Postmenopausal Pelvis - HD

Introduction

Hi, my name is Debbie Levine.
I'm from Beth Israel Deaconess Medical Center in Boston
and Harvard Medical School.
And today I'll be speaking about the postmenopausal pelvis.
On this talk, what I'd like
to talk about is what's important
to know about the postmenopausal uterus and ovary.
We'll be talking a little bit about
how hormones affect the appearance
of the uterus and ovaries.
We'll talk about how we distinguish between benign
and malignant disease and then discuss doppler
and how helpful is it in distinguishing
between benign and malignant disease.

Menopause Demographics

Now, menopause, at least in the United States,
is very, very common.
We have about 280 million people,
and over a quarter of American women are postmenopausal
with 35 million being greater than 50 years of age.
The life expectancy for a girl born today is about 80 years.
So we have a large number of people
who are living in the time of menopause.
We need to know about the appearance
of the postmenopausal ovaries
because it can sometimes be difficult to visualize them.
It's not as easy when women are younger
and they have nice large looking ovaries with lots
of follicles and cysts that let us see them.
So sonography of the postmenopausal ovaries are important
because sometimes there'll be a palpable mass on physical
exam, and we're trying to figure out if
that's an excellent etiology.
Some women will be at high risk for ovarian cancer
and desire screening.
And then if a patient has a known mass,
we need to know how to think about it.
If it's completely cystic,
then while koic gets likely benign,
no surgery's probably needed.
If it's complex or solid, there are other things
that we need to think about.

Hemorrhagic Cysts in Postmenopausal Women

Now, if you ever see a cyst like this filled
with echoes in a younger woman,
you'd say it's a hemorrhagic cyst
in a woman who's truly postmenopausal.
It's an abnormal finding.
Now, many women who are post-menopausal, for example,
50, 51, 52 still have spontaneous cycles.
And even after menopause, years
after menopause, a spontaneous cycle can occur.
So if something has a high likelihood
of being a hemorrhagic cyst by its appearance,
you might wanna give one short interval follow up in
a postmenopausal woman.
But just realize if you see something
that looks like a hemorrhagic cyst, you need
to think twice if the woman gives a history
of being postmenopausal.
This is not a normal finding in a postmenopausal woman.
If she's 40, you're gonna think about it
differently than if she's 70.

Challenges in Scanning Postmenopausal Women

Why are postmenopausal women different, difficult to scan?
One is they tend to have a little bit more, they,
I should say, we, tend
to have a little bit more abdominal fat.
There can be atrophic vaginitis,
which might make either the technologist uncomfortable
putting in the probe or even the patient uncomfortable
putting in the transvaginal probe.
And as I mentioned earlier, the ovaries can be small
and lack follicles and be difficult to see.
Here we've got a nice normal appearing postmenopausal ovary,
very almond shaped in its appearance and hypoechoic.
It turns out that ovarian visualization gets more difficult
the longer you go after menopause, and it makes sense
because the ovaries get smaller and smaller.
So if you, believe the studies that you read,
it would be about 80% less than five years
after menopause, going down to maybe 75%, five to 10 years,
and down to 60% or greater than 10 years.
Transabdominal
and transvaal visualization
of the ovaries can also be affected
by if the patient's had a hysterectomy.
Think about it.
If the uterus is in place, you have your landmarks
for knowing where the ovaries are,
and the ligaments help hold the ovaries in place.
But once the uterus is gone,
the ovaries can move elsewhere
and can be more difficult to visualize.
So if a woman has not had a hysterectomy, about 76%
of the time, we can see the ovaries.
And if she's had a hysterectomy, that can go down
to about 30, 43%.

Ovarian Volumes

Now, there was a paper published quite a while ago at this
point, ovarian volumes measured
by ultrasound, bigger than we think.
Looking at older women, these were all,
supposed
to be, postmenopausal.
But you can see the age range is different.
Transabdominal, transvaginal,
and the percent of ovaries visualized going from 20%,
to 99%.
And for postmenopausal ovaries,
I have a hard time believing, that 99%
of the time, they were seen.
And I think a lot of times when ovaries,
so-called ovaries are measured,
it's actually gonna be loops of bowel.
So you wanna be very careful,
that you're actually looking at an ovary.
And then when you look at these volumes that are recorded
as normal, they have a wide range, going from 0.2,
all the way up to 14, centimeters cubed.
So how in the world with this wide range of normal are we
to think about a postmenopausal ovary?
Basically you want to compare the two sides.
Now, some people say, you can look for peristalsis
to see if it's bowel or not.
But if you think about your own colon,
it doesn't pair stalls that often.
So if you're looking at a loop of small bowel, yes,
it might pair stalls, but if you're looking at a loop
of colon sigmoid, it might not.
You also wanna look
and see if it trails off if you have margins.
You also wanna see if you can see mucosa.
And if it really looks that like that nice
almond shaped ovary that I showed you
before, the next topic in
postmenopausal ovaries are the cysts.

