{"paper_id":"3a282df6-600e-4d4f-b531-b75f8afe9f86","body_text":"Review began\n 01/10/2021 \nReview ended\n 01/18/2021 \nPublished\n 01/19/2021\n© Copyright \n2021\nNair et al. This is an open access article\ndistributed under the terms of the\nCreative Commons Attribution License\nCC-BY 4.0., which permits unrestricted\nuse, distribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nGiant Endometrial Polyp in a Postmenopausal\nWoman\nVivek Nair \n \n, \nJitendra S. Nigam \n \n, \nJyotsna N. Bharti \n \n, \nBiswajit Dey \n \n, \nAshok Singh \n1.\n Pathology, Vikash Multispeciality Hospital, Sambalpur, IND \n2.\n Pathology/Lab Medicine, All India Institute of\nMedical Sciences, Patna, IND \n3.\n Pathology, All India Institute of Medical Sciences, Jodhpur, IND \n4.\n Pathology, North\nEastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, IND \n5.\n Pathology, All India Institute\nof Medical Sciences, Rishikesh, IND\nCorresponding author: \nVivek Nair, \ndrviveknair2001@gmail.com\nAbstract\nEndometrial polyps are the benign localized overgrowth of endometrial tissue composed of a variable\namount of gland, fibroblast-like spindle cells stroma, and thick-walled blood vessels. They develop as a\nresult of unbalanced estrogens and progestin. Polyps greater than 4 cm are considered giant polyps. We\nreport a case of giant endometrial polyp in a postmenopausal woman who presented with postmenopausal\nbleeding without any history of hormone or drug intake. However, the possible cause may be the age and use\nof phytoestrogens in the daily routine diet for a long time.\nCategories:\n Obstetrics/Gynecology, Pathology\nKeywords:\n phytoestrogens, estrogens, progesterone, aging\nIntroduction\nEndometrial polyps (EPs) are the benign localized overgrowth of endometrial tissue protruding into the\nuterine cavity, affecting approximately 25% of women \n[1,2]\n. EP comprises a variable amount of gland,\nfibroblast-like spindle cells stroma, thick-walled blood vessels, and are lined by pseudostratified active or\nflat inactive epithelium \n[1,2]\n. The pathogenesis of EP is not well known; however, they are believed to\ndevelop due to unbalanced estrogens and progestin \n[1,2]\n. Phytoestrogens (PEs), a mimic of estrogen, are\nproduced by plants and found abundantly in spices, herbs, and food \n[1]\n. Long-term consumption of PEs can\nact like estrogen, causing an unbalance between estrogen and progestin, leading to uterine pathologies such\nas endometrial hyperplasia or EP \n[1]\n. The use of tamoxifen and raloxifene is associated with an increased\nfrequency of giant EPs \n[1]\n. EPs are usually less than 2 cm, and polyps greater than 4 cm are considered giant\npolyps \n[3]\n. We report the case of a giant EP in a postmenopausal woman who presented with\npostmenopausal bleeding without any history of hormone or drug intake.\nCase Presentation\nA 67-year-old female, P4L4, presented in the gynecology outpatient department with a history of bleeding\nper vaginum for one month which was associated with spasmodic abdominal pain not relieved by\nmedication. No history of prolonged illness, drug, or hormonal intake was elicited. The patient was of\nnormal built for age with a body mass index of 20.1. Gynecological examination was unremarkable. Routine\nhematological and biochemical parameters were within the normal limits. On ultrasonography (USG), a\nhomogenous hyperechoic mass measuring 48.4 × 38.2 mm with a central anechoic area attached to the\nfundus occupying the uterine cavity was detected. A diagnosis of submucosal fibroid was made on USG.\nTotal abdominal hysterectomy was done, and the specimen was sent for histopathological examination. We\nreceived the total hysterectomy specimen. The uterus with cervix measured 11 × 7 × 5 cm with 1.5 cm long\ncervical canal. On cutting, a pedunculated polypoidal mass with a thin stalk attached to the fundus area,\nmeasuring 7 × 4 × 4 cm, was seen in the endometrial cavity. The external surface of the mass was smooth.\nThe cut surface was grayish white with multiple small cystic spaces filled with altered blood.\nMicroscopically, the cervix showed features of chronic non-specific cervicitis. The endometrium showed\nsimple endometrial hyperplasia for age. The polyp showed variable-sized glands lined by cuboidal-to-\ncolumnar cells with variable spindle cells stroma and several blood vessels (Figure \n1\n).\n1\n2\n3\n4\n5\n \n Open Access Case\nReport\n \nDOI:\n 10.7759/cureus.12789\nHow to cite this article\nNair V, Nigam J S, Bharti J N, et al. (January 19, 2021) Giant Endometrial Polyp in a Postmenopausal Woman. Cureus 13(1): e12789. \nDOI\n10.7759/cureus.12789\n\nFIGURE\n 1: (A) The homogenous hyperechoic mass with a central\nanechoic area attached to the fundus occupying the uterine cavity. (B) A\npedunculated polypoidal mass with a thin stalk attached to the fundus\narea. (C) Multiple small cystic spaces filled with altered blood. (D)\nMyometrium with endometrium and stalk of the EP. (E & F) Variable-\nsized glands with variable spindle cells stroma and many blood vessels.