Uterine Polyps: Causes, Symptoms, and Bleeding Red Flags

• Uterine (endometrial) polyps are usually benign overgrowths of the womb lining; in premenopausal women fewer than 1% contain cancer cells.
• The most common symptom is abnormal bleeding — heavy periods, bleeding between periods, after sex, or after menopause — but at least half of polyps cause no symptoms at all.
• Risk rises with age (peaking around perimenopause), obesity, high blood pressure, diabetes, tamoxifen use, and oestrogen-only hormone therapy.
• ANY vaginal bleeding after menopause must be evaluated promptly — about 5–10% of such cases turn out to be endometrial cancer, and postmenopausal polyps carry a higher cancer risk (roughly 3–5%).
• Diagnosis uses transvaginal ultrasound, saline sonography, and hysteroscopy; symptomatic and postmenopausal polyps are usually removed by hysteroscopic polypectomy, a same-day procedure.
• Removing polyps can improve fertility, and modern hysteroscopic removal does not damage the uterus or harm future pregnancy.

Uterine polyps — formally called endometrial polyps — are growths of the endometrium, the tissue that lines the inside of the uterus. They project into the uterine cavity and are made of endometrial glands, supportive stroma, and their own blood supply. A polyp may hang from a thin stalk (pedunculated) or sit on a broad base (sessile). They can be single or multiple, and range from a few millimetres to several centimetres across. Most are benign overgrowths of normal lining tissue; only a small minority contain abnormal (atypical) or cancerous cells.

Why they form is not fully understood. Current thinking is that polyps grow from small patches of endometrium that respond too strongly to the hormone oestrogen, while the normal process of cell death (apoptosis) is reduced — so glandular and stromal tissue keeps accumulating. Polyp tissue often carries genetic and hormone-receptor differences from the surrounding lining, which lets it grow somewhat independently.

Polyps are not the same as uterine fibroids. Fibroids grow from the muscular wall of the uterus (the myometrium), while polyps grow from the inner lining. The two can coexist, and on ultrasound a polyp can sometimes be hard to tell apart from a submucosal fibroid that bulges into the cavity, or from adenomyosis and lining thickening — distinctions that matter because treatment differs.

Polyps can occur at any age but are most common between 40 and 50, with prevalence rising through the perimenopausal years. They are less common — but not rare — in younger and in postmenopausal women. The same polyp means different things at different ages: a small, silent polyp in a 30-year-old carries very different implications from the same polyp in a 65-year-old, both for cancer risk and for how it is managed.

• Heavier menstrual bleeding (menorrhagia) or longer periods
• Bleeding or spotting between periods (intermenstrual bleeding)
• Bleeding after sex (postcoital bleeding)
• Any vaginal bleeding after menopause — even a single spot
• Often, no symptoms at all (found incidentally on ultrasound)

Several factors raise the chance of developing uterine polyps. Age is the most consistent: prevalence climbs through the 30s and 40s, peaks around perimenopause, then declines somewhat after menopause. The erratic, sometimes high oestrogen of the perimenopausal years drives this.

Obesity is a well-established risk factor. Body-fat tissue makes oestrogen by converting androgens through the aromatase enzyme, so women carrying more body fat have higher circulating oestrogen. This 'unopposed' oestrogen promotes lining overgrowth, including polyps — the same mechanism that links Obesity and Pregnancy: Risks, Care, and Healthy Outcomes to endometrial hyperplasia and cancer. The effect is dose-related: higher BMI, higher risk.

High blood pressure and diabetes are each independently associated with polyps, probably through shared pathways of insulin resistance and inflammation. Together — as part of the metabolic syndrome — these three conditions appear to substantially raise polyp risk.

Tamoxifen, used in breast cancer treatment, has the paradoxical effect of acting against breast tissue but stimulating the endometrium. Women on tamoxifen have markedly higher rates of polyps, hyperplasia, and endometrial cancer, and need endometrial monitoring. Similarly, oestrogen-only hormone replacement therapy in a woman who still has her uterus increases endometrial pathology — which is why progesterone is added for women with a uterus.

