DOI: 10.1111/j.1471-0528.2006.00967.

x
www.blackwellpublishing.com/bjog
General gynaecology

A randomised controlled trial comparing

outpatient versus daycase endometrial
polypectomy
FA Marsh, LJ Rogerson, SRG Duffy
Academic Department of Obstetrics and Gynaecology, St James’s University Hospital, Leeds, UK
Correspondence: Dr FA Marsh, Academic Department of Obstetrics and Gynaecology, Level 9, Gledhow Wing, St James’s University Hospital,
Leeds, UK. Email medfm@leeds.ac.uk

Accepted 6 April 2006. Published OnlineEarly 2 June 2006.

Objective To evaluate outpatient versus daycase endometrial
polypectomy by comparing success rate, complications, patient
tolerance, pain score, analgesia requirement and recovery.
Design A randomised controlled trial.
Setting A large UK Teaching hospital.
Population Forty consecutive women diagnosed with an
endometrial polyp at outpatient hysteroscopy were randomly
assigned in equal proportions to outpatient or daycase polyp
removal.
Methods The outpatient cohort underwent endometrial
polypectomy either using grasping forceps or a bipolar electrode
(VersapointTM; Gynecare Inc., Menlo Park, CA, USA) introduced
down the operating channel of a rigid hysteroscope (VersascopeTM;
Gynecare Inc.). The daycase cohort underwent traditional
endometrial polyp resection using a hysteroscopic, monopolar,
electrosurgical resecting loop, performed under general
anaesthetic.
Main outcome measures The main outcome measures were as
follows: success rates and intra or postoperative complications,
time away from home, analgesia requirements, pain scores on
the day of and one day after endometrial polypectomy, return to
work and preoperative fitness and preference for the location of a
future endometrial polypectomy.
Results The majority of women from both cohorts were
premenopausal (62.5%), parous (85%) and in paid employment
(62.5%). One woman allocated to outpatient polypectomy had
cervical stenosis and dilatation was unsuccessful in the outpatient
setting. There were no other intra or postoperative complications
in either arm of the study. The mean intraoperative visual
analogue style (0–100 mm) pain score during outpatient
polypectomy was 23.7 mm (1–62). A proportion of women (20%)
described no intraoperative discomfort; however, the majority
(75%) described mild or moderate intraoperative discomfort.
More women in the outpatient cohort (58%) described themselves
as pain free for the remainder of the day than in the daycase
cohort (28%) (P = 0.09). The day after the procedure, all women
from the outpatient group described slight or no discomfort
compared with only 41% of women from the daycase group
(P = 0.02). All women undergoing outpatient polypectomy had
a significantly shorter mean time away from home (3.24 [1.5–5]
hours) than women undergoing daycase polypectomy (7.42
[6–10.5] hours), P < 0.0005. Similarly, women from the outpatient
cohort had a significantly faster mean return to preoperative fitness
(1 [0–4] day versus 3.2 [1–13] days; P = 0.001) and required less
postoperative analgesia than the daycase cohort. Ninety-five
percent of women from the outpatient cohort and 82% of women
from the daycase cohort stated they would prefer to undergo an
endometrial polypectomy in the outpatient setting should they
require a further polyp removal.
Conclusion Endometrial polypectomy can be successfully
performed in the outpatient setting with minimal intraoperative
discomfort, a significantly shorter time away from home and faster
recovery and is preferred by women when compared with daycase
polypectomy. Resources need to be made rapidly available to
undertake larger scale research and develop this service across
the UK.
Keywords Daycase, endometrial polyp, outpatient, polypectomy.

