Uterus
Epithelial tumors
Endometrial polyp

Author: Monira Haque, M.D.
Senior author: Wadad S. Mneimneh, M.D.
Editor-in-Chief Review: Debra Zynger, M.D.

Revised: 1 October 2018, last major update July 2018

Copyright: (c) 2002-2018, PathologyOutlines.com, Inc.

PubMed Search: Endometrial polyp [title]

Cite this page: Haque, M. Endometrial polyp. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/uterusendopolyp.html. Accessed October 16th, 2018.
Definition / general
  • Hyperplastic overgrowth of endometrial glands and stroma that form a localized projection from the surface of the endometrium
  • Polypoid / pedunculated mass composed of cystically dilated glands with fibrous stroma containing thick walled blood vessels
  • May be related to hyperestrogenism, possibly originating as a localized hyperplasia of the endometrial basalis secondary to hormonal influences
Essential features
  • Polypoid shape, attenuated surface endometrium on 3 sides
  • Large, thick walled blood vessels
  • Fibrous stroma with spindled fibroblast-like cells, sometimes hyalinized
  • Glandular architectural abnormality different from the surrounding endometrium, with cystic change, sometimes glandular crowding
Epidemiology
  • Can affect up to 25% of females presenting with abnormal uterine bleeding (Case Rep Obstet Gynecol 2014;2014:518398)
  • Prevalence in asymptomatic females: 10 - 15%
  • Peak incidence: 5th decade
  • Incidence in asymptomatic females with infertility: 10 - 32%
  • Increased incidence with hormone replacement therapy, either estrogen-only or combined preparations (Am J Obstet Gynecol 2011;205:535.e1)
Sites
  • Can arise anywhere in the uterine cavity including lower uterine segment
  • Most common in the posterior wall of the uterine cavity, followed by anterior, lateral and uterotubal junction (Fertil Steril 2008;90:180)
  • Can be multiple
Etiology
  • Thought to represent a hyperplastic response of normal endometrial tissue possibly originating as a localized hyperplasia of the endometrial basalis secondary to unopposed estrogen
  • Monoclonal stromal overgrowth with secondary induction of polyclonal benign glands
  • Overexpression of endometrial aromatase suggests a role of this enzyme in the pathogenesis
  • Associated with tamoxifen therapy (Am J Obstet Gynecol 2011;205:535.e1)
  • Late menopause, hormone replacement therapy and obesity increase the risk (Maturitas 2005;50:231)
  • In postmenopausal females, the presence of metabolic syndrome is a predictor (Menopause 2016;23:759)
Clinical features
  • Small polyps are usually asymptomatic
  • Larger polys are associated with abnormal vaginal bleeding and occasionally infertility
  • Rarely, giant polyps may fill the uterine cavity and extend into the endocervical canal
  • Generally unresponsive to progesterone stimulation
  • Polyps associated with tamoxifen therapy for breast cancer are characteristically multiple, large and fibrotic (J Cases Obstet Gynecol 2017;4:55)
  • Most polyps persist if left untreated; however, a small percentage may spontaneously regress (Best Pract Res Clin Obstet Gynaecol 2017;40:89)
Diagnosis
  • Transvaginal pelvic ultrasonography
  • Saline infusion sonohysterography
  • Hysteroscopy
  • Confirmation by histopathology of the resected specimen
Prognostic factors
Case reports
Treatment
  • Premenopausal: polypectomy for symptomatic polyps, multiple polyps, polyps > 1.5 cm, prolapsed polyps or those associated with infertility
  • Postmenopausal: polypectomy or hysterectomy (J Cases Obstet Gynecol 2017;4:55)
  • Hysteroscopic removal or morcellation (Gynecol Obstet Fertil 2015;43:104)
  • Excision is curative if circumscribed foci of endometrial hyperplasia in polyp with no background hyperplasia
Gross description
Gross images

Images hosted on PathOut server:

Contributed by Monira Haque, M.D.