Adnexal Cysts in Postmenopausal Women

How in the world should we think about postmenopausal
aed, NAL cysts?
Why do we care? We care
because greater than 85% of ovarian cancers are cystic,
and we wanna make sure that we're not missing a lesion.
So what do we need to think about when we see a cyst on a
pelvic ultrasound and postmenopausal woman?
First you wanna make sure you're
not looking at the cervix.
Now, both otium cysts are very, very common.
They can be koic, they can have debris,
but they're all gonna be located in the cervix.
So that is very, very clear.
So make sure you're not being faked out.
Sometimes you'll see a mass
that looks like this out in the aa that would look very,
very scary if it was indeed arising from the ovary.
But you turn on color and this is all vasculature.
Pelvic es.
Sometimes you'll see a cyst right next to an ovary.
Para ovarian cyst
and para ovarian cysts are almost always benign.
Very, very, very, very rare, for a tumor,
let alone a cancer to arise in a para ovarian cyst.
But we wanna treat them like any other Ed Nal cyst
and look at them very, very carefully.
Look at the wall, look for any internal echoes.
Sometimes you'll see what's clearly a hydro cell.
Pinks, you'll be able to say it's a hydro cell, pinks
that does not need follow up based
on the ultrasound appearance.
But sometimes if you don't look at the hydro cell pinks
lined out like that, it will look like this.
This is the same patient.
So if you ever see what looks like a multi septated ovarian
cyst and you're worried about cancer, make sure
that it's not actually a hydro cell pinks
that you're just cutting slightly differently
and looking like a complex ovarian cyst.
This is basically a benign finding.
Very, very infrequently you'll have a bladder diverticulum,
that masquerades as an adexo cyst.
This is a very old case.
You can tell by all the scratches on the images,
but this is the bladder and this is the adexo cyst.
And the way you can tell is you have the patient empty the
bladder and the diverticulum will look different.
Or sometimes you'll actually see the communication
with the diverticulum.

Transabdominal and Transvaginal Scanning

Now I've just been talking about looking at these adnexal
cysts, and I've been assuming,
that you're doing both transabdominal
and transvaginal scanning.
Transabdominal scanning is important in order to look
outside of the range of the vaginal probe,
but transvaginal scanning is important
for the best characterization of adnexal masses.
So if you look at this particular mass here,
here's the bladder, here's this mass.
You might think it's a cyst, it's very hypo coic,
but you do transvaginal.
You can actually see that there are echoes
within this fibroma.
If you look at published literature on simple cysts,
you can see why ultrasound characterization is problematic.
I point out to this paper
because they looked at a large number
of postmenopausal women over 3000.
They found simple cysts and 6.6%,
and they operated on 18 of them.
So they only operated on the minority.
And what they found were ser cystadenomas.
That makes sense for a simple cyst,
but the other lesions don't make sense.
For a simple cyst cyst, adeno fibroma,
you'd expect a solid fibrous component.
Dermoid very rare for those to be simple cysts,
normal ovaries, maybe it was a para ovarian cyst,
maybe it was a tube, maybe they were looking
at a loop of bowel.
But the fibroin, adeno fibroma, those are solid lesions
and probably they were solid lesions
that looked like simple cyst,
but they didn't have their gain set appropriately
or they didn't look with a vaginal probe
or maybe they didn't turn on color
to see internal vascularity.
All very, very important things to look at
before you disregard a simple cyst in
a postmenopausal woman.