Please cite this paper as: Marsh F, Rogerson L, Duffy S. A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy.
BJOG 2006; 113:896–901.

bleeding.1 The true incidence is likely to be even higher as they

Introduction
are often discovered in asymptomatic women.2 Endometrial
Endometrial polyps are present in 10% of premenopausal polyps are usually benign; however, there is evidence to
and 20% of postmenopausal women with abnormal uterine confirm that they may be the site of endometrial malignancy

896 ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology


and as such should be removed, particularly in postmeno-
pausal women.3,4 Endometrial polyp resection under direct
hysteroscopic vision is more likely to completely remove the
endometrial basalis layer, and thus reduce the risk of recur-
rence, than the more traditional approach of blind removal
with polyp forceps.5 Indeed, 10–15% of polyps may be left
in situ when removed following blind curettage or polyp avul-
sion.6 Recent advances in endoscopic instrumentation allow
endometrial polyps to be removed under direct vision in
either the outpatient or daycase setting.
Outpatient gynaecological diagnostic procedures, e.g. hys-
teroscopy, are now replacing daycase procedures due to the
advantages for the woman and the health service. These
include the avoidance of general anaesthesia and its associated
risks, faster return to normal activities and less time away
from home and work.7 Furthermore, there is evidence to
suggest that outpatient gynaecological procedures provide
significant cost savings and are preferred by women when
compared with daycase procedures.8,9
Although it may be feasible to perform outpatient proced-
ures, it is important that they are systematically evaluated and
compared with their traditional counterparts under general
anaesthesia. In particular, gynaecologists should ensure that
the procedure is successful, tolerable and acceptable to the
vast majority of women in the outpatient setting. As yet, there
is little published evidence to suggest whether outpatient poly-
pectomy offers any advantage over daycase polypectomy to the
woman or the health service.
Objectives
The aim of this study was to evaluate outpatient versus
daycase endometrial polypectomy by comparing success
rate, complications, patient tolerance, pain score, analgesia
requirement and postoperative recovery.
Methods
Study design
A randomised controlled trial comparing outpatient versus
daycase polypectomy.
Women with abnormal uterine bleeding underwent diag-
nostic outpatient hysteroscopy to investigate their symptoms.
If an endometrial polyp was identified, women were given an
information leaflet inviting them to participate in the study. A
polyp was diagnosed hysteroscopically as a discrete outgrowth
of endometrium protruding into the endometrial cavity
attached by a pedicle.
There was always an interval period ranging from weeks to
several months between consenting women into the trial,
randomisation and performing the polypectomy. This inter-
val provided women with time to consider their decision and
change their mind if they wished to opt out of the trial.
ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology
Outpatient versus daycase endometrial polypectomy
Ethical considerations
Ethical approval was obtained from the Leeds Health Author-
ity/St James and Seacroft University Hospitals Clinical
Research (Ethics) Committee.
Informed consent
Informed consent was obtained before randomisation to
either outpatient or daycase endometrial polypectomy.
Participants
Forty consecutive women diagnosed with an endometrial polyp
were recruited into the study. Twenty women were randomised
to outpatient polypectomy and 20 to daycase polypectomy.
Randomisation
Randomisation was achieved using sealed, opaque envelopes
containing computer-generated block randomisation num-
bers. The envelopes were opened by L.J.R on the hospital site.
Procedure
Outpatient endometrial polypectomy
Outpatient endometrial polypectomy was performed using
a 1.8-mm, 0
, semi-rigid hysteroscope with a disposable
sheath. The sheath consists of an inflow channel that houses
the hysteroscope and allows for the infusion of 0.9% saline
distension medium, at a pressure of 150–200 mmHg. The
outflow channel also serves as an operative channel for the
introduction of 2-mm (7 French) instruments. The sheath
angles the tip of the hysteroscope to 10
, allowing for
improved visualisation of the uterine cavity. Small endo-
metrial polyps were removed using grasper forceps introduced
down the operating channel of the VersascopeTM. Larger
polyps were first divided into smaller pieces using the Versa-
pointTM bipolar electrode and the fragments were then
removed using grasper forceps. In every case, the base of
the polyp was visualised and removed. All tissues were sent
for histological diagnosis.
Intraoperative discomfort in the outpatient cohort was
determined using the following methods:
1. Visual analogue style (VAS) 100-mm pain score: Women
were asked to quantitate the discomfort they had experi-
