they become symptomatic, the most common cause is abnormal uterine bleeding. Endometrial polyps may be implicated as possible causes of infertility. Although the precise mechanism by which intrauterine polyps cause infertility is unclear, their removal has been reported to increase fertility (2). Simple curettage, which is a blind procedure, may not be considered as an effective method to treat endometrial polyps. Previous study reported that 10% of intrauterine lesions, mainly polyps, were missed during curettage (3). In contrast, hysterectomy is a major procedure at risk of morbidity and Received May 17, 2004; revised and accepted August 23, 2004. Reprint requests: Sangchai Preutthipan, M.D., Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 10400 (FAX: 662-2011416; E-mail: raspt@mahidol.ac.th). mortality for the treatment of these isolated benign lesions. Hysteroscopy now plays a major role in the rapidly changing therapeutic approach to both the diagnosis and treatment of intrauterine lesions. It allows the correct diagnosis to be made. The nature of the lesion and its precise localization can be determined. Hysteroscopic surgery reduces the need for major and unnecessary surgery. The purpose of our study was to determine the efficacy and reproductive benefits of hysteroscopic surgery using different means in the management of intrauterine endometrial polyps in 240 patients, most of whom suffered from abnormal uterine bleeding or infertility. MATERIALS AND METHODS This study was approved by the Departmental Ethics Committee. All participants were informed of the risks and benefits of hysteroscopic polypectomy and consents were obtained. From August 1994 to October 2002, 230 premenopausal and 60 postmenopausal women with the diagnosis of endo- 0015-0282/05/$30.00 Fertility and Sterility Vol. 83, No. 3, March 2005 doi:10.1016/j.fertnstert.2004.08.031 Copyright 2005 American Society for Reproductive Medicine, Published by Elsevier Inc. 705

metrial polyps, treated by hysteroscopy and confirmed histologically, were included in this study. Operative hysteroscopies were performed by the same operator (SP) during this period at Ramathibodi Hospital. Among the 290 patients, 160 patients were referred from infertility clinic after the infertility investigation with either hysterosalpingography (HSG) or transvaginal ultrasonography that revealed intrauterine polyps. Another 70 patients were from the general gynecological clinic and had abnormal uterine bleeding (AUB) or ultrasonography revealed endometrial polyps. Sixty more patients were from a menopause clinic and had had AUB and ultrasonography demonstrating endometrial polyps, or were asymptomatic patients who had had a routine ultrasonography before starting hormone replacement therapy, which revealed intrauterine polyps. Hysteroscopy was performed mostly in the proliferative phase of the menstrual cycle under general anesthesia using propofol as total intravenous anesthesia. Diagnostic hysteroscopy was performed with a standard rigid hysteroscope (Karl Storz GbmH & Co., Tuttlingen, Germany) with a 5.5-mm diagnostic sheath. Operative procedures were carried out either using an operative hysteroscope (Karl Storz) with a 7-mm. operative sheath or a resectoscope (Karl Storz) with an outer sheath of 9 mm in diameter. The technique of operative hysteroscopy has been described previously (4). Intrauterine polyps were removed hysteroscopically with various instruments such as microscissors, grasping forceps, or electrosurgery using either a monopolar probe or a resectoscope. For small or narrow stalk polyps, polypectomy was performed using either microscissors, grasping forceps, or a monopolar electrode through an operative hysteroscope. For those with broad base or large polyps, the polyps were resected by a resectoscope. Complete removal of intrauterine polyps was attempted in all patients. Polypectomy was continued until a normal panoramic view of the endometrial cavity was noted and both tubal ostia were visualized. Sterile 1.5% glycine solution was used for uterine distention and irrigation except in those with known liver diseases who would be at risk of ammonia intoxication. Fluid infusion was controlled by a Hamou Hysteromat (Karl Storz). To prevent excessive intravasation, fluid balance was recorded strictly by measuring the infused and drained fluid from the continuous flow hysteroscope, taking into account the fluid irrigated separately from the operative field into a collecting bag. Prophylactic doxycycline (100 mg twice a day) was given for 7 days to all patients. All patients return for follow-up with history taking and transvaginal ultrasonography at 2 weeks, 3 months, and every 6 months after surgery. Fifty patients with hysteroscopic polypectomies during the studying period