Endometrial polyp



Images hosted on other servers:

Fundic polyp expands uterine cavity

Polyp fills the uterine cavity

Partially cystic polyp

Small fundic polyp

Large endometrial polyp

Microscopic (histologic) description
  • Polypoid fragments of endometrial tissue lined by epithelium on 3 sides

  • Surface epithelium:
    • May be atrophic but often is proliferative even in postmenopausal women
    • Papillary proliferations with fibrovascular cores occasionally occur on the surface of an endometrial polyp or within cystically dilated glands
    • May exhibit a degree of atypia, often with degenerated appearing nuclei and sometimes hobnail cell change
    • Reactive surface changes, including breakdown (shedding) and hemorrhage, can be seen

  • Stroma:
    • Fibrous stroma, rich in collagen with abundant extracellular connective tissue
    • Can contain variable amount of edema, occasional myxoid change and hemosiderin pigment laden macrophages
    • Collections of thick walled blood vessels are common; ectatic thin walled vessels may be seen
    • Bundles of smooth muscle within the stroma may be present, often close to thick walled blood vessels
    • Foci of decidua (usually reflecting exogenous progestin use or pregnancy) may be present
    • Mitotic figures in the stromal cells may be present
    • Rarely sex cord-like areas have been described (Int J Gynecol Pathol 2006;25:170)

  • Glands:
    • Glandular architecture out of phase with the background endometrium
    • Angulated, tubular or cystically dilated
    • Usually endometrioid in type: inactive, proliferative or functional
    • May exhibit metaplastic changes, including ciliated, eosinophilic, mucinous and squamous metaplasia
    • Proliferative activity in a polyp in a postmenopausal woman is of no clinical importance (it is useful to comment on if present in the nonpolypoid endometrium)
    • Polyps originating at the junction of the upper endocervix, lower uterine segment contain both endocervical and ciliated lower uterine segment type glands
    • Useful diagnostic finding, if present, is the parallel arrangement of the long axis of the endometrial glands to the surface epithelium; this feature is helpful especially in premenopausal women (Am J Surg Pathol 2004;28:1057)

  • Tamoxifen associated endometrial polyps:
  • Extensively necrotic polyps can be seen secondary to torsion or if polyps outgrow their blood supply; vascular thrombosis and surface atypia may be seen in such cases

  • Variants:
    • Endometrial polyp with atypical stromal cells: stromal cells with markedly atypical symplastic-like nuclei resembling those seen elsewhere in the female genital tract, such as in fibroepithelial stromal polyps of the vulva and vagina (Int J Surg Pathol 2016;24:320, Am J Surg Pathol 2002;26:505)
      • Mitotic figures are absent (useful feature to differentiate from adenosarcoma)
      • Immunohistochemically, the atypical cells express vimentin, estrogen, progesterone and androgen receptors and may express desmin, CD10 and muscle specific actin (Am J Surg Pathol 2002;26:505)
    • Atrophic: usually seen in postmenopausal women; low columnar to cuboidal epithelial lining, cystic dilatation of the glands and fibrotic stroma
    • Functional: if secretory features present, these are underdeveloped features compared to the background endometrium
    • Myomatous: abundant smooth muscle in the stroma (versus adenomyoma: see differential diagnosis) (Int J Gynecol Pathol 2000;19:195)
    • Mixed polyps or polyp of mixed endometrial endocervical type

  • Other rare findings include: tuberculosis (Case Rep Obstet Gynecol 2013;2013:176124), placental site trophoblastic tumor (Eur J Gynaecol Oncol 2014;35:87), primary diffuse large B cell lymphoma (Int J Gynecol Pathol 2005;24:347), sarcoidosis (Int J Surg Pathol 2017;25:246) and metastases of various carcinomas developing in endometrial polys (Malays J Pathol 2008;30:125, APMIS 2008;116:538, Int J Gynecol Pathol 2009;28:343)

  • Must be carefully examined for foci of endometrial hyperplasia and carcinoma:
    • Diagnosis of simple hyperplasia should not be made in a polyp since proliferative activity with glandular dilatation is a feature
    • Complex atypical hyperplasia:
      • Diagnostic features similar to those in nonpolypoid endometrium
      • Should be specified in the diagnosis if these are confined to the polyp (may not require additional therapy)
      • However, in women with complex hyperplasia in polyps, complex hyperplasia and carcinoma in background surrounding endometrium is not uncommon (it is useful to comment on if present in the nonpolypoid endometrium) (Int J Gynecol Pathol 2008;27:45, BJOG 2007;114:944)
    • Endometrial carcinoma:
      • Most commonly serous and endometrioid
      • Carcinomas found in polyps (tamoxifen related and unrelated) may be confined to the polyp or be part of a multifocal endometrial hyperplasia
      • Stains may be helpful to diagnose serous carcinoma
Microscopic (histologic) images

Images hosted on PathOut server:

Contributed by Monira Haque, M.D.

