Just Say Normal: US Uterine Findings That Simulate Disease - SD

Introduction

Hi, my name is Maitre Patel.

I'm the chief of ultrasound at the Mayo Clinic in Arizona, and I'll be presenting my lecture on just say normal ultrasound uterine findings that simulate disease.

My lecture today is just say no or just say normal ultrasound uterine findings that simulate disease.

And I have no disclosures to make.

Sometimes when I give this lecture, one could change the title of it to uterine findings that stimulate disease.

And that's because the findings I'm gonna talk about today are ones that are sometimes confusing and if you overcall an abnormality, they can cause a disease and that disease is a headache in you and in your clinicians who get the report.

The "Just Say No" Campaign Analogy

You may remember back in the early eighties that there was a public health awareness campaign on drug use.

And the philosophy behind the campaign was to instill a mantra into the Youth of America of just say no.

And that was to just say no to drugs.

The thought being that if you were presented with an opportunity to take a drug by someone that if you had burned into your brain this notion of just saying no, that you would hesitate and just say no and not take that drug.

And what I'd like to do today is to burn into your brains the notion of just saying no to these over calls, which can be just as seductive as any addictive drug.

There are two types of over calls that we'll be talking about, potentially confusing incidental findings and physiologic processes that can be misinterpreted as disease.

Vaginal Incidental Findings and Probe Placement

So here is a longitudinal or sagittal transabdominal image of the uterus, which looks fairly routine and normal.

And in fact it is.

And it allows me to sort of segue into the next slide, which shows a particular finding.

Now, it's not that important that we recognize what this finding is.

That's not my purpose in showing it.

What this happens to be is a pessary that's been placed in a very old woman.

This is a postmenopausal woman who has a pessary.

And the reason I'm showing to you is not that you recognize the normal appearance of a pessary, which frankly is not that confusing when you have the appropriate history.

The reason I'm showing it to you is because you realize that the pessary can indent the anterior fornix of the vagina by quite a bit, and in fact there is a lot of capacity for volume in the anterior and posterior fornices of the vagina.

And now why is that important for us to recognize?

Well, when we put an endovaginal probe into the vagina as we have in this case, the end of the probe is not sitting on the end of the cervix.

That's a mistaken notion by many novices in ultrasound.

In fact, the endovaginal probe end is sitting on the side of the cervix because you've placed the probe usually into the anterior fornix.

And in fact, with the next slide, you can see that we use this to our advantage.

We place that probe as far anteriorly into the anterior fornix as possible in order to get the most optimal images of the uterus and the endometrium, as you can see in this case.

And as you can see, the endovaginal probe here is situated quite high in that anterior fornix allowing us the best visualization of those structures.

Well, this leads to a particular phenomenon that can occur that if you're not aware of, you will think it reflects some abnormality of the patient's ligaments.

And in fact, I have seen people miscall this particular phenomenon.

And this is where the uterus looks like it's normal in position, or at least not retroverted on the transabdominal image filled with the filled urinary bladder.

And then when they go to the endovaginal examination, for whatever reason, the uterus has flipped and now the fundus of the uterus is pointing backwards.

And this is clearly a retroverted uterus.

And some people will mistakenly feel that this reflects some ligamentous laxity, abnormal ligamentous laxity of the patient's uterus.

And in fact, that's not the case necessarily.

What it does reflect is that we've placed the probe into a different fornix extent we typically would have placed it.

So here are two schematic drawings, one on the left, on the image left, showing the probe placed into the anterior fornix and the one on the right showing the probe placed into the posterior fornix.

So let's rotate these images and correlate them with the ultrasound image in order for us to better understand what they represent.

So here if we rotate this image 90 degrees, you can see the conventional demonstration of how we depict an ultrasound on a transvaginal view.

And you can see how the probe in the anterior fornix allows us to see the uterus to best advantage with respect to this endometrium as we do in this case when we place the probe into the posterior fornix as we have in this patient and rotate the view so that we correlate it with the ultrasound.