were excluded from this study: 20 patients were lost to follow-up, and 30 patients failed to attend regularly. Outcome assessed includes duration of operation, amount of glycine absorption, and complications from using various instruments for hysteroscopic polypectomy, rate of resumption of normal menstruation, cumulative pregnancy rate, and recurrence of endometrial polyps after operation. The data was analyzed using the unpaired t-test or Mann- Whitney U-test, 2, or Fisher s exact test where appropriate. Kruskal-Wallis was used to test the mean difference of operating time and glycine absorption among the four different hysteroscopic techniques with multiple comparison using Bonferroni adjustment. P values.05 were considered statistically significant. RESULTS Two hundred forty cases of hysteroscopic polypectomies were reported in this study. Of the 240 patients, 190 were premenopausal and 50 were postmenopausal patients. Menstrual disorders and infertility were the prominent clinical symptoms in patients with intrauterine polyps. We found 155 of 240 (64.6%) patients suffered from AUB. The characteristic pictures of AUB in 155 patients included metrorrhagia (48 patients, 31.0%), hypermenorrhea (45 patients, 29.0%), intermenstrual bleeding (29 patients, 18.7%), menorrhagia (17 patients, 11.0%), and menometrorrhagia (16 patients, 10.3%). One hundred thirty of 190 (68.4%) premenopausal women also suffered from infertility. Table 1 shows the comparison of the premenopausal and postmenopausal patients; the mean age of the 190 patients in the premenopausal group was 33.8 6.5 years (range 24 49 years). Of the 190 premenopausal patients, 130 (68.4%) suffered from infertility, 145 (76.3%) had AUB. Fifty patients (26.3%) had had more than one dilatation and curettage from previous history. The mean diameter of the polyps was 3.4 0.9 cm (range 0.5 5.0 cm) and the number of the patients having a single polyp was 136 (71.6%). The pathological examination revealed endometrial hyperplasia without atypia in 4 (2.1%) patients. The mean age of the 50 postmenopausal patients was 53.8 6.2 years (range 40 70 years). Of the 50 postmenopausal patients, 10 (20.0%) patients had AUB, 5 (10.0%) patients have had more than one dilatation and curettage from previous history. The mean diameter of the polyps was 2.5 0.8 cm (range 0.5 4.0 cm) and the number of the patients having a single polyp was 42 (84.0%). The pathological examination revealed endometrial hyperplasia in 3 (6.0%) patients including one patient with atypia. Table 2 shows the comparison of hysteroscopic polypectomy using various instruments. Hysteroscopic polypectomies were performed with microscissors through the operative hysteroscope in 40 patients, with grasping forceps in 20 patients, with electrosurgery using a monopolar probe in 50 patients, and the remainder of the patients (130) mainly with resectoscope. The mean time used with microscissors, grasping forceps, electric probe, and resectoscope was 23.1 4.7, 20.9 3.9, 25.2 4.9, and 31.9 8.3 minutes, respectively. The mean amount of glycine absorption was 215.0 706 Preutthipan and Herabutya Outcome of hysteroscopic polypectomy Vol. 83, No. 3, March 2005

TABLE 1 Comparison of premenopausal and postmenopausal women. Premenopause Postmenopause P value No. of patients 190 50 Mean age (y) 33.8 6.5 (24 49) 53.8 6.2 (46 70).001 Size of the lesion (cm) 3.4 0.9 (0.5 5.0) 2.5 0.8 (0.5 4.0).001 Single polyp 136 (71.6) 42 (84.0).074 Abnormal bleeding 145 (76.3) 10 (20.0).001 Previous history of 1 D&C 50 (26.3) 5 (10.0).015 Postoperative pathological report of endometrial hyperplasia 4 (2.1) 3 (6.0) a.160 Note: Data are presented as mean SD (range) or number (%). One of three patients had atypia. 131.2, 265.0 122.6, 158.4 102.8, and 462.2 320.4 ml, respectively. There were complications in 21 (8.8%) patients: cervical tears in 14 (5.8%), uterine false track 5 (2.1%), uterine perforation 1 (0.4%), and fluid overload 1 (0.4%). The recurrence rate of polyps was 5 (2.1%). This occurred in 2 patients (5%) using microscissors, 3 patients (15%) using grasping forceps, 1 patient (2%) using electric probe, and none in patients using the resectoscope. Table 3 shows the reproductive outcomes according to the size of the polyps after the hysteroscopic polypectomy in 190 premenopausal patients. There were 55 patients with polyps 2.5 cm. The normal menstruation resumed in 44 (97.8%) patients. There was one (1.8%) recurrent polyp that required a repeated hysteroscopic polypectomy. After the follow-up of 9 years, 2 months we found the cumulative pregnancy rate to be 45.5%. There were 135 patients with polyps 2.5 cm. Ninety-one (91.0%) patients resumed normal menstruation, and 5 (3.7%) patients had recurrent polyps in which 3 patients needed a repeated hysteroscopic