Epidemiology & Risk Factors

Hyperplastic growth of endometrial glands & stroma around a central vascular core.
Peak incidence: 40–50 years of age (perimenopausal/postmenopausal).
Tamoxifen therapy (selective estrogen receptor modulator with partial agonist activity on endometrium; high-yield USMLE association).
Hyperestrogenic states: Obesity, exogenous estrogen therapy/HRT, early menarche/late menopause, anovulatory cycles.
HTN, Lynch syndrome, Cowden syndrome.

Clinical Features

Abnormal Uterine Bleeding (AUB-P): Most common presenting symptom.
- Premenopausal: Intermenstrual bleeding (spotting), heavy menstrual bleeding (menorrhagia). c
- Postmenopausal: Postmenopausal bleeding (requires mandatory workup to rule out malignancy).
Infertility: Primary or secondary (mechanical interference with embryo implantation).
Asymptomatic: Incidental finding on routine pelvic imaging.

Initial Test: Transvaginal Ultrasound (TVUS).
- Findings: Focal hyperechoic endometrial lesion with smooth borders; vascular pedicle visible on Doppler ultrasound.
Best Test / Confirmatory: Saline Infusion Sonohysterography (SIS) or Hysteroscopy.
- SIS: Highly sensitive; saline distends the uterine cavity to delineate focal intracavitary lesions from diffuse endometrial thickening.
- Hysteroscopy: Gold standard for direct visualization + simultaneous diagnostic biopsy/resection.
Histopathology: Confirms diagnosis (benign polyp vs endometrial hyperplasia/carcinoma).

Submucosal Leiomyoma (Fibroid): Differs by hypoechoic origin from the myometrium on TVUS/SIS; presents more frequently with severe heavy menstrual bleeding rather than intermenstrual spotting.
Endometrial Hyperplasia / Endometrial Carcinoma: Differs by diffuse endometrial thickening (>4 mm in postmenopausal women) and histological cytological atypia or malignant invasion.
Endometrial Adhesions (Asherman Syndrome): Differs by history of aggressive uterine curettage or infection; shows hyperechoic intra-uterine synechiae on SIS, presents with amenorrhea/hypomenorrhea.

Symptomatic (AUB / Infertility): Polypectomy via hysteroscopy (first-line; diagnostic & therapeutic).
Asymptomatic + High Risk: Hysteroscopic polypectomy.
- Indications: Postmenopausal state, Tamoxifen use, polyp size >1.5–2 cm, or multiple polyps.
Asymptomatic + Premenopausal + Low Risk: Conservative management with observation (high rate of spontaneous regression for small polyps <1.5 cm).

Malignant Transformation: Risk ~1–5% (significantly higher in postmenopausal patients and Tamoxifen users).
Infertility / Recurrent pregnancy loss.
Iron deficiency anemia secondary to chronic AUB.

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