Observation Of Hysteroscopic Transcervical Resection Of Polyp Combined With Levonorgestrel Releasing Intrauterine System In The Treatment Of Recurrent Endometrial Polyps

Endometrial polyp(EP) is a kind of excessive hyperplasia of local endometrium tissues affected by some factors, resulted in a single or multiple neoplasm, EP with smooth surface is mostly oval-shaped or finger-protruding, pale red and variable in sizes. Most of EP have pedile that joined to the uterine wall, and few sessile polyps have no pedile but a wide pars basilaris. EP is the common cause of abnormal uterine bleeding and infertility in the susceptible age of 29-59 years. The morbidity of EP is about 25.0%, which has a increasing trend in recent years. The incidences of canceration in the patients of reproductive age and the post-menopause are 4.18% and 10.10% respectively. The clinical effect of hemostatic and misappropriate hormone in the treatment of vaginal bleeding in EP is poor. What’s more, long-term uterine abnormal bleeding can lead to severe anemia, which troubles the physical and mental health of the patient and the family.The purpose of treatments aims to remove the polyps and disabuse the symptoms in EP, thereby reduce the recurrence of endometrial polyps. At present, the domestic and international treatment methods of EP are as follows:(1) Operation:including the curettage and the hysteroscopic transcervical resection of polyp (TRCP), they are singnificantly effective, but poor in avoiding recurrence. According to the research, which said some polyps, especially at the bottom or angular of the uterus are not easy to be clean, leading to the high residual rate and recurrence rate, sightless curettage is rare now. With the advance of medical technology, endometrial polyps curettage performed by hysteroscopy and TCRP had been the common treatment methods in clinic. Hysteroscology originated from the 1970s. In 1990, Professor Xia Enlan in Beijing Fuxing Hospital took the lead in launching the hysteroscopic resection. Hysteroscopic diagnosis technology had gradually become mature in 1980-1990, and it would be the time of minimally invasive surgical technology in gynaecology. Through the hysteroscopy, we can identify the location and the size of EP visually, and take the biopsy immediately without injuring the normal endometrium, which cannot be done by other audio technology and curettages, that’s why the hysteroscopy is the golden standard of diagnosis and treatment of uterine cavity lesions. Endometrial polyps curettage performed by hysteroscopy, which ascertain the position of polyps with hysteroscopy then curettage pointedly. It’s quick and easy, but the tissues are fractured which is not good for the pathological examination. What’s more, the rate of relapse will increase as it’s not easy to remove the root of polyps in the basal layer of the endometrium. TCRP has a wide clinical application, which can locate accurately, prompt hemostasis timely with electric coagulation hemostasis. result in less bleeding and perforation of the uterus. In addition, postoperative patients recover quickly, have lower complication rate and reserved organ and reproductive function. And TCRP can resect the base of polyps, thereby reducing the recurrence rate significantly. Cravello L reported that TCRP success rate in the treatment of endometrial polyps was about 80%, which can be called "the gold standard" in the treatment of endometrial polyps.(2) Total hysterectomy, which is obviously effective for those who recured, was not symptomatic improved and even suspected malignance. Some of the patient that taken total hysterectomy finally found that there was only local polyps instead of other pathological changes, Total hysterectomy can influence the patients’ sexual life and diminished the quality of life as that the blood supply would be cut down because of the operation, leading to premature ovarian failure and disruption of pelvic floor structure.