Other possible contributors — chronic lining inflammation, prior endometrial procedures, and certain genetic factors — are less firmly established. Interestingly, smoking is linked to lower polyp risk, probably through anti-oestrogenic tobacco compounds; this is in no way a reason to smoke, given tobacco's overwhelming harms.

Evaluation usually starts with a transvaginal ultrasound, the most accessible first test in Indian practice. Polyps show up as bright (echogenic) areas within the cavity, sometimes with a feeding vessel on Doppler. The endometrial thickness also matters, especially after menopause — a lining thicker than about 4–5 mm in a postmenopausal woman needs further evaluation whether or not a discrete polyp is seen.

Saline infusion sonography (SIS), or sonohysterography, improves the view by gently filling the uterus with sterile saline during the scan, separating the walls and outlining anything inside. It is more sensitive than a standard scan for spotting polyps and is widely available at gynaecology centres; cost in private settings is roughly ₹1,500–₹4,000.

Hysteroscopy is the gold standard for both diagnosing and treating polyps. Office hysteroscopy with a slim scope lets the doctor see the cavity directly, often without general anaesthesia. Operative hysteroscopy in theatre allows diagnosis and removal in one go and is the standard treatment. Diagnostic-to-operative hysteroscopy costs roughly ₹15,000–₹50,000 depending on facility and complexity.

Endometrial biopsy — sampling lining tissue, usually with a pipelle in the clinic — is essential whenever cancer is a concern, particularly for postmenopausal bleeding. The sample's histopathology confirms a polyp and rules out hyperplasia or carcinoma. The procedure costs about ₹500–₹2,000, plus a similar amount for histopathology.

MRI is reserved for complex cases — for example when a polyp and a submucosal fibroid cannot be separated on ultrasound — and is not routine, costing roughly ₹5,000–₹15,000 for a pelvic scan.

Postmenopausal bleeding — any vaginal bleeding more than 12 months after your last period — is in a different category entirely. FOGSI Good Clinical Practice Recommendations and international guidelines (NICE, ACOG, RCOG) are unanimous: it requires prompt evaluation to rule out endometrial cancer. About 5–10% of postmenopausal bleeding is due to endometrial carcinoma, and the proportion rises with age. A polyp causing postmenopausal bleeding is, until proven otherwise, a polyp that could harbour cancer.

The workup starts with history, examination, and transvaginal ultrasound. A lining of 4 mm or less has a high negative predictive value for cancer; but if bleeding persists despite a thin lining, further evaluation may still be needed. A thicker lining, a focal lesion such as a polyp, or persistent bleeding regardless of thickness all warrant endometrial sampling.

That sampling — by pipelle biopsy, or by hysteroscopy with curettage — is what definitively distinguishes normal or atrophic lining (common after menopause) from a polyp, hyperplasia, or carcinoma, and directs treatment. Polyps in postmenopausal women carry a higher chance of containing atypical or cancerous cells — roughly 3–5%, versus under 1% in premenopausal polyps — which is why complete removal and histopathology matter more in this group.

Families sometimes assume bleeding after menopause is 'just hormones' or a harmless polyp and wait. This is dangerous. Caught early, endometrial cancer has excellent outcomes — five-year survival above 90% for early-stage disease — but delay worsens the prognosis substantially. Any postmenopausal bleeding, however brief or light, deserves a prompt visit to a gynaecologist.

The standard treatment for symptomatic polyps and for any polyp after menopause is hysteroscopic polypectomy — removing the polyp through a hysteroscope passed via the cervix. It is minimally invasive, done under general anaesthesia or sedation, usually as a day-care procedure with same-day discharge. The whole polyp, including its base, is removed and sent for histopathology.