\nEP, endometrial polyp\nNo atypia was noted in all the sections examined. A histopathological diagnosis of simple endometrial\nhyperplasia for age with benign hyperplastic EP was made. Further history was elicited from the patient for\nthe possible etiology. She gave a history of daily intake of turmeric, garlic, ginger, onion, and the occasional\nintake of thyme and soybean in her diet, which are rich in PEs. Based on the clinical and histopathological\nfindings, a final diagnosis of benign hyperplastic EP probably caused by the long-term dietary intake of PEs\nwas made. The postoperative period was uneventful and the patient was doing well after six months of\nfollow-up.\nDiscussion\nEPs are a common benign endometrial pathology that affects approximately 25% of women \n[2,4]\n. They are\ngenerally asymptomatic but can be seen with abnormal uterine bleeding in 13-50% of the cases. EPs may\nalso present with infertility, premalignant, and malignant endometrial lesions \n[2]\n. In the present case, the\npatient presented with abnormal uterine bleeding associated with spasmodic abdominal pain without any\nhistory of prolonged illness, drug, or hormonal intake. The pathogenesis of EPs is not well known. However,\nby a systematic, semi-quantitative review on the pathogenesis of EP, Indraccolo et al. concluded that in\npostmenopausal women or during the first phase of the menstrual cycle, hyperactivation of \nβ\n estrogen\nreceptors on the \nα\n receptor enhance estrogen sensitivity in some areas of the endometrium leading to polyp\nformation \n[5]\n. Apoptosis via BCL-2 gene expression is blocked by estrogen-related inflammation, preventing\ntheir shedding during menstruation \n[5]\n. Indraccolo et al. also observed that there is a causative link between\nEP and BCL-2 expression, obesity, unbalanced estrogen therapy, imbalance between estrogen and\nprogestins, estrogen-like effect, the relationship between estrogen and progestins, and tamoxifen,\nregardless of the timing \n[5]\n. Giant EPs are rare and are mostly associated with tamoxifen and raloxifene\ntreatment \n[1]\n. Aging has also been linked to EPs \n[5]\n. In the present case, the patient was a 67-year-old\npostmenopausal female, and aging may be linked to the giant EP formation in the patient. The normal body\nmass index of the patient and normal biochemical results ruled out the possibility of any metabolic disorder.\nCertain plant-derived phytochemicals known as PEs are functionally and structurally similar to 17\nβ\n-\neestradiol (isoflavones) or synthetic estrogens such as diethylstilboestrol (lignins) \n[4]\n. Grains, fiber-rich\nfoods, legumes, and nuts used in the diet rich in PEs present as glycosides \n[4]\n. Thyme, turmeric, garlic,\nginger, onion, soy, pomegranate, licorice, red clover, hops, and Verbena are rich sources of PEs and\nphytoprogestins, which act as agonists and antagonists in vivo \n[6]\n. These are commonly consumed foods,\nherbs, and spices in an average Indian diet. Their activity in a female depends on their concentration,\nendogenous estrogen concentration, and menopausal status \n[1]\n. PEs with their estrogen-like effect can cause\nan imbalance with progesterone, which may lead to endometrial hyperplasia in postmenopausal women \n[1]\n.\nIn the present case, there was a history of daily intake of turmeric, garlic, ginger, onion, and the occasional\nintake of thyme and soybean in her diet, which may be the possible cause of EP. Aging, obesity, arterial\nhypertension, postmenopausal period, and tamoxifen are also risk factors for malignancy development in\n2021 Nair et al. Cureus 13(1): e12789. DOI 10.7759/cureus.12789\n2\n of \n3\n\nthe EP \n[2]\n. However, malignancy in EPs is uncommon and seen in 1-3% of the cases \n[2]\n. EPs larger than 15\nmm are associated with endometrial hyperplasia, and in general, polyps measuring more than 10 mm are\nassociated with an increased incidence of malignancy \n[2]\n. In the present case, no atypia or malignancy was\nseen after extensive sampling.\nConclusions\nThe origin and pathogenesis of EPs are still not fully understood. However, in our case, we assume that aging\nand use of PEs in the daily routine diet for a long time may be the cause of the giant EP.\nAdditional Information\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. \nConflicts of interest:\n In\ncompliance with the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services\ninfo:\n All authors have declared that no financial support was received from any organization for the\nsubmitted work. \nFinancial relationships:\n All authors have declared that they have no financial\nrelationships at present or within the previous three years with any organizations that might have an\ninterest in the submitted work. \nOther relationships:\n All authors have declared that there are no other\nrelationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nUnal B, Dogan S, Karaveli FS, et al.: \nGiant endometrial polyp in a postmenopausal woman without\nhormone/drug use and vaginal bleeding\n. 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Proc Soc Exp\nBiol Med. 1998, 217:369-378. \n10.3181/00379727-217-44247\n2021 Nair et al. Cureus 13(1): e12789. DOI 10.7759/cureus.12789\n3\n of \n3","source_license":"CC0","license_restricted":false}