Today, a patient came to me for review. She had undergone hysteroscopic removal of endometrial polyps 3 months ago, but the ultrasound showed that she still had endometrial polyps. She asked me in distress: Why did the polyp recur so soon? Was the polyp not removed cleanly? What is the next treatment? Definition of endometrial polyp An endometrial polyp (EP) is a localized overgrowth of endometrial tissue that forms a tunicate or non-tunicate redundant organism, consisting of a small amount of dense fibrous connective tissue composed of mesenchyme, thick-walled blood vessels, and endometrial glands. It may be solitary or multiple. It is one of the most common endometrial lesions in women, and its clinical manifestations mainly include abnormal uterine bleeding and infertility. Incidence and recurrence rate The prevalence of endometrial polyps ranges from 7.8% to 34.9%. The incidence of endometrial polyps is about 3% in women under 35 years of age, 23% in women over 35 years of age, and 31% in postmenopausal women, with a peak incidence at 50 years of age and rarely occurring after 70 years of age. Studies have shown that the malignant rate of endometrial polyps tends to increase with age, and the malignant rate can be as high as 10% after menopause. The postoperative recurrence rate is 6.2% to 29%. The time of recurrence after surgery ranges from a few days to several years. Short-term recurrence is from a few days to 1 month, and late recurrence is from a few months to a few years after surgery. Various forms of endometrial polyps Causes of endometrial polyps: 1. Inflammation. 2. Hormonal disorders: excessive local estrogen synthesis or high local estrogen receptor expression and low progesterone receptor expression. 3, cell proliferation / apoptosis imbalance theory: proliferation / apoptosis related genes Ki-67, Bcl-2/Bax, p63 expression imbalance. 4. Imbalance of cytokines: EGF, IGF, VEGF and TGF, etc. act on the endometrium through autocrine or paracrine mechanisms, and the abnormal expression of growth factors and their interactions may be involved in the occurrence of endometrial polyps. Genetic factors: endometrial polyp cells have multiple chromosomal structure and number of abnormalities. 6, drug factors: such as taking mifepristone and tamoxifen, the incidence of endometrial polyps is 2-3 times higher than those who do not take drugs. Diagnosis Transvaginal ultrasonography (TVUS): fast, convenient, non-invasive and economical. Diagnostic curettage: inaccurate. Sonography of the uterus (SHG): mostly used as a complementary method to ultrasonography. Hysteroscopy combined with pathology examination: not only can it observe the uterine cavity comprehensively, but also can remove the lesions under direct vision, which is the gold standard for endometrial polyp diagnosis. Endometrial Polyp Treatment Guidelines (AAGL) Small asymptomatic polyps can be treated conservatively (Grade A) Drug therapy is not recommended at this time (Grade B) Hysteroscopic resection is the gold standard (Grade B) There is no significant difference in the clinical prognosis between different hysteroscopic polypectomies (Grade C) Removal of polyps contributes to a greater chance of natural or assisted reproduction (Grade A) Population Treated 1. Symptomatic abnormal uterine bleeding 2. Infertile patients Incidence accounts for 2.8% to 34.9%. Endometrial polyps may affect embryo implantation, change the environment of the uterine cavity to reduce endothelial tolerance, polyp bleeding leading to endothelial inflammation and receptor abnormalities. In addition, endogenous glycoproteins, can block the fertilization process. If endometrial polyps combined with pregnancy, it may lead to meconium dysplasia, causing abnormal embryonic development and miscarriage. Studies have shown that removal of polyps in infertile patients improves fertility, increasing pregnancy rates by 43% to 80%, and increasing pregnancy rates from 28% to 63% with artificial insemination. Treatment of endometrial polyps 1, drug therapy: LNG-IUS, progesterone, COC. limited role, can be used as a means of treatment to prevent recurrence after hysteroscopy. 2.Surgical modalities: scraping; hysteroscopic clipping or removal; hysteroscopic resection. Hysteroscopic polypectomy is considered to be the first choice or the gold standard for polyp treatment because it is performed under direct vision to avoid damage to the normal lining. Reasons for polyp recurrence There are two scenarios. Endometrial polyp excision did not reach the basal layer, polyp excision did not “remove the root cause”, the polyp grows in situ after the operation, which is called polyp recurrence; there is no polyp in the area at the time of the operation, and the polyp found after the operation is called polyp recurrence. 1, hormone replacement therapy, childlessness or infrequent births, late menopause, prolonged anovulation and endometrial hyperplasia are associated with polyp recurrence. Multiple polyps have a higher rate of recurrence after surgery than solitary polyps. 2, polyp removal is not complete. The endometrium consists of the functional layer (dense layer, spongy layer) and the basal layer. The functional layer is naturally shed during each menstrual cycle, so it is only transient, and it is the basal layer that determines the retention and growth of the functional layer. It is the basal layer that determines the retention and growth of the functional layer. If the “root” of the polyp is in the basal layer, it will be difficult to remove it cleanly. Pathologic features of endometrial polyps Endometrial polyps are restricted growths of the basal layer. Endometrial polyps consist of endometrial glands, thick-walled blood vessels, and a small amount of dense fibrous connective tissue. Pathologic types: functional polyps (originating from mature endometrium), non-functional polyps (originating from immature endometrium), adenomyomatous polyps, postmenopausal polyps (also known as atrophic polyps). Treatment Principles 1. For those who do not want to have children, the polyp can be completely removed. 2. 2, for those who require pregnancy, appropriate resection, the purpose is to restore the shape of the uterine cavity. 3, endometrial polyps after surgery recurrence rate is high, we should pay attention to follow-up treatment, oral, vaginal progesterone and Mannix uterine placement can inhibit the growth of polyps. 4, oral progesterone or uterine placement of Mannuelle should be carried out as soon as possible. Oral progesterone is ineffective, not Mannuelle is ineffective. 5.If you are anxious to get pregnant, review the hysteroscopy 3 months after placing the IUD, if there is no sign of recurrence and the tubes are clear, you can take the IUD to try to get pregnant. 6, with recurrence or / and other infertility factors continue to retain Mannuelle. Finally, we came back to the previous patient, 40 years old, gave birth to 2 children, no fertility requirements, hysteroscopic surgery pathology report suggests: endometrial polyps. So I recommended her to go on Mannix.