Clinical manifestations and suspected pathology
Patients may present with complaints of pronounced menstrual cycle disorders. Characteristic clinical manifestations include metrorrhagia (acyclic uterine bleeding) as well as contact spotting. Regardless of the size of the suspected formation, the presence of such symptoms requires the mandatory exclusion of pathological processes in the mucous membrane of the uterine cavity and cervical canal.
To verify the diagnosis, a separate diagnostic study is performed. A primary filling defect of the uterine cavity is often detected during standard ultrasound examination or metrography, after which clarifying differential diagnosis between an endometrial polyp and a submucosal myoma is required.
The role of hydrosongraphy (HSG) in diagnosis
Hydrosongraphy (HSG) is a specialized ultrasound imaging method that is critically important for a detailed assessment of the state of the uterine cavity. The main clinical value of HSG lies in the ability to reliably differentiate between an endometrial polyp and a submucosal myoma node.
During hydrosongraphy, the physician addresses several diagnostic tasks simultaneously:
- Evaluation of characteristics: the clearest possible determination of the true dimensions of the identified intrauterine formation.
- Topographic anatomy: precise localization of the pathological focus relative to key anatomical landmarks, such as the isthmus of the uterus and the ostia of the fallopian tubes.
- Evaluation of the uterine cavity: determination of the degree of deformation of the uterine cavity by the growing formation.
On echograms during HSG, one can clearly visualize the type of node (e.g., type I submucosal node) and the degree of distortion of the cavity contours.
Technical parameters of ultrasound scanning
Three-dimensional ultrasound imaging (3D US) is actively used to detect intrauterine pathology. Image quality directly depends on the device settings. Examples of standard technical parameters during gynecological scanning (preset GYN) using a RAB 2-5L transducer include the following data:
- Scan depth: varies within 7.1–8.0 cm depending on the size of the organ.
- Frame rate: maintained at a high level (68–78 Hz) to ensure image smoothness.
- Safety indices: the mechanical index (MI) is usually 0.9–1.0, and the soft tissue thermal index (Tls) is maintained at a safe level of 0.2.
- Reconstruction settings: high-quality modes are used (e.g., Qual high2, Th20, B56, V55, Mix 1000), as well as the image freeze function (Freeze) for detailed study of the echogram and placement of user markers (e.g., cubmukoz to designate submucosal location).
Hysteroscopy: visual criteria and fluid test
Hysteroscopy possesses the highest accuracy in diagnosing even small intrauterine formations. This endoscopic method is absolutely essential for elucidating the true nature of the filling defect discovered on ultrasound.
A key technique for the differential diagnosis of an endometrial polyp and a submucosal myoma during hysteroscopy is changing the rate of fluid delivery into the uterine cavity. With fluctuations in intrauterine pressure and fluid flow, submucosal myoma nodes do not change their shape and size, whereas polyps demonstrate different biomechanics.
To rule out a myoma, the physician evaluates the endoscopic picture. A myoma node, unlike a polyp, is characterized by:
- Spherical shape and clear contours.
- Whitish surface color.
- Presence of pinpoint or extensive hemorrhages.
- Visualization of a network of stretched, dilated blood vessels covered by a thinned layer of endometrium.
- Pronounced deformation of the uterine cavity.
When a formation is detected, its size, exact localization, width of the base, and the size of the intramural component are evaluated.
Limitations of endoscopy and related methods
The informativeness of hysteroscopy has its limits. The method is indicated for patients with menstrual cycle disorders provided that the size of the uterus does not exceed 12–13 weeks of gestation. If the uterus is enlarged beyond this period, the diagnostic value of hysteroscopy is significantly reduced.
In complex clinical cases, when differential diagnosis with pelvic tumors, retroperitoneal tumors, or enlarged lymph nodes is required, computed tomography (CT) and magnetic resonance imaging (MRI) are used in addition to ultrasound. They allow for the evaluation of giant formations and the planning of surgical access. To perform myomectomy using a transcervical approach, it is critically important to know the location of the interstitial part of the formation and the proximity of its lateral pole to the serosa of the uterus.