enced by placing a mark along a 100-mm horizontal line
bounded by the descriptors (0 mm = no pain, 100 mm =
worst pain imaginable).
2. Summated (Likert) rating scale with options to describe
pain as follows: None, mild, moderate, severe, very severe,
worst pain ever experienced.
Daycase endometrial polyp removal
A week before the daycase endometrial polypectomy was
scheduled, all women attended a preassessment clinic to
ensure suitability and fitness for general anaesthesia.
897
 Marsh et al.
Under general anaesthesia, the cervical canal was dilated to
Hegar 9 and a 8.5-mm operative hysteroscope, attached to
a camera system, was inserted into the uterine cavity. Sorbitol
distension media was flushed through the endometrial cavity
using an automatic pump and low-level suction to maintain
visibility. Careful recording of sorbitol input and output was
documented to ensure that fluid balance was maintained
throughout the procedure, with a final check at the end. All
endometrial polyps were removed using a monopolar, elec-
trosurgical resecting loop and were sent for histological diag-
nosis. After recovery from the general anaesthetic, women
were discharged home under the supervision of a family
member or friend.
Materials
On the day of the endometrial polypectomy, women from
both cohorts were asked to specify an overall pain score
describing the discomfort they had experienced as a result
of the procedure. The options provided ranged as follows:
0 = No pain at rest or on movement.
1 = No pain at rest, slight pain on movement.
2 = Slight pain at rest, moderate pain on movement.
3 = Moderate pain at rest, severe pain on movement.
4 = Severe pain at rest and on movement.
Women also specified the overall discomfort they experi-
enced the day after endometrial polypectomy using the same
scale cited above.
Follow up
All women completed a diary, recording time away from home
on the day of the endometrial polypectomy, analgesia require-
ment, return to preoperative fitness and work following the
procedure. Women documented whether they would prefer
to undergo an endometrial polypectomy as an outpatient or
daycase procedure were they to require it again in the future.
Women chose up to three adjectives to describe the pro-
cedure they had undergone. The adjectives were as follows:
h Interesting
h Quick
h Convenient
h Thorough
h Intimidating
h Unpleasant
h Embarrassing
h Painful.
Hence, women had the option of describing the experience
they had undergone in a positive and/or negative manner.
Statistical analysis
The results were managed by Statistical Package for the Social
Sciences (SPSS; SPSS Inc., Chicago, IL, USA). Sample char-
acteristics were determined using descriptive statistics. T tests
were used to analyse data that approximated to a normal
distribution, e.g. age.
898
Mann–Whitney U test was used to analyse differences in
the mean discomfort experienced, analgesia requirement,
recovery and time away from home and work.
A chi-square test was used to analyse differences in women’s
description of the two procedures. Analysis was undertaken on
an intention-to-treat basis.
Results
Forty-nine women diagnosed with endometrial polyps were
approached and counselled about the trial. Forty women
agreed to participate and consequently 20 women were ran-
domised to outpatient endometrial polypectomy and 20 to
daycase endometrial polypectomy. Nineteen (95%) women
from the outpatient cohort returned their diary and 17
(85%) returned their diary from the daycase cohort.
All four nonresponders were sent a written reminder but
failed to return their diaries.
The majority of women in this study were premenopausal,
parous and in paid employment (Table 1). A flow of women
through the trial is shown in Figure 1.
Failure rate and complications
One woman allocated to outpatient endometrial polypectomy
had cervical stenosis and dilatation was unsuccessful in the
outpatient setting. This woman subsequently underwent
endometrial polypectomy as a daycase under general anaes-
thesia. A second woman allocated to the outpatient arm of the
study had no visible endometrial polyp when she attended for
polypectomy and an endometrial biopsy was simply taken.
There were no other intra or postoperative complications
in either arm of the study. Good-sized samples were taken in
all cases allowing for adequate histological assessment. All the
polyps removed in this study were benign.
Intraoperative discomfort during outpatient
endometrial polypectomy
The mean intraoperative VAS pain score was 23.7 mm with
a range of 1.0–62.0 mm. Four women (20%) described the
procedure as painless. However, the majority of women (75%
Table 1. Demographic data
Outpatient Daycase P value
cohort cohort
(n 5 20) (n 5 20)
Mean age, years (range) 50.5 (37–72) 50.0 (37–79) N/S
Women in paid 12 (60) 13 (65) N/S
employment, n (%)
Nulliparous women, n (%) 3 (15) 3 (15) N/S
Postmenopausal women, n (%) 8 (40) 7 (35) N/S
N/S, not statistically significant (i.e. P . 0.05).
ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology
 Outpatient versus daycase endometrial polypectomy