Now you can see how this image translates, how this schematic translates to this image again, the uterus is pointing backwards and it turns out that this can occur as a function of where you place the probe.

So here's a patient who has a very distended bladder and you can see that the uterus is not retroverted in this case at this point.

Now, when we put the endovaginal probe in, you can see that placing the probe in the anterior fornix results in a picture of the uterus where the fundus is pointing towards the anterior abdominal wall.

And there's a Nabothian cyst here, which allows me to convince you that this is actually the same woman on all of these pictures because if we were to move this probe back and press up against the edge of the cervix, we can induce a deformity in this woman and start to cause a little bit of a change in her uterine orientation.

And if we move that probe even farther posteriorly now situated in the posterior fornix, as you see in this case, the uterus looks like it's retroverted.

And in fact, this is the same woman here.

The uterus is pointing towards the anterior abdominal wall here, the uterine fundus is pointing towards her back.

And it's because in this image we've placed the probe in the anterior fornix and in this image we've placed the probe in the posterior fornix.

This is normal and should not be confused for any abnormality of the patient's ligaments.

And in fact, you can use this technique to help you get better images of the endometrium when in fact there is a better image of the endometrium to be obtained by placing the probe in the posterior fornix.

So we would just say no to vaginal incidental findings such as a pessary, but also to changes in orientation of the uterus that can occur with placements of the probe.

Commenting on Uterine Flexion

But having said that, I do think it's important that you do comment on whether the uterus is retroflexed or not, because retroflexion induces a bend at the cervical uterine junction, that can sometimes be a difficult point for insertion of an endometrial biopsy device.

So in our practice, we always will comment if the uterus is retroflexed because should that patient go onto an endometrial sampling procedure as sometimes our postmenopausal patients will, you'll see that the gynecologist who's not aware that the uterus is retroflexed might actually have their Pipelle biopsy device stop here at the cervical uterine junction, and could in fact lead to a perforation of the uterus if they're not gentle.

So, it's important to comment on the flexion of the uterus.

So we do describe that.

Cervical Findings: Nabothian Cysts

Now the next set of images show a very common finding in the cervix and that are these avascular hypoechoic or anechoic spaces that are Nabothian cysts.

And these are nearly ubiquitous in patients and we don't comment on them.

And although they've been measured as in this instance, we typically don't measure them and we certainly don't report those measurements in our report.

These are essentially normal findings and most people are aware of that color Doppler can help because these should not have color flow in them.

So just say no to Nabothian cysts.

Sometimes these Nabothian cysts will line up against the endocervical canal and will simulate pathology of the endocervix.

So in this case, this patient has a number of Nabothian cysts that are lined up in the inner lining of her cervix.

And it makes one think that there might be actually an endocervical polyp sitting here in a dilated cervix.

But in fact you can see that the endocervix is actually here and imperceptible at this point, but this actually represents Nabothian cysts in the posterior lip of the cervix.

Endocervical Heterogeneity and Polyps

Now the cervix itself can be quite heterogeneous in its appearance.

Sometimes it has a very feathery internal architecture so that it actually has a layered appearance as we see in this case.

And in fact, here's another demonstration of that here.

Our probe is in the anterior fornix up against the side of the cervix.

This is the external cervical os, the internal cervical os is here.

And you can see that there are three or four different echogenicities of the cervix.

There is this bright line which is actually the opposed surface of the endocervical lining.

There's this hypoechoic layer, which is probably mucus.

There is this layer which is intermediate in echogenicity, and yet another layer that's the outer fibrostroma of the cervix.

And so this is actually a potentially normal appearance of the cervix.

Do not be alarmed if you see heterogeneity of the cervix, but sometimes that heterogeneity is actually rather discontinuous.

So as we see in this case here, it looks like there might be some focal heterogeneity of the endocervical region.

And in this case there's some focal heterogeneity of the endocervix simulating the possibility that there's a polyp.