Atrophic epithelium

Cystically dilated glands

Marked stromal hyalinization


Stroma

Stromal edema and myxoid changes

Irregular dilated glands and thickened blood vessels

Thick walled blood vessels

Highly thickened vessels with fewer glands

Variably cellular stroma and stromal hemorrhage


Glands lined by normal proliferative type endometrium

Cystically dilated glands

Focus of squamous metaplasia

Markedly dilated glands

Glandular architectural disarray

High grade serous carcinoma



Papillary serous carcinoma

Endometrioid adenocarcinoma

Contributed by Yuri Tachibana, M.D.

Polyp with pedicle

Positive stains
Negative stains
Molecular / cytogenetics description
Differential diagnosis
  • Adenofibroma:
    • Much less common
    • Papillary fronds with cleft-like architecture of adenofibroma
    • Stroma of endomyometrial polyp tends to be more hyaline than that of adenofibroma
  • Adenomyoma:
    • Typically not polypoid
    • Contains prominent stromal smooth muscle
    • Distinction is somewhat arbitrary, based on the amount of smooth muscle present
  • Adenosarcoma:
    • Usually bulky polypoid mass
    • Leaf-like or club-like architecture, broad papillae lined by surface epithelium and intraglandular stromal projections, with overall architecture resembling a phyllodes tumor of the breast
    • Typically no cystically dilated glands or thick walled blood vessels
    • Stroma is more cellular with increased mitotic activity and a degree of nuclear atypia, especially immediately surrounding the glands
    • With multiple recurrent endometrial polyps, adenosarcoma should be suspected since the morphological features may be subtle
  • Atypical polypoid adenomyoma:
    • Stroma exhibits more extensive smooth muscle differentiation
    • More complex glandular architecture
    • Often shows extensive squamous morular formation
  • Endocervical polyp:
    • Dilated glands are endocervical (mucus) in type
    • Stroma is edematous, inflamed and usually fibrotic
    • Polyps originating at the junction of the upper endocervix and lower uterine segment contain both endocervical and ciliated lower uterine segment type glands (the term "polyp of mixed endometrial endocervical type" may be used in such cases)
  • Endometrial hyperplasia:
    • Usually not polypoid
    • Usually a diffuse process, involving the entire endometrium
    • May be confused with hyperplasia arising in an endometrial polyp; will see background endometrial hyperplasia and lack of thick walled vessels
  • Endometrial stromal tumor:
    • Uniform oval small cells, enveloped by reticulin fibers
    • Small vessels characteristically encircled by reticulin fibers
    • Does not have the dilated glands or thick walled blood vessels
  • Endometritis:
    • Typical morphological features of polyp such as polypoid shape and thick walled vessels are absent
  • Leiomyoma (intracavitary / submucosal):
    • Smooth muscle with fascicular growth pattern
    • Dilated glands and thick walled vessels are not seen
    • On hysteroscopy, generally white and firm, with surface blood vessels
  • Lower uterine segment endometrium:
    • Polypoid shape and thick walled blood vessels are typically not present
  • Secretory endometrium:
    • Secretory endometrium corresponds to a cyclical endometrium, secretory in type, which will be seen in the background endometrium
Board review question #1
Which chromosomal abnormality is likely to be associated with the histologic findings from endometrial biopsy of a 35 year old woman with abnormal uterine bleeding?



  1. 1p aberrations
  2. 6p21 aberrations
  3. 9q34 aberrations
  4. Loss of 7q
Board review answer #1
B. 6p21 aberrations. The histology is consistent with endometrial polyp. The most common cytologic abnormality associated with endometrial polyps are aberrations of chromosome 6p21. Aberrations of chromosome 1p, 9q34 and loss of 7q are associated with uterine leiomyoma.
Board review question #2
Tamoxifen related endometrial polyps are frequently associated with which of the following?

  1. Epithelial and stromal metaplasia
  2. Hypercellular stroma
  3. Malignant transformation in up to 10%
  4. Unique cytogenetic profile
Board review answer #2
A. Epithelial and stromal metaplasia. Tamoxifen related endometrial polyps are generally larger, sessile with bizarre stellate shapes and frequent epithelial and stromal metaplasia. They may show stromal fibrosis and periglandular stromal condensation. Malignant transformation can be seen in up to 3%. Interestingly, their cytogenetic profile is similar to noniatrogenic lesions.