(3) Combining transcervical resection of polyp performed by hysterectomy and oral drugs, like norethindrone, ethinyloestraldiol, medroxyprogesterone and marvelon, to treat the EP. It’s said that, progesterone may have a important role in the prevention of endometrial pre-cancerous. Whether oral progesterone can help in prevention of EP afer TCRP is inconchlusive, because patients need long-term treatment and have poor compliance of oral progesterone. Wang Jian and Deng Haiyang Reported that TCRP combined with levonorgestrel releasing intrauterine system(LNG-IUS, marvelon) for 3 months could improve nearly 6% menstrual disorders, and reduce the recurrence rate to 5%.The recurrence of polyps is the difficulty and key point of treatment. Most scholars thought it’s closely related to high estrogen level, and it also has correlation with the inflammatory diseases, endocrine disorders. Estrogen induced endometrial growth while progesterone can inhibit the high levels of estrogen and promote proliferation phase endometrium transform to secretion phase, the periodic withdrawal of endometrium, which can help inhibit the recurrence of EP.Levonorgestrel intrauterine device (IUD, mirena, Levonorgestrel-releasing intrauterine system, LNG-IUS). LNG-IUS is a T type intrauterine device containing progesterone, which release 20ug/d dose LNG implanted in the uterine cavity, acting on the endometrium directly. The concentration of LNG in the endometrial tissue is 1000 times higher than the Peripheral Blood, It’s not only used as a contraceptive, but also can be used for shortening menstrual period, reducing the menstrual blood loss and relieving dysmenorrhea symptoms to some extent.According to the foreign study, we found that LNG IUS can preventthe formation of EP caused by taking tamoxifence(TAM) in patients with breast cancer, which illustrated that the use of progesterone may have the effect in preventing recurrence of EP. Both in China and abroad, the reports about whether intrauterine Mirena combined with TCRP can reduce the recurrence rate of EP in patients without taking tamoxifence is rare.In summary, the TCRP surgery is the preferred method of treatment of EP in recent years, but it’s still likely to relapse after surgery. The conclusion whether oral progesterone can prevent recurrence of EP was controversial. There are few reports about whether Mirena can reduce the recurrence rate of polyps in the domestic and overseas so far. This study aims to retrospectively analyze the 92 cases of patients who had taken TCRP operation, and investigate and evaluate the effect of LNG-IUS compared with oral progesterone in preventing the recurrence of patients with EP after hysteroscopy.1 Contents and methodsTo explore the effect of levonorgestrel-releasing intrauterine system (LNG-IUS) or Medroxyprogesterone combined with hysteroscopic transcervical resection of polyp (TCRP) in preventing the recurrence of endometrial polyps. A total of 92 patients with endometrial polyps received TCRP treatment in our Hospitall from 2011 January to 2014 June. According to the different ways of the TCRP postoperative treatment divided into three groups.30 cases without special treatment were in control group,32 cases treated with Medroxyprogesterone for 3-6 months were in Medroxyprogesterone group and 30 cases inserted LNG-IUS into uterine cavity 3-5 days after surgery were in LN-IUS group. All the 92 patients were followed up for 6-24 months postoperatively to inquire about the recurrence of endometrial polyps and bleeding symptoms. Datas were analyzed by chi-square test and to explore the diagnostic value of hysteroscopy in endometrial polyps.2 Results92 cases of endometrial polyp all successfully completed the one-time hysteroscopic surgery, the success rate was 100%. The coincidence rate in ultrasonography and pathological diagnosis of endometrial polyps was 53.2%, but in hysteroscopy and pathologicaldiagnosis was 96.6%.56 patients were diagnosed as multiple endometrial polyps, and the other 32 patients were diagnosed as single endometrial polyp. The abnormal uterine bleeding symptoms were improved, but there was no significant difference between the groups (P>0.05). The recurrence rate and dysmenorrhea improved rate of endometrial polyps in LNG-IUS group is lower than the control group and Medroxoyprogesterne group (P<0.05). No significant difference existed in the recurrent rate and dysmenorrhea improved rate between the control group and Medroxoyprogesterne group (P>0.05).3 Conclusions1. Hysteroscopy is valueable for the clinical diagnosis. The effect of hysteroscopy and pathological diagnosis of endometrial polyps is similar. TCRP is a safe, reliable and effective method to cure endometrial polyps.2. The TCRP postoperative with Medroxoyprogesterne can not reduce the recurrence rate and LNG-IUS can decrease the recurrence rate of endometrial polyps.