Endometrial Polyp in a Postmenopausal Woman with Comorbidities: A Diagnostic and Therapeutic Challenge

We present the case of a 90-year-old patient with a history of arterial hypertension who consulted for postmenopausal uterine bleeding. Ultrasonographic diagnostic evaluation revealed the presence of two endometrial polyps. Clinical findings, laboratory results, and therapeutic management are discussed, emphasizing the importance of timely evaluation of postmenopausal bleeding and the consideration of associated comorbidities.

Abnormal uterine bleeding after menopause is a clinical manifestation that requires immediate attention, as it may indicate various conditions, ranging from benign to malignant pathologies. 
Different global guidelines recommend measuring endometrial thickness through transvaginal ultrasound (TVUS) as the first step in the evaluation of postmenopausal bleeding [1]. In clinical practice, 100% sensitivity is sought. The most used cut-off values of 4- and 5-mm show 95% and 90% sensitivity, respectively. A 3 mm cut-off value achieved 98% sensitivity [1].
In postmenopausal women with increased endometrial thickness, with or without abnormal uterine bleeding, performing a hysteroscopy allows for an accurate diagnosis of benign endometrial pathologies, as well as targeted biopsies in lesions suspected of malignancy [2]. Endometrial cancer presents in 90% of cases with abnormal uterine bleeding; however, only 10-15% of women with postmenopausal bleeding have endometrial carcinoma [2].
Endometrial polyps are a common cause of abnormal uterine bleeding in postmenopausal women. These are focal intrauterine neoplasms of the endometrium, which can appear as single or multiple lesions. Their size varies from a few millimeters to several centimeters, and their morphology can be sessile (with a broad implantation base) or pedunculated [3]. Transvaginal ultrasound (TVUS) has been reported to have a sensitivity of 51% and a specificity of 95% for the diagnosis of endometrial polyps [14].
The known risk factors for the development of endometrial polyps include advanced age, hypertension, obesity, and tamoxifen use, among others. Although they may be asymptomatic, endometrial polyps often manifest clinically as abnormal uterine bleeding, including postmenopausal bleeding, and, to a lesser extent, infertility [4]. This requires a thorough diagnostic evaluation.
Performing hysteroscopy allows for immediate visual diagnosis with the possibility of treatment during the same procedure "see and treat" [2].
Additionally, hysteroscopy enables the evaluation of endometrial polyp anatomy, including surface irregularity and the presence of blood vessels. Hysteroscopic characteristics can contribute to the diagnosis of malignancy [12]. The resection of endometrial polyps is recommended in postmenopausal women, especially if they are accompanied by symptoms [2].
Extensive cohort studies have reported that the malignant transformation of endometrial polyps, although rare, ranges between 0% and 12.9%, being more common in postmenopausal women [5]. The de-novo incidence of endometrial polyps during menopause is still unclear [6]. Despite hysteroscopy, performing a histological study is mandatory when any lesion is present in patients with postmenopausal bleeding [2].

A 90-year-old patient, gravida 6 para 6, in menopause for more than 30 years. Medical history of arterial hypertension controlled with telmisartan 40 mg, spironolactone 25 mg, and cardiac arrhythmia treated with digoxin 0.25 mg and bisoprolol 2.5 mg daily. Relevant history includes a cerebrovascular accident 10 years ago, for which she was on treatment with apixaban 2.5 mg, later replaced by subcutaneous enoxaparin sodium 40 mg. She also has a generalized anxiety disorder treated with escitalopram 10 mg and quetiapine 25 mg daily. She denies diabetes mellitus, the use of hormone replacement therapy, or any personal oncological history.
She is seen at medical office due to episodes of scant vaginal bleeding, bright red in color, without clots and without associated pain during the last six months. She denies any urinary or gastrointestinal symptoms.
Vital signs were within normal ranges, the abdomen was soft and non-tender, and the pelvic examination showed no significant findings except for scant bleeding in the vaginal canal. 
Laboratory results, including a complete blood count, hormonal profile, and lipid profile, were within acceptable parameters. Cervical cytology was unremarkable. Transvaginal ultrasound revealed an echogenic and centrally located endometrium with a thickness of 4.1 cm, hydrometra, and two hypoechoic, non-vascularized images measuring 8.8 and 8.5 mm, respectively, with no vascularity on color Doppler, suggesting endometrial polyps.
Due to the transvaginal bleeding, a diagnostic hysteroscopy under sedation was performed, confirming the presence of a pedunculated endometrial polyp approximately 2 x 1.5 cm, which was resected with cold scissor cutting without complications. Histopathological analysis confirmed the benign nature of the polyp, with no atypia or malignancy, and the result was classified as an atrophic-type endometrial polyp.

Figure 1:Hysteroscopic appearance of a polypoidlesion on the posterior wall with an atrophic cystic appearance and the presence of arborized vascularization.

Figure 2: Hysteroscopic appearance of atrophic endometrium and the presence of endometrial polyps with irregular surfaces

Figure 3:Resection of endometrial polyps with cold cutting.

