Ultrasonographic features of endometrium

Ultrasonographic features of endometrium in pre- and postmenopausal women
By:C. Tracy Suit, MD
Cornelia de Riese, MD
Samuel Prien, PhD
Kelsey Kelso, BS

Background

* The endometrium is a dynamic tissue
o Menstrual cycle
o Postmenopausal
o Exogenous hormones

Transvaginal US
* Non-invasive
* Relatively inexpensive
* Good safety profile
* Readily available

Normal endometrium
* Menstrual phase
* Proliferative phase
* Secretory phase
* In the follicular phase, the endometrium becomes relatively hypodense
* As the cycle progresses the endometrium becomes more hyperechoic
* Ovulatory period = trilaminar endometrium
* Usually disappears 48 hours after ovulation
* Postmenopausal women
* A small amount of fluid may be considered normal

Premenopausal—Differential Diagnosis
* Often due to normal proliferation under hormonal influences
* Can include:
o Polyps
o Polypoid growths
o Hyperplasia or cancer
o Submucosal fibroids
Postmenopausal
* Important distinction: symptoms
* Exogenous hormones
Postmenopausal—differential diagnosis
* Polyps
* Hyperplasia or cancer
* Fibroids
Associated sonographic findings
* Polyps: cystic spaces
* Hyperplasia: regular/homogeneous echotexture
* Cancer: irregular margins, indistinct borders between the endometrium and myometrium, heterogeneous echotexture, complex fluid

Study objective
* To evaluate the predictive value of endometrial thickness and descriptive sonographic appearance on pathology in pre- and postmenopausal women
Methods
* 1903 gynecologic ultrasounds of the endometrium were performed between January, 2004 and January 2009
* Stratification: Of these, 367 had pathology performed within 3 months of the ultrasound
* The patients were then divided into either pre- or post menopausal after review of the chart
* Each US was critically evaluated for:
o Endometrial thickness
o Descriptors of the endometrium
Exclusion criteria
* No corresponding pathology (EMB, curettage, or hysterectomy) within 3 months of the US
* No measurement of the endometrial thickness or distortion by fibroids so that the endometrium could not be meaningfully evaluated
* Patient less than 18 years old
Methods
* Pathology was classified into groups:
o Benign: proliferative or secretory, atrophic, or chronic endometritis
o Precancerous or cancerous: simple hyperplasia with or without atypia, complex hyperplasia with or without atypia, endometrial cancer
Statistics
* Endometrial descriptors were compared with pathology using a Chi-Square analysis
* Endometrial thickness and age were compared using a Student’s t-test
Results
Result: Postmenopausal group
Results: Premenopausal group
Conclusions
* Confirmed that endometrial thickness is increased in pathological conditions such as hyperplasia and cancer
* But hyperplasia was diagnosed often within the “normal” ranges, especially in the premenopausal women
* In the postmenopausal group, complex hyperplasia and cancer were diagnosed with an endometrial thickness of 3 and 5 mm, respectively
* In premenopausal women, the average endometrial thickness in women with pathology was still in the normal range for secretory endometrium
* In addition, no simple hyperplasia was diagnosed in the postmenopausal group—when pathology was found, it was much more likely to have become frank cancer
* Heterogeneity and irregularity in echo pattern were significantly more likely to be associated with hyperplasia or cancer in the premenopausal group. It may have not reached significance in the postmenopausal women due to the smaller sample size.
* One weakness of the study is the low rate of pathology
* DO THE EMB in symptomatic women
OUTLOOK

* What can the sonohysterogram add?
* We need to correlate findings to ethnicity, metabolic and exogenous as well as endogenous hormonal influences to further define high risk scenarios.

Ultrasonographic features of endometrium in pre- and postmenopausal women.ppt