In my experience, these focal areas of heterogeneity are not worrisome.

And in fact, I am asked why aren't you worried that this might represent the sonographic demonstration of early cervical cancer?

And my response is that you one needs to recognize that ultrasound really isn't a tool that's used for the identification of early cervical cancer.

And if you are compelled to state in every report where you see heterogeneity of the endocervix that you cannot rule out cervical cancer, then I would submit to you that you need to say that in every report because you really can't rule out endocervical cancer even when the cervix looks normal.

So hesitate from thinking that this always represents pathology, and in fact it almost never represents pathology.

One of the clues that we can use to see whether it is pathologic or not, is to assess whether there is a focal vascular pedicle that goes to this area because endocervical polyps can demonstrate that finding.

So here's another example of a patient who has a little bit of focal heterogeneity of the endocervix near the cervical uterine junction.

And here's another picture of the same patient to a better advantage showing this focal area.

Now, is this an endocervical polyp?

It most likely is not.

And in fact, here's yet another case of heterogeneity that's very focal, does not have any pedicle vessel.

And in this case, somebody had interpreted this as potentially being an endocervical polyp that led to the patient having a saline infusion sonohysterogram, which if you've ever done that for an endocervical lesion, is actually rather challenging.

But here we've put the end of the catheter at the outer part of the cervix.

You can see the balloon has been blown up and we've instilled fluid and the fluid has come in through this heterogeneous area into the endometrial cavity.

And in fact, this was not an endocervical polyp.

So it's very common for there to be focal or diffuse heterogeneity of the endocervix.

And in my experience, this is something that you should learn to pretty much ignore unless there are compelling reasons to suspect an endocervical pathologic process.

Those compelling reasons would include focal color flow in a pedicle vessel or relevant clinical symptoms.

So just say no to endocervical heterogeneity and endocervical mucus.

Here's another example of a patient who's got focal heterogeneity, but in this case, when we put color flow in there, there is a pedicle vessel.

And in fact, that is something that we would want to look for another case where it looks like there's focal thickening of the endocervix, and a color picture shows us a pedicle vessel coming to this area from the posterior aspect of the cervix.

This is a cervical polyp.

You should recognize however, that cervical polyps are not comprised of the same material as endometrial polyps.

Endocervical polyps are almost always fibrous etiology.

They are not precursors to cancer, whereas endometrial polyps, as we know, can be actually a representation of a cancer, although more frequently are benign.

So these endocervical polyps actually do not really need to be removed, certainly not if the patient is asymptomatic.

Now, if the patient is having abnormal vaginal bleeding, removal of these is usually performed to help the woman get over that particular malady.

So just say no to endocervical heterogeneity and endocervical mucus, but certainly do look for a pedicle artery.

Echogenic Foci in the Cervix

This is another cervical finding that can be mistaken for disease and that's the presence of these echogenic foci, sometimes clumped as we see in this case in the cervical lining.

Here are three different patients that have different manifestations of the same process.

Here there are quite a few of these foci up towards the cervical uterine junction here.

There's a fewer number of these, and here there are a number of them that are linearly oriented with respect to the endocervix.

Now there was an interesting study done by a Spanish group that looked at 512 patients that were having a hysterectomy.

And what these investigators did is they did a detailed sonographic evaluation of the uterus while the woman was anesthetized in the operating room, took careful pictures and then after they did the hysterectomy, they did a sequential series of pathologic slides looking and correlating any abnormalities seen pathologically with any abnormalities that were seen on the ultrasound.

And it turns out that when you have these little echogenic foci either scattered or clumped in the endocervix, as we see in these cases, that 43 of the patients who had that finding of the 43 20 of them had what was pathologically considered to be chronic cervicitis, whereas only five of the patients who did not have this finding five of the 469 other patients had chronic cervicitis.

So clearly this is a finding that is associated or increases the chance that you have chronic cervicitis, but note that the positive predictive value for this is still less than 50%.