polypectomy and 2 patients underwent a hysterectomy. The cumulative pregnancy rate was 40.0%. There were no statistical difference between the two groups in reproductive outcomes after the hysteroscopic polypectomy. DISCUSSION Hysteroscopy provides a simple, safe, and effective mean of diagnosing intrauterine abnormality. Hysteroscopic surgery has become a common and important therapeutic procedure in patients with intrauterine lesions. Endometrial polyps are commonly found during diagnostic hysteroscopy (5 7). In this study we reported the reproductive outcomes of 240 patients who underwent hysteroscopic polypectomy. The mean age of all 240 patients was 37.6 years (range 24 70 years), with 33.8 years in the premenopausal group and 53.8 years in the postmenopausal group. The prominent clinical problems were AUB, which was found in 155 of 240 (64.6%) patients and infertility in 130 of 190 (68.4%) patients in the premenopausal group. Reslova et al. (8) reported that of the 245 patients having intrauterine polyps, 143 (58.4%) had AUB. In the premenopausal group 76 (81.2%) and in the postmenopausal group 67 (44.1%) patients had AUB. The most common AUB found in premenopausal patients was hypermenorrhea (38.7%), metrorrhagia (18.3 %), and intermenstrual bleeding (11.8%). In contrast to our study we found metrorrhagia the most common (31.0%) and subsequently, hypermenorrhea (29.0%) and intermenstrual bleeding (18.7%). The prevalence of AUB in premenopausal and postmenopausal group was 76.3% and 20.0%, respectively. Comparing 190 premenopausal and 50 postmenopausal patients, the mean diameter of the polyps in the first group was significantly larger than in the second group (3.4 vs. 2.5 cm, P.001) but a single polyp was found more often in the second group than in the first group (84.0% vs. 71.6%), although there was no statistical difference. The most common problems in the premenopausal group were AUB (76.3%) and infertility (68.4%), whereas in the postmenopausal group only 20.0% had AUB and the remainder had the provisional diagnosis of intrauterine polyps from the ultrasound findings. It is a practice here in the menopause clinic that before putting any patient on hormonal replacement therapy, all patients need to have ultrasound scanning of the reproductive organs. If intrauterine lesions are detected the diagnosis is confirmed by hysteroscopic examination and those lesions including polyps are removed hysteroscopically. At the present time, hysteroscopy is considered the gold standard for the investigation of any intrauterine lesion. Hysteroscopy permits panoramic visualization of the uterine cavity and direct biopsy of lesions, thus increasing precision and accuracy in the diagnosis of intrauterine conditions in contrast to dilatation and curettage, which is a blind technique. Simple curettage may not be considered as an effective method to treat endometrial polyps. Abnormal uterine bleeding caused by endometrial polyps frequently fails to respond to simple curettage. Fertility and Sterility 707

TABLE 3 TABLE 2 Comparison of hysteroscopic polypectomy in 240 patients using various instrumentations. P value Microscissors Grasping forceps Electric probe Resectoscope No. of patients 40 20 50 130 Operating time (min) 23.1 4.7 (12 30) 20.9 3.9 (11 25) 25.2 4.9 (14 30) 31.9 8.3 (10 45) a.05 Glycine absorption (ml) 215.0 131.2 (0 450) 265.0 122.6 (0 450) 158.4 102.8 (0 300) 462.2 320.4 (0 1500) a.05 Complications 3 (7.5) 1 (5.0) 3 (6.0) 14 (10.8).377 Cervical tears 2 1 2 9 Uterine false track 1 1 3 Uterine perforation 1 Fluid overload 1 Recurrence of polyps 2 (5) 3 (15) 1 (2) (0) Note: Data are presented as mean SD (range) or number (%). a Statistically significant difference from mico-scisssors, grasping forceps, and electric probe group. Reproductive outcome of hysteroscopic polypectomy in 190 premenopausal patients comparing between polyps 2.5 cm and >2.5 cm. Size of the polyps 2.5 cm >2.5 cm P value No. of patients 55 135 Cumulative 25 (45.5) 30 (40.0).534 pregnancy rate Resumption of 44 (97.8) 91 (91.0).174 normal mense Recurrence of 1(1.8) 5 (3.7).674 polyps Hysterectomy 0 2 (1.5) Note: Data are presented as number (%). Word et al. (3) demonstrated that 10.0% of intrauterine lesions remained in situ after curettage. They found 47 missed benign lesions including 38 endometrial polyps in 512 uteri immediately after curettage. In our study, 50 (26.3%) patients in the premenopausal group and 5 (10.0%) patients in the postmenopausal group had a previous history of curettage more than once (Table 1). The AUB from the polyps still persisted after the curettage, which failed to remove them. Hysteroscopic surgery has become increasingly common, essential, and popular in the field of gynecology. It is effective and safe to treat submucous myomas, endometrial