Studies on Postmenopausal Cysts

This is a study, that we did a long time ago, 1992,
looking at asymptomatic postmenopausal woman.
And we did transabdominal
and transvaginal scans every three months for a year,
and then every six months in the second year,
and we found lots of adexo cyst.
Now, most of these cysts were very, very small,
less than a centimeter.
17% of the women had cysts on their first screen,
24% had them at some point in time
during the 2-year-old follow up, and 97% were less than
or equal to three centimeters.
Then looking at over time what happened
with these postmenopausal cysts, you might think, if it's a para ovarian cyst, it won't change.
That's this 28% didn't change,
but a large number actually disappeared.
Now, cysts can disappear because you don't see them or
because they actually resolve.
So you wanna make sure that you're doing good
quality follow-up studies.
But the postmenopausal ovary can actually, like I said
before, have a spontaneous cycle,
especially if you're in your first five
years after menopause.
The early postmenopausal period, some
of these cyst enlarged during the follow-up period.
Some got bigger and then smaller and some got smaller
but didn't completely disappear.
Here's another study, reported in 2002.
By Valentine, they had 134 postmenopausal women
with 160 cysts.
They said 25% were complex but benign appearing,
and they followed up them up for eight years.
9% of the CYS ended up being removed.
29% of them disappeared.
13% of the women got new cysts over time, and 49% increased
or decreased in size or stayed the same.
So again, they're finding similar size,
similar appearances of cysts.
Some go, some occur,
some increase in decrease in size.
Very important to realize this.
And I think the other issue are these complexes.
You might see a little bit of debris within them,
but overall they look benign.
These are very scary and we tend
to follow them up very closely.
This is the, example of a cyst
that's disappearing on the first screen.
It's three centimeters on a follow up, six months later,
three millimeters.

Complex Cysts and Malignancy Indicators

What if it's not a simple cyst?
You can see from this image last menstrual
period 15 years ago.
This really looks like a dermoid.
It's got all these bright echoes.
It's got some linear bright echoes within it.
If it looks like a dermoid, it probably is a dermoid.
We think about dermoids as being tumors of younger women,
but if this patient had a dermoid her whole
life, it was never removed.
It's still there. It's not gonna go away on its own.
So if it looks like a dermoid, it's a dermoid.
The problem with postmenopausal women is that the incidence
of dermoids transforming into squamous cell carcinoma,
that risk increases with patient age.
So frequently, if you see a dermoid of this size
in a patient of this age,
it will end up being removed even though it's
most likely a benign finding.
Here's another postmenopausal woman with a lesion
that looks like a dermoid.
It's a dermoid. This though doesn't
really look like a dermoid.
It's a 28 centimeter cyst. It's got a few septations.
Most likely it's gonna be a sero cystadenoma.
Even though the patient's postmenopausal this has,
even though this is big,
it still has very benign characteristics.
But when these lesions get to be this size,
they tend to be removed.
One of the concerns is
that you might not be seeing the entire wall of the cyst
if a patient really doesn't wanna have surgery.
If a lesion is more than seven centimeters in size,
we're currently recommending an MR to ensure,
that the entire cyst is being well characterized.
Once you see solid elements, that's when you're going
to worry about malignancy.
So cyst with solid elements,
you're gonna look for blood flow.
Look for blood flow in that solid element
and see if there's any blood flow.
If that's a real finding,
you're gonna worry about a malignancy.
One single thin septation isn't bad.
One tiny nodule without flow is not necessarily bad,
but once you get to the thick, irregular septations,
the nodules, the nodules with flow,
that's when you're gonna think about cancer.
So here we've got somebody, her,
her last menstrual period was 45 years ago.
She was like 90 years old. This is her bladder.
This is a transvaginal scan.
She couldn't empty her bladder real well.
You're seeing this cyst.
This is a thin septation here,
but this is a more solid appearing nodule.
You're gonna think about a malignancy in her,
and this is more florid appearing malignancy with large,
solid area.
And here's a different patient with a very complex cys,
cystic and solid areas and blood flow.
Blood flow is so incredibly helpful,
but we'll get back to that in a little bit.
Here's a solid lesion with flow. I know it's a solid lesion.
It doesn't look like a fibroma, fibro the coma.
If it's bilateral. We're gonna think about
metastatic disease.
Here. We've got bilateral enlarged ovaries and ascites.
You're gonna think about metastatic disease here.
We've got some omental cake,
definitely metastatic disease.