Techniques include cold-loop dissection, bipolar or monopolar resection, or mechanical morcellation, chosen by polyp size, location, and equipment. Modern instruments allow precise removal while preserving the surrounding lining and future fertility. Recovery is quick — most women return to normal activity in 1–3 days and to work within a week. A few days of light spotting afterwards is common; heavier bleeding is unusual.

When watchful waiting is reasonable: for a small, symptom-free polyp in a premenopausal woman under 40 with no fertility concern, observation can be appropriate, as some small polyps regress on their own. The decision should be made with your gynaecologist, with a repeat ultrasound at 6–12 months. Polyps that persist, grow, become symptomatic, or develop worrying features should be removed.

After menopause, removal is generally advised regardless of symptoms because of the higher cancer risk — the threshold for intervention is lower, and the benefit of removal plus histopathology usually outweighs the small surgical risk.

For women with infertility or recurrent pregnancy loss, polypectomy is recommended even when symptom-free, because it improves conception rates; Indian fertility centres routinely include it in the workup when a polyp is found. Polypectomy is curative for the individual polyp, but new polyps form in about 10–15% of women over the following years — so continue routine gynaecological care and report any new abnormal bleeding.

Polyp diagnosis and treatment is widely available across India. An initial transvaginal ultrasound is available at virtually all radiology centres and gynaecology clinics (about ₹500–₹2,500 privately, free or subsidised in government facilities). Saline sonography runs about ₹1,500–₹4,000. Hysteroscopy is offered at hospitals with theatre facilities — gynaecology departments at multispecialty hospitals and dedicated fertility centres.

Hysteroscopic polypectomy in private practice costs roughly ₹25,000–₹75,000, covering pre-operative assessment, surgery, anaesthesia, day-care stay, and histopathology, with tertiary corporate centres at the higher end. Government hospitals provide it at far lower cost, and the Pradhan Mantri Jan Arogya Yojana (PMJAY) covers many gynaecological procedures including hysteroscopy. Private health insurance generally covers it when medically indicated.

FOGSI Good Clinical Practice Recommendations specifically require prompt workup of postmenopausal bleeding — ultrasound, endometrial sampling, and histopathology — before any therapeutic procedure on the uterus, aligning with NICE, ACOG, and RCOG. For reproductive-age women, FOGSI guidance places polyps within the standard PALM-COEIN framework for abnormal uterine bleeding (Polyps, Adenomyosis, Leiomyoma, Malignancy/hyperplasia; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified).

For confirmed endometrial cancer, specialist gynaecological-oncology care is concentrated at tertiary centres such as Tata Memorial Centre (Mumbai), Kidwai Memorial Institute (Bengaluru), Adyar Cancer Institute (Chennai), AIIMS Delhi, PGIMER Chandigarh, and the regional cancer centres. Referral pathways are well established at academic centres but more variable in private practice — women with confirmed atypical hyperplasia or carcinoma should ensure referral to a trained gynaecological oncologist for definitive management.

• ANY vaginal bleeding after menopause — even a single light spot — needs prompt evaluation to rule out cancer.
• Bleeding or spotting between periods, or periods that have become noticeably heavier or longer.
• Bleeding after sex.
• Difficulty conceiving or recurrent early pregnancy loss, especially if a polyp has been seen on a scan.
• A polyp already found on ultrasound that is growing, becoming symptomatic, or causing concern.
• Heavy bleeding leaving you tired, breathless, or pale — possible signs of iron-deficiency anaemia that needs treating alongside the polyp.

• ACOG — Abnormal Uterine Bleeding (FAQ and Practice Guidance)
• NICE NG12 — Suspected cancer: recognition and referral (postmenopausal bleeding)
• RCOG / BSGE Green-top Guideline — Management of Endometrial Polyps
• Munro MG et al. — FIGO PALM-COEIN classification of abnormal uterine bleeding
• NHS — Womb (uterus) polyps
• Federation of Obstetric and Gynaecological Societies of India (FOGSI) — Good Clinical Practice Recommendations