So if you were to find this and you were to say if the patient had chronic cervicitis or not, if you say the patient has chronic cervicitis, you're still gonna be wrong more often than you would be right.

More importantly is the recognition that chronic cervicitis isn't really a condition that is treatable or treated in our medical regimen.

So, it's generally a sign of previous inflammation.

It can predispose the woman to having cervical stenosis, but it's not something that they take antibiotics for.

So when you see these clustered foci, endocervical calcifications just say no.

Endometrial Fluid

Here's a patient who has images of the uterus showing a small amount of fluid in the endometrial cavity.

And this allows us to actually nicely see the endometrial lining, which is normal and thin as in this case.

And here's yet another patient with a slightly retroverted and retroflexed uterus that has fluid in an endometrial cavity.

This allows us to see the endometrial lining as a thin structure.

So the presence of a small amount of fluid in the endometrial cavity is actually a helpful finding.

And although you should look carefully for any obstructing mass or other abnormality, once you are assured that there is none, you do not need to worry about some process that you're not seeing well.

So we're going to consider as essentially normal or certainly not worrisome, the presence of a thin layer of endometrial fluid in such patients.

Now, having said that, when I do see that, I always mention that the patient probably has cervical stenosis, especially if the patient is postmenopausal because if she's having some vaginal spotting and she rightly goes on to having an endometrial sampling procedure for that, then in that instance, the gynecologist will be happy to know in advance that the patient probably has cervical stenosis.

They may tailor the aggressiveness or certainly the type of biopsy that they choose to do.

C-Section Scars

Here's a sagittal image showing a finding in the lower uterine segment.

And there are one of four possibilities for this in terms of how you might approach it.

And in my estimation, this is a common finding that you should ignore.

It's a C-section scar, and once you get to see a few of these, it becomes much more recognizable to you what a C-section scar can do in terms of deforming the anterior part of the uterus and the refractive shadow that results from that.

Here are some other examples.

The C-section scars occur obviously in the lower uterine segment.

They can be echogenic or hypoechoic.

They typically distort the sonographic beam such that you get a refractive shadow.

In this case, it looks like the endometrium is growing out into the scar itself.

That's not the case in this case, the echogenicity of the scar merely reflects fibrosis of the scar.

And here's another case where there's fluid in this patient because we've done actually these are two different patients, I believe because we've done a saline infusion sonohysterogram, and you can see that the layer of myometrium overlying the scar is rather thin, alarmingly thin, but still this is normal.

This is what people look like after having a C-section.

And you'll almost always see these defects in patients who've had saline infusion sonohysterograms when they've had a C-section scar.

So a C-section scar by itself should not alarm you, and you should become comfortable with recognizing these even in patients who are not having a saline infusion sonohysterogram.

Now having said that, this patient presents with abnormal vaginal bleeding.

She has intermenstrual bleeding.

If you see a C-section scar that's filled with fluid in a patient who you've not done a saline infusion sonohysterogram, and who does have symptoms of intermittent bleeding, this is something to mention and recognize because what's likely happening here is that during menstruation, the blood comes out through the cervix through the endocervix, but some of it accumulates in the scar.

And the theory is that there's a small fibrotic flap that acts as a wind sock so that the fluid collects here.

Then when she ceases menstruation a few days later after the coagulated blood starts to lyse it leaches out.

And these patients can benefit from resection of the fibrotic flap.

So we do mention a C-section defect if it's filled with fluid, if the patient has abnormal uterine bleeding.

This was written up, I wrote this up for the Society of Radiologists in Ultrasound newsletter in January 2008 that you should be able to get to online.

And this is the data behind that these investigators showed that premenopausal women with this finding and symptoms benefited from surgical resection of the flap.

Evaluation of the Endometrium

This leads us to evaluation of the endometrium itself.

These are images of the normal endometrium during the early proliferative phase, and I think we would all recognize this as a normal endometrium in the early proliferative phase.