Doppler in Distinguishing Benign and Malignant Lesions

Let's now turn to doppler.
Is doppler helpful in helping us determine when we see one
of these lesions, if it's benign or malignant?
When doppler first came out, low malignant,
low resistive index,
and I'm showing you the resistive index here.
You take systole minus diastole divided by systole.
That's gonna give you the resistive index.
Low resistive index, less than four was associated
with malignancy, but there were a lot of problems with this
because the corpus lium has a lot of blood flow
and has a low resistive index and so do inflammatory
and metabolically active masses.
A high resistive index is associated
with a non-functioning ovarian with benign masses.
But you can also see areas
of high resistance within tumors.
A a lot of papers have come out on, re use
of doppler in nexel masses and the very high sensitivity
and specificity that was originally reported has definitely,
fallen outta favor.
This exam, paper from Bromley 1994 had 8% sensitivity in
82% specificity, for looking at malignant masses.
Here I'm looking at a solid element
in what looks like a tumor.
And in one area I get an RI of 33%
and in another area an RI of 77, or I'm sorry, 66%.
So again, you need to look around in the solid area,
for the most abnormal appearing area of resistance.
And here we've got a tumor,
with blood flow in the solid element.
And of course, you're gonna think about a cancer in this
case or in this case,
and it really doesn't matter what size this lesion is.
This is a 2.2 centimeter nodule
with a tiny little solid element within it.
But that tiny solid element has blood flow.
And so it doesn't matter what this patient's age is,
it doesn't matter that this cyst size is in
the physiologic range.
Once you have a solid nodule with blood flow,
the likelihood is that it's malignant.
And this was a very early stage cancer.
This is what we need to look
for if we wanna find early cancers.
Here's one of the lesions I showed you
before with this large kind of frond,
like solid area, lots of blood flow.
Look at this resistive index.
This is a beautiful resistive index for a benign lesion,
but none of us would call this a benign lesion.
There's a large solid area with blood flow.
This is malignant, ignore the resistive index.

Management of Postmenopausal Adnexal Masses

Let's kind of put all of this information together in
how we should think about postmenopausal solid and exile.
Masses. Masses, anti coex cyst, very, very, very common
Thin walled koic through transmission, they're benign.
If they're large, they might be neoplastic like a serous
cystadenoma, but it will still be a benign lesion.
Complex cyst.
You can have a hemorrhagic cyst if a woman's
spontaneously ovulated, so you want to check for that,
but if it's persistent, if there's nodularity in septations,
that's gonna increase the likelihood of malignancy.
If it's a solid mass, it turns out that fibroma
and theas are gonna be the most common solid mass.
But you don't wanna forget about metastatic disease
and undifferentiated carcinoma.
Here's a very interesting autopsy study done by Valentine.
In 2003, they took 52 women
who were having an autopsy without a history
of gynecologic malignancy,
and they scanned the ovaries that were removed at autopsy.
So these are the ovaries that are actually out of the body,
and they found 54%
of them had cysts ranging in size from two
millimeters to six centimeters.
Half of the women had cysts.
Interestingly, 12% of solid lesions including fibromas cyst,
adeno fibroma, brenner tumor,
and a chunk of calcification,
what they called a dystrophic calcification.
Now the pathologist then sliced and diced the ovaries
and found an additional solid lesion
and an additional 85 cysts.
So what's the take home message from here?
Cysts are incredibly common, so are fibromas.
Now, I think when the ovaries are out
and you're seeing one of these small solid lesions,
that's different when the ovaries are in the body
and you're seeing small solid lesions.
Probably the lesions that we're seeing are larger than the
lesions that that we're seeing on this autopsy study.
But nonetheless, realize that these are incredibly common,
usually benign findings.
In fact, from this study, their conclusion was
that small benign and nyl cysts
and small benign solid tumors are
so common in postmenopausal women
that their presence may be regarded as normal.
I don't have a problem ignoring the small benign
appearing at nexel cysts.
I tend to follow up the hemorrhagic cysts that
otherwise look benign.
To reassure everyone, the solid tumors still tend
to be operated on.
Although women are not a good operative risk,
you might wanna look up this paper
and use this as a reason,
to follow these patients very carefully.
So again, management of postmenopausal and nexel cyst.
If they're benign appearing koic thin while
through transmission, less than a centimeter,
they can be safely ignored, one to seven centimeters.
We tend to get a yearly follow-up ultrasound greater
than seven centimeters.
They're likely neoplastic, but likely benign cystadenoma.
You might wanna do an MR
to make sure you're not missing anything.
You might wanna do surgery,
but if the patient's not an operative candidate,
you can safely follow these.
Anything atypical solid element septations.
Think about having surgery.
This is the only example I have
of a totally benign appearing, a NAL cyst coming back
and having a solid element.
We know it has to happen at some point in time
that cystadenomas cyst adeno fibromas,
did I miss a tiny nodule back here?
Who knows? But she was three years post menopause.
12 millimeter anti coexist came back with this tiny nodule.
There was no blood flow in the nodule.
Three years later, you see that
she ended up not having surgery
and continuing to be followed and did fine.