49 women eligible to be
recruited into trial

9 women declined to
participate in trial

40 women randomised

20 women allocated to outpatient 20 women allocated to daycase

endometrial polypectomy endometrial polypectomy

1 woman had cervical stenosis;

underwent daycase
polypectomy

18 women underwent outpatient 20 women underwent daycase

polypectomy, 1 woman had no visible polypectomy (3 women did not return
polyp and underwent hysteroscopy and follow-up questionnaires)
endometrial biopsy (all women returned
follow-up questionnaires)

Figure 1. A flow of women through the trial.

n = 15) described mild or moderate intraoperative pain with
only one woman describing severe pain (Table 2). The pain
scores and Likert style description from all 20 women allo-
cated to outpatient endometrial polypectomy were included
in keeping with intention-to-treat analysis.
Overall description of discomfort on day of
and day after endometrial polypectomy
On the day of the procedure, 58% of women undergoing
outpatient polypectomy described no pain at all compared
with only 28% of the daycase group (P = 0.09) (Figure 2).
The day after the procedure, there was a statistically signifi-
cant difference in the severity of pain experienced by women
in the outpatient versus daycase cohorts. All women from the
outpatient cohort described either no pain at all (74%) or
only slight pain on movement (26%) the following day. In
the daycase group, 41% of women described no pain at all and
18% described moderate pain on movement the following
day (P = 0.03) (Figure 3).
Time away from home and analgesia
requirements as a result of the endometrial
polypectomy
Women undergoing outpatient endometrial polypectomy
had a significantly shorter mean time away from home than
those undergoing the daycase procedure. Similarly, signifi-
cantly fewer women undergoing outpatient polypectomy
required postoperative oral analgesia compared with those
undergoing the daycase procedure. Women from the outpa-
tient cohort also returned to preoperative fitness significantly

Table 2. Likert style description of pain

n (%)

None 4 (20)
Mild 9 (45)
Moderate 6 (30)
Severe 1 (5)
Very severe 0
Worst pain ever experienced 0
Figure 2. Severity of pain on the day of endometrial polypectomy.
OP, outpatient; DC, daycase.

ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology 899

 Marsh et al.