Here in the mid cycle, you can see that the endometrium has gotten a little bit thicker, but it's gotten thicker because the superficial layer is hypoechoic the deep layer, the basal layer, it actually remains the same thickness in the same thickness.

And this is a normal appearance of the endometrium at the mid cycle.

And in early to mid secretory phase, the superficial hypoechoic layer actually gets more echogenic from out to in so that we rapidly get disappearance of that superficial hypoechoic layer.

In fact, the superficial layer is the same thickness as it was previously, it's just that it's becoming more echogenic and blending in with the basal layer.

And finally, you'll get to the point near the end of the secretory phase where you no longer can recognize the superficial layer as a separate structure from the deep layer.

It all looks the same.

And in fact, you won't even be able to recognize the opposed layer of the endometrial lining as a line.

And this represents the normal secretory phase.

So we're comfortable with that.

And this is a 12 millimeter thickness of the endometrium in the secretory phase.

And this is where people start to have problems because they want to know what number is abnormal in the secretory phase in terms of thickness of the endometrium.

And in fact, there is no good number for what is abnormal.

Certainly there'll be some cases that seem excessive in terms of the thickness of the endometrium, but if you are confident and if the patient assures you that you are studying her in the secretory phase of the menstrual cycle, especially if she's near the onset of menses but has not yet started menses, this can be entirely normal.

And so you should learn to recognize secretory endometrium for what it is.

It's thick, it's generally of similar echogenicity throughout, and measurements of the secretory endometrium are not helpful.

Measuring the Endometrium and Common Errors

So how do we measure the endometrium?

And sometimes we can make mistakes in that.

Here is a woman who's postmenopausal, she's 60 years old and I've given you three choices in terms of how you might choose to measure her endometrium.

So if you can think to yourself which of these three choices is best, I'll tell you that C is the accurate method of measuring this woman's endometrium.

But some people will mistakenly choose B or even worse, A as the measurement to make.

And that's because they've mistaken the hypoechoic inner layer of the myometrium as the superficial layer of the endometrium in a premenopausal patient.

So in postmenopausal patients, you can get a very hypoechoic inner layer of the myometrium, the junctional zone that simulates this hypoechoic superficial layer.

Note the difference between how we measure this, which is from the basal layer to the basal layer, and this which is also from the basal layer to the basal layer, not the myometrium to the myometrium.

So you wanna say no to hypoechoic inner myometrium, it can fool you.

Now here is a patient who has an endovaginal examination and we have her the probe in the anterior fornix.

But despite that, when you're asked to give a measurement of the endometrium, you might as well insert whatever number you want.

It's a wild guess because we're not seeing the endometrium.

Well, in this particular case we're not seeing it well because the patient has adenomyosis.

But we did see it fairly well on the transabdominal view.

Here you can see that the endometrium seems thin, and that the junctional layer is hypoechoic.

But certainly this is a better method of measuring the endometrium in this particular case than this.

So I would encourage you to always look at your transabdominal images for correlation with your endometrial thickness as compared to your transvaginal images.

Here's another patient who has a wild guess on your endovaginal examination as to the endometrial thickness, but we're able to say with more confidence that the endometrium is normal in appearance on the transabdominal view.

A third patient here, if you were to measure the endometrium in this case on this particular image, you might choose to put your cursors here and here, but that's because your eye is being fooled by this refractive shadow that's coming at this point and at this point due to perhaps some heterogeneity of the way the sound bends here at this angle.

And so it's a common mistake to measure this from here to here.

How do we avoid that mistake?

Well, one way to avoid that mistake is to look back on your transabdominal view and have an expectation for what the endometrium should look like or will probably look like.

Here on this image.

Before we did the endovaginal, we saw that the endometrium was likely thin.

Now, when we did the picture on the transvaginal view, we were surprised at what we were seeing.