Postmenopausal Uterus

We're done with the ovary.
We're now ready to move to the uterus.
After menopause, the body of the uterus gets smaller
and smaller and many, many years
after menopause, the uterus will attain kind
of an infantile configuration with the body
of the uterus being smaller than the cervix sometimes,
especially if the patient has hypertension, renal failure,
diabetes, you'll see arcuate artery calcifications.
And the reason that I mentioned these,
they're in the outer third of the myometrium, is
that frequently people don't realize that outside
of the arcuate arteries is where you're going
to measure the uterus.
And these can also make it difficult to see the endometrium
because of shadowing.
So here's a patient with arcuate artery calcifications
transabdominal scan.
In each of these patients here we're looking
at the transvaginal scan.
A little bit of fluid that you couldn't see here.
Transvaginal scan for a better look at the endometrium.
So the postmenopausal uterus is generally smaller
than premenopausal.
What should we do if it's big?
You can imagine if a woman had a, a huge number
of fibroids, premenopausal per menopausal, they can go wild
and grow postmenopausal.
It's gonna take a long time for that uterus
to get back down to size.
So what do we do when there's
postmenopausal uterine enlargement?
The first thing is to look at old studies.
Were there fibroids before? Was there adenomyosis before?
How has it changed in size?
If a woman has a growing uterus
after menopause, you need to worry about sarcoma.
These can appear similar to fibroids,
but will tend to have rapid growth.
Adenomyosis has a very classic appearance
with these alternating bands of shadowing.
And through transmission, you can have heterogeneous diffuse
asymmetric enlargement of the uterus without a focal mass.
You may or may not see small myometrial cysts.
Now adenomyosis, we typically think
of involving women ages 40 to 60.
So you can imagine in that early postmenopausal period,
you're gonna frequently see adenomyosis
as you're scanning patients with enlarged uterine.
Another cause of postmenopausal uterine enlargement
that should be very obvious is fluid.
Now, fluid can occur in an obstructed uterus,
and we always worry about
that obstruction being due to cancer.
Here we can see a tumor, hard to know if this coming out
of the cervix or the lower endometrium,
but it's definitely causing obstruction.
So the obstruction can lead to a fluid-filled uterus.
But if we don't see a lesion,
we're gonna look very carefully of course, for a lesion.
If we don't see a lesion, then the most common cause
of the obstructed uterus is actually benign Cervical
stenosis, women who've had prior children, which is many,
many women in our population,
if they've had previous instrumentation
or trauma, they're at risk for cervical stenosis
and down on our list.
But not to forget about our cervical
and endometrial cancer, such
as what we're seeing in this patient.
So when you see fluid in the uterus, you wanna look
for a tumor, but sometimes the tumor will actually be
grossly invasive instead of obstructive.
And in that case, you might just see uterine enlargement.
This is a 91-year-old woman
and you can't even see where the endometrium begins or ends.
In this case, 65-year-old woman
who hadn't had a pap smear in a long time,
there's a big cervical mass, very, very rare for us
with ultrasound to make the diagnosis of cervical cancer
because usually patients have a pelvic exam first,
and the physician would end up seeing
that or testing for it.
So we think about endometrial cancer when you have poor
definition of the endometrium
and loss of the endometrial myometrial
interface in a patient with bleeding.
Usually not as advanced as this.
And I'll show you some other images in a minute.
Cervical cancer, we're gonna think about when there's a
solid cervical mass that's hypo coic.