polyps, and other lesions such as septate uterus and intrauterine synechiae. In case of intrauterine polyps, hysteroscopy can be used to distinguish clearly between submucous myoma and endometrial polyp, which is not always possible by other means such as ultrasonography (9, 10) or HSG (11). Hysteroscopic polypectomy is a minimal invasive operation and it allows the complete removal of the polyps under direct visual control, which prevents the recurrence in situ of these lesions. The type of instruments used depends on the operators experience and also on the location and size of the lesion. In our experience, we removed large and sessile polyps with a resectoscope, smaller or pedunculated polyps with either microscissors or grasping forceps or an electric probe operated through an operative hysteroscope. On many occasions, we use these different instruments for demonstration and training of the rotating fellows of reproductive medicine. In this study, the resectoscope was used in 130 (54.2%), electric probe in 50 (20.8%), microsissors in 40 (16.7%), and grasping forceps in 20 (8.3%) patients. 708 Preutthipan and Herabutya Outcome of hysteroscopic polypectomy Vol. 83, No. 3, March 2005

Comparing the different instruments used for polypectomy, the resectoscopic polypectomy took a significantly longer time to complete the operation and had more glycine absorption compared to other instruments such as electric probe, microsissors, and grasping forceps operated through a smaller size of operative hysteroscope (P.05). These were due to the bigger size of the polyps in a resectoscopic group and the difficulty of introducing the larger diameter of a resectoscope through a narrow cervix as well as a more difficult procedure when operating with a resectoscope. We found that there were more complications in the resectoscopic group than in the other groups of instruments used. They occurred in 14 (10.8%) patients. Most of the complications were minor such as cervical tears in 9, uterine false track in 3, and uterine perforation in only 1 patient (Table 2). All of these complications were related to the difficult entry of a resectoscope through a narrow cervix and the difficult cervical dilatation with the Hegar 9-10 (Dimeda Instruments GmbH, Tuttlingen, Germany) to accommodate the large resectoscope as compared to dilate with the Hegar 7 for the other instruments. Interestingly there was no recurrence of polyps when the resectoscope was used; the gasping forceps had the most recurrence rate of 15.0%. In our experience, we believe that the resectoscope can remove the polyps completely without any remnant. We suggest that the resectoscope is a more preferable instrument to prevent the recurrence of the intrauterine polyps. The cumulative pregnancy rate in this study after hysteroscopic polypectomy of 42.1% was less than in other studies with a follow-up pregnancy rate ranging from 50% to 78% (2, 12). We have shown that hysteroscopic removal of intrauterine polyps was safe and effective to control AUB with a low rate of recurrence. Patients resumed normal menses in 93.1% after hysteroscopic surgery; this result was similar to those reported by other investigators (13, 14). A total of 21 (8.7%) complications occurred but no major complications were noted. The most common complication was a cervical tear, occurring in 14 of 240 (5.8%) patients, which did not require suturing. Our data show that the recurrence of polyps after hysteroscopic surgery occurred in 6 (3.2%) patients, which needed a repeated hysteroscopic removal in 4 (1.7%) and subsequent hysterectomy in 2 (0.8%) patients. Orvieto et al. (15) reported that of 146 postmenopausal women with endometrial polyps, 15 (10.3%) had endometrial hyperplasia, 4 with atypia. In the present study, we found that postmenopausal women with endometrial polyps tended to have more endometrial hyperplasia including atypia (6.0%) than premenopausal women with endometrial polyps (2.1%), but no difference in the prevelence of endometrial hyperplasia was observed between the two groups. When we compared the reproductive outcome after hysteroscopic polypectomy according to the size of the polyps, the cumulative pregnancy rate and the resumption of menstruation were not significantly different. The recurrence rate of polyps occurred more often in the group with polyps 2.5 cm, but it was not statistically significant (Table 3). We concluded that the reproductive benefit after hysteroscopic surgery does not depend on the size of the intrauterine lesion. In conclusion, our study shows that hysteroscopic polypectomy is a safe and effective procedure and benefits patients suffering from AUB and infertility. No major complications were associated with the procedure. 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