So we wanted to look even more carefully and with more careful imaging of the endometrium, we were satisfied that in fact we were dealing with a thin endometrium as we suspected.

So I don't want to leave you with the wrong impression.

Clearly you are charged with measuring the endometrium on the transvaginal view.

That is the most accurate way to measure the endometrium.

But there are instances in which the transabdominal view will inform your decision as to how to best measure the endometrium transvaginally.

And there are some instances in which you just can't get a good transvaginal image of the endometrium and the transabdominal view will help you be a little bit more reassured that the endometrium is not abnormal.

Another case where a Nabothian cyst is leading to a refractive shadow such that the endometrium is not well imaged transvaginally, if you can, you'd wanna put the probe in the anterior or the posterior fornix, but in some postmenopausal patients, you'll not be able to move the probe into the anterior posterior fornix and you're left with really a bad measurement of the endometrium.

And in such cases, I would advise you to look at your transabdominal view if you do them to help inform your decision about what the endometrium actually is.

Another case where transvaginally you would have a difficult time measuring the endometrium accurately, but because on the transabdominal view we had a suspicion that the endometrium was thin and eccentrically placed with respect to the AP diameter of the uterus because of the presence of adenomyosis.

With that understanding, we were able to go back into our transvaginal view and achieve an image that was albeit by itself not very convincing that we're measuring the endometrium in combination with the transabdominal view, very convincing that the endometrium is in fact normal.

So just say no to endometrial measuring errors and do use all the tools that are available to you to help make those accurate measurements.

Echogenic Endometrial Foci

Now here's a case of a patient who has small echogenic foci associated with her endometrium.

And I think many people are comfortable with this particular finding as something that might represent evidence of a previous D&C or other biopsy, but not something to worry about.

And these can actually be within the endometrium itself as we see in this echogenic lining echogenic focus, which is probably within the endometrium and not in the inner myometrium.

But having said that, you should recognize that some postmenopausal patients will have even broader swaths of increased echogenicity associated with their endometrium.

Sometimes these are diffuse and sometimes they're more focal.

Here's a case where the endometrium is very echogenic on both the transabdominal and endovaginal views, but there's not really a mass associated with this.

This is a quite thin endometrium, but rather echogenic.

When I first encountered these findings, I was always a bit worried that I'd be dealing with some sort of dystrophic calcification or even perhaps osseous metaplasia of the endometrium.

But in the few hysterectomy specimens that our pathologists looked at in patients who had these sorts of findings, they almost always found just fibrosis or actually made no comment whatsoever.

Here's another case of endometrium that's rather echogenic.

In fact, in this patient she has a little bit of cervical stenosis and so she has a little bit of fluid and you can see that the lining is echogenic, but there's not a mass.

This echogenicity matches that of this calcified fibroid in the posterior myometrium.

So they're rather bright, but notice that they don't usually shadow.

That's a hallmark of fibrosis of the endometrium.

So just say no to echogenic endometrial foci and echogenic endometrial lining.

These are typically, although perhaps not normal, they're certainly usually processes that are not of any significance.

Saline Infusion Sonohysterography in Secretory Phase

Now, let's go back to this case.

If you remember, I showed this case as an area of focal heterogeneity of the endocervix that didn't have color flow, but was still read out as a possible endocervical polyp in this asymptomatic patient.

Not a diagnosis that I would encourage you to make after this lecture.

But having said that, we were compelled to do a saline infusion sonohysterogram in this patient, and we proved that this was not an endocervical lesion, but in the process of doing that, we learned something else that is a truism about the endometrium.

And that is that you should not do saline infusion sonohysterography in patients who have secretory endometrium.

This patient assured us that she was not pregnant and she was not pregnant.

Nor could she have been pregnant.

And that's not really why I'm showing you this.

I'm showing you this because once we put the fluid in, we were left with this a small cleft in the endometrium that simulated a polyp.

There was no focal vascularity, but this now raised the possibility of endometrial polyp.

