Bleeding Risk Management in Endometrial Curettage with Polypectomy

Introduction to Bleeding Risk

The American Society for Gastrointestinal Endoscopy suggests that diagnostic endoscopy with mucosal biopsy carries minimal bleeding risk with no severe hemorrhage reported in studies of thousands of patients 1, 2
The American College of Gastroenterology implies that polypectomy procedures demonstrate post-procedure bleeding rates of 0.6-2.2% for delayed bleeding and 1.14% overall bleeding risk 1, 2
Severe bleeding requiring transfusion occurs in 0.08% of polypectomy cases, according to the American Society for Gastrointestinal Endoscopy 1

Endometrial curettage with polypectomy involves removal of tissue from a highly vascular endometrial surface, which is mechanistically similar to gastrointestinal polypectomy and EMR procedures that are universally classified as high bleeding risk, as stated by the American Society for Gastrointestinal Endoscopy 1, 2
Tissue removal creates raw mucosal surfaces similar to gastrointestinal polypectomy, where bleeding risk increases by a factor of 11.14 compared to diagnostic procedures alone, according to the American College of Gastroenterology 1
The American Heart Association recommends that for patients on warfarin, discontinue warfarin 5 days before the procedure and verify INR <1.5 prior to the procedure 8
The American College of Cardiology suggests that for patients on direct oral anticoagulants (DOACs), omit the morning dose on the day of the procedure at minimum for low-risk procedures 1, 2

Aspirin can typically be continued as observational data shows no significant increase in bleeding risk for most procedures, according to the American College of Gastroenterology 4, 5
Clopidogrel should be discontinued 5 days before high-risk procedures in patients with low thrombotic risk, as recommended by the American Heart Association 3
Patients on continued or resumed anticoagulation face higher delayed bleeding risk and require clear discharge instructions, as stated by the American Society for Gastrointestinal Endoscopy 8

Delayed bleeding can present up to 14-30 days post-procedure, with mean onset at 4-6 days, according to the American College of Gastroenterology 1, 6, 7
Hemoglobin drop >20 g/L, need for transfusion, or unplanned hospital admission defines clinically significant hemorrhage, as defined by the American Society for Gastrointestinal Endoscopy 1, 2