Postmenopausal bleeding is a symptom that should always be thoroughly investigated due to the risk of malignant pathologies. In this case, the patient presented with risk factors such as advanced age and arterial hypertension, which have been associated with a higher incidence of endometrial polyps and potentially endometrial hyperplasia or carcinoma.
Transvaginal ultrasound is a useful tool in the initial evaluation of postmenopausal bleeding, allowing for the identification of endometrial abnormalities. Hysteroscopy, complemented by targeted biopsy, is essential for definitive diagnosis and treatment of focal lesions.
Hysteroscopy is considered the gold standard for evaluating the uterine cavity. It allows direct visualization of intracavitary lesions and the performance of targeted biopsies, improving diagnostic accuracy. Due to the high risk of malignancy, hysteroscopy with histopathological analysis of the sample is mandatory in all symptomatic postmenopausal women [7]. The use of blind uterine curettage or endometrial biopsies should be avoided due to the reported lack of precision in diagnosing endometrial polyps [8]. Hysteroscopy with the use of bipolar energy is widely available at a low cost. Direct visualization and removal of polyps has been shown to be effective in reducing the risk of recurrence associated with the use of mechanical instruments (grasper or scissors) [9].
The risk of malignancy in endometrial polyps in women with abnormal uterine bleeding or postmenopausal bleeding is not related to the size of the lesions [10]. However, the presence of abnormal uterine bleeding is significantly associated with an increased risk of atypical hyperplasia or carcinoma in postmenopausal women (4.15–5.14% versus 1.89–2.30%) [11].
In the study by Shor et al., the usefulness of hysteroscopic findings in diagnosing malignant and premalignant polyps was evaluated in a cohort of 556 women undergoing operative hysteroscopy with polypectomy. The main findings showed that abnormal vascularity and the presence of three or more polyps were the most significantly associated findings with malignancy or premalignant pathology [12].
Increased vascularization of the polyp had a specificity of 94.3% and a negative predictive value of 97.1%, suggesting that its’ absence is a strong indicator of benignity. However, both the sensitivity and positive predictive value of abnormal vascularization and the presence of multiple polyps were low, meaning that although these findings may suggest malignancy, their presence alone is not sufficient for diagnostic confirmation without a histopathological study [12].
The presence of known comorbidities that expose women to a higher risk of endometrial cancer, such as hypertension, obesity, diabetes mellitus, and tamoxifen use, should be considered when recommending polypectomy. Class II and III studies have found a significantly higher risk in patients with obesity, polycystic ovary syndrome, polyps larger than 2.2 cm, and the presence of multiple polyps [13]. Therefore, endometrial polyps, even in asymptomatic postmenopausal women, should be removed if they present a diameter greater than 2 cm or if the patient has known risk factors for endometrial carcinoma.
This case highlights the importance of a thorough evaluation of postmenopausal bleeding, considering the patient’s comorbidities. The combination of transvaginal ultrasound and hysteroscopy with targeted biopsy is essential for an accurate diagnosis and proper management. An endometrial thickness of 3 mm is suggested as an appropriate cutoff point to rule out malignancy, achieving high sensitivity during postmenopause [1].
Ngo et al. analyzed the hysteroscopic characteristics that allow differentiation between malignant and benign endometrial polyps, highlighting three main findings of malignancy: hypervascularization, ulcerations, and irregular surfaces. These findings showed a sensitivity of 96% and a specificity of 93.5% [14].
We define hypervascularity as the presence of tortuous and deformed vascular structures, with blind ends and abnormal branching on the surface of the polyp. In histopathological findings, 72% of malignant polyps presented this characteristic compared to 2.6% of benign polyps [14]. Ulcerations were characterized by focal areas with a yellowish coating, indicating inflammatory processes or tumor necrosis. This pattern was found in 64% of malignant polyps and 0% of benign ones, indicating a specificity of 100% [14]. Malignant polyps exhibited irregular surface projections compared to benign polyps, which are smooth and pedunculated. 24% of malignant polyps showed these surface irregularities compared to 3.9% of benign polyps [14].
Overall, identifying these hysteroscopic patterns should guide targeted biopsies and treatment planning due to the increased risk of malignancy in polyps presenting these features [14].
In the retrospective study by Elyashiv et al., which included 1,766 women who underwent hysteroscopic polypectomy, 43 cases (2.4%) of premalignant and malignant lesions were identified, of which 34 patients (79%) underwent hysterectomy. Among these, 88.9% had residual disease in the endometrium, and 55.6% had multifocal residual pathology. This confirms that the disease was not localized solely in the polyp. Therefore, if a histopathological result of atypical hyperplasia or endometrioid carcinoma is obtained from a hysteroscopic polypectomy, it cannot replace hysterectomy due to the strong association with the presence of multifocal residual uterine pathology in a non-polypoid endometrium [15].
Various studies have evaluated the relationship between the size of endometrial polyps and their risk of malignancy in postmenopausal women. In a multicenter retrospective study conducted by Ferrazi et al., where 1,152 asymptomatic women and 770 women with abnormal uterine bleeding who underwent hysteroscopic polypectomy were analyzed. The findings indicated that polyp size is a predictive factor for malignancy in asymptomatic women, with a cutoff of ≥18 mm associated with a 6.9 times higher risk of abnormal pathology (atypical hyperplasia or cancer) compared to smaller polyps. However, if accompanied by abnormal uterine bleeding, polyp size had a lower impact, with bleeding being a stronger clinical marker. The prevalence of endometrial cancer in these patients was ten times higher when postmenopausal bleeding was present. This reinforces the need for diagnostic hysteroscopy in asymptomatic women and supports the recommendation to evaluate and treat women with postmenopausal bleeding regardless of polyp size [16].

The identification and proper management of endometrial polyps in postmenopausal women are essential due to the low but present risk of malignancy. The role of hysteroscopy in diagnosing premalignant and malignant endometrial polyps, as well as identifying the optimal hysteroscopic technique for polypectomy, remains under investigation, although this technique has proven useful.