## Correct Answer: D. Endometrial polyp Endometrial polyps are benign proliferations of endometrial glands and stroma that project into the uterine cavity. The key discriminating feature in this case is the **feeding vessel** visualized on ultrasonography—this represents the vascular pedicle supplying the polyp, which is pathognomonic for polyps. Postmenopausal bleeding is the classic presentation, occurring in 20–40% of women with endometrial polyps due to surface ulceration and bleeding. On ultrasound, polyps appear as echogenic or isoechoic masses with a well-defined stalk and single or multiple feeding vessels (color Doppler shows arterial flow). Endometrial polyps are extremely common in postmenopausal women and are benign lesions with <1% malignant potential. They are managed by hysteroscopic polypectomy, which is both diagnostic and therapeutic. The presence of a feeding vessel on imaging essentially rules out fibroid (which is myometrial, not endometrial, and lacks a single pedicle) and makes carcinoma less likely (which typically shows irregular vascularity and heterogeneous echotexture). This is a high-yield imaging-based diagnosis question testing recognition of the classic sonographic sign. ## Why the other options are wrong **A. Fibroid uterus** — Fibroids (leiomyomas) are myometrial masses, not endometrial, and arise from smooth muscle of the uterine wall. They do not project into the endometrial cavity with a single feeding vessel; instead, they distort the endometrium from outside. Fibroids may cause abnormal uterine bleeding but typically present with menorrhagia (heavy menstrual bleeding) rather than postmenopausal bleeding. The sonographic finding of a discrete endometrial mass with a feeding vessel is incompatible with fibroid pathology. **B. Leiomyosarcoma** — Leiomyosarcoma is a rare malignant smooth muscle tumor (0.1–0.3% of uterine tumors) that arises from myometrium, not endometrium. It presents with rapid uterine enlargement, abnormal bleeding, and pelvic pain, but the imaging would show a large, heterogeneous, infiltrative mass with irregular vascularity—not a well-demarcated endometrial polyp with a single feeding vessel. The benign appearance and location make malignancy extremely unlikely here. **C. Endometrial carcinoma** — Endometrial carcinoma does cause postmenopausal bleeding and may show vascularity on Doppler, but the sonographic hallmark is an irregular, heterogeneous mass with thickened endometrium (>4 mm) and abnormal, chaotic vascularity. A well-defined endometrial mass with a single feeding vessel (pedicle) is characteristic of benign polyp, not malignancy. Carcinoma typically lacks the discrete, stalk-like appearance with organized vascular supply seen in polyps. ## High-Yield Facts - **Feeding vessel on ultrasound** is the pathognomonic sign for endometrial polyp; represents the vascular pedicle of the polyp. - **Postmenopausal bleeding** is the most common presentation of endometrial polyps (20–40% of cases); caused by surface ulceration and bleeding. - **Hysteroscopic polypectomy** is the gold standard for diagnosis and treatment of endometrial polyps in India (FOGSI guidelines). - **Malignant potential <1%** for endometrial polyps; they are benign lesions and do not require adjuvant therapy after removal. - **Endometrial polyps are common** in postmenopausal women, especially those on tamoxifen or with obesity and metabolic syndrome. ## Mnemonics **POLYP FEATURES (Sonographic)** **P**rojects into cavity | **O**rganized feeding vessel | **L**ocalized/well-defined | **Y**ellow/echogenic | **P**edicle (stalk) visible **Postmenopausal Bleeding Differential — CAFE** **C**arcinoma (irregular, heterogeneous) | **A**trophic vaginitis (clinical diagnosis) | **F**ibroid (myometrial, no pedicle) | **E**ndometrial polyp (feeding vessel, stalk) ## NBE Trap NBE pairs postmenopausal bleeding with malignancy (carcinoma) to lure students into choosing option C; however, the specific sonographic finding of a **feeding vessel** is the discriminating feature that points to benign polyp rather than malignancy. Students who focus only on the symptom (bleeding) rather than the imaging sign (pedicle) will miss this question. ## Clinical Pearl In Indian clinical practice, endometrial polyps are the most common benign cause of postmenopausal bleeding and are frequently encountered in outpatient gynecology clinics. The presence of a feeding vessel on transvaginal ultrasound essentially confirms the diagnosis and guides the gynecologist to proceed directly to hysteroscopic polypectomy without further imaging, making this a cost-effective and rapid diagnostic approach in resource-limited settings. _Reference: DC Dutta's Textbook of Gynaecology (6th ed.), Ch. 18 (Abnormal Uterine Bleeding); FOGSI Guidelines on Abnormal Uterine Bleeding in Postmenopausal Women_
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