Re. The management of endometrial polyps in the 21st Century


Dear Sir

I am writing to express my concern regarding the article ‘The management of endometrial polyps in the 21st century’.[1]

Whilst I read this article last year, I have only now got round to reading the references I requested to check on the validity of the comments made.

My concerns centre around page 35 of the article where the merits of hysteroscopic resection of endometrial polyps is discussed. The article states that ‘malignant cells at the base of the polyp can be missed with blind avulsion’. Reading the reference article to this,[2] it is clear that this statement is misleading. The authors of the paper merely biopsied the polyps hysteroscopically before then pressing on with a formal resection of the lesion. Given that some of these polyps were quite large (up to 6 cm) it is hardly surprising that a hysterosopic biopsy did not always pick up the atypia. The article does not mention blind avulsion of the entire polyp.

The TOG article then goes on to state that ‘hysteroscopic resection avoids excessive cervical dilatation, which is when uterine perforation and creation of a false passage usually occur’. Again the reference paper to this,[3] does not support the statement made. Conversely, this rather old article comments on the complications of perforation and false passage associated with hysteroscopic resection. It does not entertain the idea of excessive cervical dilatation consequent upon blind avulsion techniques.

The TOG article then states ‘not a single recurrence of endometrial polyps was reported when resection under vision was compared with removal with a grasping forceps (recurrence rate 15%)’. The paper cited on this occiasion[4] reveals that the recurrence rate of 15% refers to just 20 out of 240 patients in the series, i.e. only three patients in the sub-group of 20 had recurrence of polyps and this did not reach statistical significance.

The reason I looked into this in some depth was that as a consultant of 25 years’ standing, I was surprised that working as I do with an elderly population that is relatively static, I have not experienced cases of malignancy in cases where polyps have been avulsed, cases of uterine damage from blind avulsion or significant numbers of women where polyps have recurred where one could be convinced that incomplete blind avulsion was the reason for them representing.

TOG articles need to be absolutely watertight in their recommendations as less experienced individuals will no doubt now be recommending hysteroscopic resection for polyps when there really is little evidence for this. I shall be interested to hear your views.