Figure 4. Adjectives women chose to describe their experience

of the endometrial polypectomy. OP, outpatient; DC, daycase.
Figure 3. Severity of pain the day after endometrial polypectomy.
OP, outpatient; DC, daycase.
has shown that outpatient endometrial polypectomy can be
faster than the daycase cohort and returned to work, on aver- successfully performed in the vast majority of women. There
age, a day earlier (Table 3). was only one woman in which outpatient polypectomy was
unsuccessful.
Women’s description of and satisfaction These findings are similar to a feasibility cohort study of
with the procedure outpatient endometrial polypectomy in which all 31 women
All women from the outpatient cohort, bar one (n = 18), allocated to this procedure underwent successful outpatient
stated that they would choose to undergo a repeat outpatient endometrial polypectomy.10 The majority (65%) of women in
polypectomy were they to require the procedure again. our study, undergoing outpatient polypectomy, described
Fourteen women (82.4%, n = 14/17) from the daycase either none or mild intraoperative discomfort, with a mean
cohort would prefer to undergo an outpatient endometrial intraoperative VAS pain score being 23.7 mm. Indeed, more
polypectomy if they needed the procedure in the future. Thus, women from the outpatient cohort described none or mild
only three women (17.6%) would opt for a daycase endome- discomfort on the day of and day after endometrial polypec-
trial polypectomy again. The majority of adjectives used to tomy than from the daycase cohort. Our findings confirm
describe both outpatient and daycase endometrial polypec- that it is both feasible and preferable to women to undergo
tomy were positive; however, women from the outpatient endometrial polypectomy in the outpatient setting.
cohort used significantly more positive adjectives than These findings have important implications for the future
women form the daycase cohort (44/49 [90%] versus 28/42 of clinical practice. A national survey investigating the current
[67%]; P < 0.0005) (Figure 4). UK practice for the treatment of endometrial polyps11 showed
that over 90% of gynaecologists remove intrauterine polyps
and that 90% of these polypectomies are performed as an
Discussion inpatient procedure, using blind avulsion under general
This is the first randomised controlled trial comparing out- anaesthetic. One of the most important advantages of this
patient versus daycase endometrial polypectomy. This study study is that outpatient endometrial polypectomy was per-
formed in a true outpatient setting, without local anaesthetic
or intravenous sedation and requiring only a short time away
Table 3. Time away from home and recovery data
from home. This service offers several advantages over the
Outpatient Daycase P value traditional method of polyp removal still commonly under-
cohort cohort taken in the UK including less time away from home, faster
(n 5 19) (n 5 17) return to preoperative fitness and obviates the need and costs
of an anaesthetist, operating department assistant and oper-
Mean hours away 3.25 7.42 ,0.0005 ating theatre. The polyp is also removed under direct vision,
from home
rather than blind avulsion, thus reducing the risk of recur-
No. of women requiring 4 (21) 9 (53) 0.05
postoperative oral
rence. The availability to perform outpatient endometrial poly-
analgesia, n (%) pectomy immediately following diagnosis in an outpatient
Mean time to return to 1 (0–4) 3.2 (1–13) 0.001 hysteroscopy clinic expedites treatment and avoids the risks
preoperative fitness (days) and further waiting time prior to a polypectomy under gen-
Mean time off work 2.3 (1–5), 3.4 (1–5), N/S eral anaesthesia. Furthermore, there is evidence to suggest
(days [range]) n 5 12 n 5 11 that substantial health service cost savings would result from
transferring endometrial polypectomy from the daycase to the
N/S, not statistically significant (i.e. P . 0.05).
outpatient setting.9,10

900 ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology


The small numbers of women included in this trial is
a limitation of the study. It became increasingly difficult
to recruit for the study as progressively more women
became aware that outpatient polypectomy was being per-
formed within the unit. Many women with polyps directly
requested an outpatient polypectomy and were not prepared
to be randomised. Nonetheless, a larger randomised con-
trolled trial is required to determine whether our results
are generalisable. This trial would require long-term follow
up in order to compare operative complications, symptom-
atic cure rates, polyp recurrence rate and a cost analysis of
the two procedures.
A ‘one stop’ direct access clinic for the investigation and
treatment of abnormal uterine bleeding is the future of gynae-
cological ambulatory services. Women diagnosed with endo-
metrial polyps would benefit from the convenience of
immediate treatment, avoid a general anaesthetic and make
a faster postoperative recovery. In light of the NHS Plan to
provide a ‘patient-led service’ and target resources towards
the preference of patients, this study highlights the need to
increase the provision of an outpatient endometrial polypec-
tomy service to more women in the UK.
Conclusion
Endometrial polypectomy can be successfully performed in
the outpatient setting with minimal intraoperative discom-
fort. Outpatient polypectomy is associated with a significantly
shorter time away from home, faster recovery and is preferred
by women when compared with daycase polypectomy.
Resources need to be made rapidly available to undertake
larger scale research and develop this service across the UK. j
ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology
Outpatient versus daycase endometrial polypectomy
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