Endometrial Assessment

Let's now turn to the endometrium itself.
And I have some pictures here of basically a cylinder,
and I'm thinking of the endometrium as a cylinder.
And we know it's not a cylinder,
but I wanna just show you what happens.
If you cut the cylinder obliquely,
you're gonna make the endometrium look larger.
If you get perpendicular to the cylinder,
then you're gonna get a good measurement.
How does that apply to the endometrium?
Think about the endometrium as our cylinder.
We wanna line it up
and cut perpendicular
to it when we're assessing the endometrial thickness.
So you need the uterus and a sagittal plane.
By definition, we're using both layers of the endometrium.
We wanna exclude any endometrial fluid
and exclude this hypo coic outer layer of myometrium.
Always use transvaginal sono sonography if you want
to evaluate the endometrium.
With women with bleeding, this is a reason
to do a vaginal scan.
Now, patients of course can always decline a vaginal scan.
If you have a vaginal patient, you wouldn't want
to do a vaginal scan.
Even if she's very post-menopausal
and is reluctant, you can show her the probe,
you can tell her you'll, you'll lose lots of extra gel.
You can put it in very gently, slowly
and see if she can tolerate it,
because we wanna get a good look at the endometrium.
Here's a very full bladder.
We're looking at the uterus here in the endometrium.
It looks normal. The same patient, trans vg, tiny amount
of endometrial fluid, tiny polyp.

Reasons for Endometrial Evaluation

Why do we worry about the postmenopausal endometrium?
In women with postmenopausal bleeding,
we wanna look for the cause.
Polyps, hyperplasia, cancer.
We also wanna screen high risk women.
It turns out that women who are taking unopposed,
estrogen are also at risk, for bleeding abnormalities.
Tamoxifen causes an estrogenic effect in the uterus.
It increases the risk of cancer
and also increases the risk of polyps and hyperplasia.
Sometimes we'll look at the postmenopausal endometrium
to titrate the progesterone dose.
For women on progesterone
and hormone use is something
to consider when you're looking at the endometrium.
Women are given estrogens
to help alleviate menopausal symptoms
and to prevent fractures.
But estrogen use is not necessarily a benign drug.
In 2002, an article came out in JAMA
that really changed the way people thought about
postmenopausal hormone use.
And what they found in this article, risks
and benefits of estrogen plus progestin in healthy
postmenopausal women, was
that there were seven more cardiac deaths,
eight more strokes, eight more pulmonary emboli,
and eight more invasive breast cancers per 10,000 person
years in women who were taking this particular drug regimen.
And the benefits were fewer colorectal cancers
and fewer hip fractures.
But in this case, in this assessment, there were more risks
than benefits and
therefore a lot of women opted
to no longer take these hormones.
However, hormone use didn't disappear.
So we can't think just
because this paper came out in 2002,
people stopped using hormones,
they decreased use of hormones.
And here is a study from 2004 looking at five health
maintenance organizations assessing pharmacy records
and, showing that the use of hormones had gone down
but hadn't completely disappeared.
So you still need to know about hormones
and you need to realize
that if a woman is taking sequential hormones,
meaning she's taking estrogen, for the first two thirds
or three quarters of the month,
and then progesterone, that she'll actually go through,
changes in the endometrium, proliferative
and secretary phases.
We looked at some women over time in
that same study I mentioned
before where asymptomatic women came in, and we looked at them frequently.
During the month, eight women went in through eight,
eight to 20 exams.
Over time, two of them had no change,
but six had changing endometrial thickness,
with the maximal thickness mid cycle,
just like you would expect to see in premenopausal women.
And interestingly, two of these women
with changing endometrium were greater than 70 years of age.
So here's showing, two graphs of endometrial thickness
of two women over time.
Here's showing how this really looks proliferative,
and then looks like the normal atrophic endometrium.
This is the same patient from this study.
So when we looked at different women
who were evaluated over time, controls were on no hormones.
There were a few patients on estrogen only.
Some were on continuous combined estrogen
and progesterone where you would expect
after a woman's been on this particular regimen
for three months, the endometrium to be atrophic.
And then sequential estrogens and progesterones.
The thickness changed over time.
It was greatest in this last group, 8.3 millimeters,
but it changed in every group over time.
And the change, some of that could be due
to technical factors, but some of it's also due
to endogenous hormones.
The range of thickness
of the endometrium was also greatest in the women
who were on hormones.
So here the, graphical display of what I just mentioned,
that hormone group four, the sequential estrogen
and progesterone had the highest incidence
of the thickest endometrium,
but also had, the most patients
who had a changing endometrium.