Remember, in this asymptomatic patient who was brought back for a possible endocervical polyp, which we proved wasn't there.

Here's a more dramatic case of a patient who's perimenopausal and who is having abnormal bleeding.

And the person who was doing the study elected to go ahead and do the saline infusion sonohysterogram.

And you can see that there are a lot of clefts in this endometrium.

In fact, it simulates multiple uterine polyps in this endometrium.

But in fact, after we gave this patient progestin and induced a medical curettage or a progestin withdrawal bleed, this is what her endometrium looked like.

It was entirely normal.

She had no polyps.

So refrain from doing saline infusion sonohysterography in the secretory phase.

You just have to say no to that because this will get you in trouble.

Tamoxifen Surveillance

Now here's a question for you.

Is ultrasound a test that we should be using for routine surveillance of the endometrium in asymptomatic patients who are taking tamoxifen or other SERMs?

The answer here is false.

Routine ultrasound surveillance of patients taking tamoxifen or other SERMs is likely to be confusing and not helpful.

What you find is that a number of investigators have looked at that and there is no good number 6, 9 15, there's no good endometrial measurement number that helps to define a likelihood ratio.

That's anything more than one to three.

And that's not good enough for making a patient move on to an endometrial sampling procedure when she's asymptomatic.

Here are some examples.

This patient looked like she had focal thickening of her endometrium, but she was taking tamoxifen.

The sonographer in this case chose to measure this focal area as a possible mass, but in fact, no mass was present at surgery.

Another patient who has diffuse subendometrial cystic changes characteristic of tamoxifen change, but also had perhaps a focal area that looked a little bit different.

She went on to have surgery, and not necessarily because we had recommended it, but she was asymptomatic and there was nothing here.

So you wanna say no to asymptomatic patients who are taking tamoxifen with respect to worrying about focal heterogeneity of the endometrium when you see cystic changes in many other places, because more likely than not, that is not gonna be related to true endometrial pathology.

It's gonna be related to tamoxifen change.

Arcuate Vessels

And finally, I think we're all comfortable with this normal variant where the arcuate vessels in the uterus look very prominent.

And sometimes these will fill with color, other times they will not fill with color depending on how sluggish the flow is and the distance between the finding and your probe, these are prominent arcuate vessels and you should recognize that as such.

And that's usually not a problem.

In fact, this is usually not a problem.

Most people are familiar with this, where those arcuate vessels calcify, especially in patients who are diabetics and this is a normal or not pathologic finding.

I mean, it is pathology in the sense that there is calcification, but it's not something to worry about.

But if you look closely at your endovaginal sonograms, you'll see that you can almost always see a thin line here that defines or bisects the myometrium.

This is where the arcuate layer or arcuate vessels lay.

And sometimes in our desire to be as compulsive as possible, we will see things like this.

Now, here in this patient, this I think most people would recognize is just prominent arcuate vessels.

But this might raise your concern that there is a fibroid.

And I've seen lots of sonographers and radiologists put calipers on things like this that lie right at the arcuate layer and call that a fibroid.

Now, in fact, that could have been a small fibroid, but one of the hallmarks is that it should look like a mass on all the views obtained here.

This looks like a mass, but in the transverse view, it doesn't really look like a mass at all.

In fact, it looks more like a prominent arcuate space as this is here.

And in fact, an MRI on this patient that was done for other reasons showed that there was no fibroid in this spot.

So you wanna say no to arcuate artery pseudo lesions.

Conclusion

Well, what I've tried to do today is to give you a framework for just saying no or normal to many of these incidental findings that you will find on ultrasound images of the uterus.

And I think that's important because if you get into the habit of calling these things abnormal and certainly raising the possibility of disease, don't be surprised if one day you hear a click while you're sitting in your reading room.

And what that click will represent are a bunch of gynecologists coming to your office and closing the door behind you to do an intervention because I'm sure they're gonna think that you're on drugs.

Thanks very much.