Briefly: answers to topical questions
What clinical symptoms are characteristic of endometrial polyps?
The clinical presentation of endometrial polyps may be asymptomatic. Asymptomatic presentation is observed in 10% of menstruating patients and 40% of postmenopausal patients. Main symptoms:
- Uterine bleeding — more often acyclic bleeding (metrorrhagia), less frequently menorrhagia.
- Pain syndrome — cramping lower abdominal pain, characteristic of large endometrial polyps.
- Infertility — most often primary, resulting from anovulation.
What histological types of endometrial polyps are distinguished in modern classification?
Depending on morphological features and the patient's age, the following typical forms of endometrial polyps are distinguished:
- Glandular polyps — more common in the reproductive period; may occur against the background of endometrial hyperplasia or normal mucosa.
- Glandular-fibrous polyps — more common in pre- and perimenopause.
- Fibrous-glandular polyps — characteristic of postmenopause.
- Fibrous polyps — characteristic of postmenopause and occur against the background of atrophic mucosa.
- Adenomatous polyps — characterized by intense proliferation of glands and their epithelium, relatively high mitotic activity, and atypia of glandular cells; they are classified as precancerous conditions.
What risk factors and pathogenetic mechanisms lead to the formation of endometrial polyps?
Endometrial polyps can develop with normal hormonal ratios, but hyperplastic processes of the endometrium, including polyps, are also associated with hyperestrogenism. Key factors and mechanisms include:
- Hormonal imbalance — relative or absolute predominance of estrogens over progesterone.
- Infectious-inflammatory changes — infection or signs of chronic inflammation are detected in 95.3% of patients with glandular-fibrous polyps.
- Tissue reception disorders.
- Immune disorders.
- Imbalance between cell proliferation and apoptosis — cellular resistance to apoptosis leads to the accumulation of altered and excessively proliferating cells, which can lead to neoplastic changes.
What does the surgical treatment of endometrial polyps consist of?
The main method of treatment for endometrial polyps is targeted polypectomy. Radical removal involves excision of the polyp together with the basal layer of the endometrium at the site of stalk localization; it is possible only under hysteroscopic control using mechanical endoscopic, electrosurgical, or laser instruments.
- Electrosurgical excision is recommended for fibrous, sessile, and recurrent polyps.
- Hysteroresectoscopy is recommended for recurrent polyps to control complete removal of the base and coagulation of the polyp base.
- In perimenopause, hysteroscopic polypectomy should advisably be combined with endometrial ablation.
To remember how lesions behave during hysteroscopy: Myoma is Monolithic (does not change shape when fluid is supplied), while a polyp is pliable.
Class and exam questions
How to reliably distinguish an endometrial polyp from a myoma on ultrasound?
Standard ultrasound can only reveal a filling defect. For precise differential diagnosis, saline infusion sonography (SIS) is used, allowing a detailed assessment of the lesion's structure and the degree of uterine cavity deformation.
Which test during hysteroscopy helps rule out a submucosal node?
The physician alters the rate of fluid delivery into the uterine cavity. Submucosal myomas, unlike polyps, have a dense structure and do not change their shape and dimensions with variations in fluid pressure.
At what uterine dimensions is hysteroscopy most informative?
The method exhibits high accuracy when uterine size does not exceed 12–13 weeks of gestation. With greater organ enlargement, the diagnostic value of the examination decreases.
Which symptoms require the mandatory exclusion of endometrial pathology?
The onset of metrorrhagia (acyclic uterine bleeding) and contact spotting. In such cases, fractional diagnostic curettage of the mucosa is indicated.
What else to study on this topic
- Technique of saline infusion sonography (SIS) and assessment of the topographic anatomy of the uterine cavity.
- Endoscopic presentation of various types of submucosal myomas.
- Criteria for selecting a transcervical surgical approach in intrauterine pathologies.
- The role of CT and MRI in the differential diagnosis of pelvic masses.
- Interstitial myomas with centripetal growth: visualization features during hysteroscopy.
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