Uterine Polyps: Bleeding, Diagnosis, and When They Need to Come Out

If you are bleeding between periods, bleeding after menopause, or having periods that have quietly become heavier than they used to be, a uterine polyp is one of the first things worth ruling out. They are common, they are almost always benign, and when they cause trouble they can usually be removed in a short outpatient procedure that does not involve cutting through the abdomen.

What a uterine polyp actually is

An endometrial polyp is a localized overgrowth of the lining of the uterus — endometrial glands and supporting stroma wrapped around a small blood vessel core. It grows into the uterine cavity, either on a narrow stalk (pedunculated) or on a broad base (sessile). Polyps range from a few millimeters to several centimeters, and you can have one or many.

They are hormonally responsive tissue that has stopped following the normal monthly instructions. The lining around them sheds with each period; the polyp largely does not. That mismatch is what produces the bleeding pattern.

Two clarifications people frequently need:

• A uterine polyp is not a fibroid. Fibroids are muscle tumors of the uterine wall. Polyps are lining tissue. A submucosal fibroid can look similar on imaging and cause similar bleeding, but the two are managed somewhat differently. If a fibroid turns out to be the culprit, gynecological surgery options differ.
• A uterine polyp is not a cervical polyp. Cervical polyps sit at the cervical opening, are usually visible on a routine speculum exam, and are often removed in the office in seconds.

Polyps become more common with age, peak around the perimenopausal years, and are associated with obesity, tamoxifen use, and menopausal hormone therapy.

Symptoms

Many polyps cause nothing at all and are found incidentally on an ultrasound done for another reason. When they do cause symptoms, the pattern is fairly characteristic.

• Bleeding or spotting between periods. The single most typical complaint. Often light, brown, and unpredictable.
• Heavier or longer periods. A gradual change from your own baseline matters more than any absolute number.
• Bleeding after intercourse.
• Irregular cycles, particularly in perimenopause, where they are easy to dismiss as "just hormones."
• Any bleeding after menopause. This is never normal, regardless of how light or how brief, and always requires evaluation.
• Difficulty conceiving or recurrent pregnancy loss, sometimes with no bleeding at all.

Polyps rarely cause pain. If you have significant cramping or pelvic pain, something else is usually contributing. For a broader look at bleeding patterns, see menstrual issues; if you are in the menopausal transition, menopause management covers what is and is not expected.

How polyps are diagnosed

Diagnosis is a stepwise process, and the order matters because the cheapest test is not always the conclusive one.

Transvaginal ultrasound is the starting point. A polyp may appear as a focal thickening or a distinct echogenic mass within the cavity, sometimes with a feeding vessel visible on Doppler. Timing helps: scanning in the first half of the cycle, when the lining is thin, makes a polyp far easier to see. A normal-looking ultrasound does not fully exclude a polyp.

Saline infusion sonohysterography (SIS) is ultrasound repeated while sterile saline is instilled through a thin catheter to gently distend the cavity. The fluid outlines the polyp, separating it from surrounding lining. It is markedly more sensitive than ultrasound alone and is often the test that settles the question. It takes a few minutes in the office and feels like cramping.

Hysteroscopy is the reference standard. A slim camera is passed through the cervix and the cavity is viewed directly. Its advantage is that it both confirms the diagnosis and allows removal in the same sitting.

Endometrial biopsy samples the lining blindly with a thin catheter. It is essential for evaluating postmenopausal bleeding and for excluding hyperplasia or cancer, but it is unreliable for polyps specifically — a blind sample can easily miss a focal lesion. The same is true of a blind dilation and curettage. If a biopsy comes back benign but you keep bleeding, that result does not close the case; the cavity still needs to be visualized.

When polyps need to be removed

Not every polyp needs treatment. Small, asymptomatic polyps found incidentally in premenopausal women may be watched, and a proportion of small ones regress on their own.

Removal is generally recommended when:

• The polyp is causing abnormal bleeding
• You are postmenopausal, particularly with any bleeding
• You are having difficulty conceiving or are about to undergo fertility treatment
• The polyp is large, or there are multiple polyps
• You are taking tamoxifen
• Imaging shows features that raise concern, or the diagnosis is uncertain

The decision balances the nuisance of the symptom against the modest risk of an office procedure. If bleeding is disrupting your life, that is a sufficient reason on its own.

Hysteroscopic polypectomy

Removal is done through the cervix — no abdominal incision.

In the office, with a small-diameter hysteroscope, often with a local anesthetic block and ibuprofen beforehand. Suitable for smaller, accessible polyps. You go home shortly afterward and most women return to normal activity the same or next day.

In the operating room, under sedation or general anesthesia, when the polyp is large, multiple, or when the cervix is difficult to enter — common after menopause or after prior cervical surgery.

The polyp is separated at its base with scissors, a grasping instrument, a mechanical tissue-removal device, or an electrosurgical loop. Removing it flush at the base, rather than merely amputating the visible portion, is what reduces recurrence. The tissue is always sent to pathology.

Afterward, expect cramping for a day and light spotting or watery discharge for up to a week or two. Pelvic rest is usually advised for one to two weeks. Call for heavy bleeding, fever, or worsening pain. Polyps can recur, so returning symptoms deserve re-evaluation rather than assuming the problem was solved permanently.

Cancer risk

This is the question underneath most of the anxiety, so it deserves a straight answer.

The overwhelming majority of endometrial polyps are benign. Malignant or premalignant change within a polyp is uncommon overall, but the risk is not evenly distributed. It is lowest in premenopausal women with no symptoms and rises with:

• Menopause, and particularly postmenopausal bleeding
• Increasing age
• Larger polyp size
• Obesity, diabetes, and hypertension
• Tamoxifen use
• Lynch syndrome or a strong family history of endometrial or colorectal cancer

The practical consequence is simple. A small silent polyp on a scan in a 34-year-old is a very different situation from a polyp in a 62-year-old with spotting, even though the ultrasound image may look alike. Postmenopausal bleeding always warrants evaluation, and in that setting removal with pathology — not observation — is the appropriate response.

Polyps and fertility

Polyps can interfere with conception in several plausible ways: by physically obstructing the passage of sperm or an embryo, by distorting the area where an embryo would implant, and by producing local inflammation in the lining that makes implantation less likely.

The clinical position is reasonably settled. When a polyp is found during an infertility workup, removal before proceeding is generally recommended, and it is standard to clear the cavity before intrauterine insemination or IVF. Hysteroscopic removal is low-risk and the cavity heals well, so the threshold for taking one out in a woman trying to conceive is lower than it would otherwise be.

If you are trying to conceive and have unexplained spotting between periods, ask specifically about imaging the uterine cavity rather than assuming it has already been checked. Our infertility page covers the wider evaluation.

When to be seen

Make an appointment for any of the following:

• Bleeding or spotting between periods that has happened more than once
• Periods that have become noticeably heavier or longer than your normal
• Bleeding after intercourse
• Any vaginal bleeding after menopause — do not wait to see whether it repeats
• Twelve months of trying to conceive without success, or six months if you are over 35

Dr. Adeeb Alshahrour evaluates and treats abnormal uterine bleeding at the Women's Health Center of Chicago, including office ultrasound, saline sonohysterography, and hysteroscopic polypectomy. To be seen, book an appointment or view our locations.

Medical disclaimer

This article provides general health information and is not a substitute for individual medical evaluation. Abnormal uterine bleeding has many possible causes, and only an examination and appropriate testing can determine yours. Postmenopausal bleeding in particular requires prompt assessment by a clinician. Seek urgent care for very heavy bleeding, dizziness or fainting, fever, or severe pelvic pain.