Tamoxifen Effects

Let's discuss tamoxifen brief briefly.
Tamoxifen is used to treat breast cancer
and also to prevent breast cancer in women
who are very high risk,
it's a mild estrogen agonist in the uterus
and it can cause a thick appearing endometrium with cysts.
Now some of this can be the inner layer of myometrium
and people call this reactivation of foci, adenomyosis.
So you need to be sure whether you're dealing
with the endometrium or with the inner layer of myometrium,
but you can't forget that the rate of endometrial lesions
increases in women on estrogen.
And this increase is related to the cumulative dose,
how much they're taking, and for how long?
In this study, they looked at endometrial cancer in polyps
in women who've been treated with tamoxifen.
So they evaluated 15 patients
with endometrial cancer who'd been taking tamoxifen,
and five had cancer only in the endometrial polyp.
So usually we think if you see a polyp,
it's a benign lesion, it's a lesion that can cause bleeding
and it should be removed.
Obviously that's true,
but it's especially true in women in tamoxifen
because the risk of cancer occurring in a polyp is so high.
So what do we do when a woman's on tamoxifen?
We'll talk about cutoffs of endometrial thickness,
but less than five millimeters,
four millimeters or less.
You don't need to do anything else.
If there's a focal mass,
you're gonna recommend a hysteroscopic biopsy so
that they actually go in
and see the lesion and can remove it.
And for all others, you probably should do a sono histogram
to see if there's a focal mass that would lead
to hysteroscopic biopsy
or if there's diffuse thickening
where a blind biopsy would suffice.
And if you do something like this,
you can reduce invasive sampling procedures by 55%.

Endometrial Thickness Thresholds and Hormone Use

Alright, so how should we think about hormones overall?
If a woman postmenopausal is not taking any hormones,
we expect her endometrium to be thin and atrophic.
And less than five millimeters,
four millimeters or less is normal.
Why then on this slide,
do I have less than eight millimeters?
Endometrial polyps are very, very common
and they typically, aren't problematic.
They can harbor cancer, but cancer tends to bleed.
So if a woman is not bleeding, if she's asymptomatic,
she's not taking any hormones, we use eight millimeters
as the thickness cutoff.
Now, if a woman's on unopposed estrogen, she's at risk
for polyps, hyperplasia cancer, this is somebody
that we're going to worry about
and watch very, very carefully.
Her endometrium might be thick and might be heterogeneous,
but I'm not gonna change my threshold
for suggesting a biopsy.
If the endometrium is greater than eight millimeters,
she should be biopsied.
If she's bleeding, she should be biopsied.
If a woman is on daily estrogen
and progesterone, again we expect her endometrium
to be thin and atrophic.
It should really be just a two
or three millimeter endometrium.
But again, we use this eight millimeter threshold
because if she's asymptomatic, if she's not bleeding,
we don't want too many biopsies.
We're willing to Ms. Small asymptomatic polyps.
Sequential estrogen
and progesterone is the one you really need to pay attention
to because here the thickness can vary
with the phase of the cycle.
So if someone comes in
and they have a thick endometrium, even 16 millimeters
and she's on sequential estrogen and progesterone
and she's mid cycle, this is someone you might wanna bring
back to see if the endometrium becomes thin earlier
or later in the menstrual cycle.
And if you can avoid having a biopsy tamoxifen,
as I mentioned, the endometrium can be thick,
it can have cystic spaces.
You need to realize that some
of these are actually in the myometrium.
But just because some
of the changes are in the myometrium doesn't mean you can
say she's on tamoxifen, you can ignore it.
In fact, you need to say she's on tamoxifen.
I need to worry more and look more carefully.

Endometrial Fluid

So let's look at fluid, endometrial fluid.
Normally you might see just a trace
of endometrial fluid in a postmenopausal uterus,
and that's probably because there's a small element
of cervical stenosis.
The surrounding endometrium should be thin.
If a patient has recently had a DNC
or instrumentation, you might see a little bit
of fluid in the endometrial cavity.
If there's an infection, you might see fluid.
And of course with gross cervical stenosis you
might see quite a bit of fluid.
But again, the endometrium should be thin surrounding it.
Cervical stenosis, as I mentioned
before, has an increased incidence in,
women who've had children, instrumentation
and prior x-ray therapy, cervical cancer,
you should see an irregular mass in the cervix.
This is a woman who was one of our asymptomatic women
and had a whole bunch of fluid in her endometrium
and we were really surprised that she was asymptomatic.
And sure enough, a couple weeks later she started having
pain due to distension of her uterus
and she'd been on sequential hormones
but had never had, one of those menstrual cycles
that you get with sequential hormones.
And so she'd been accumulating all
of this debris within her uterus
and once they, dilated her cervix, the fluid came out
and her pain decreased.
But if we see a lot of fluid, we wanna be very, very careful
that we look for actually any fluid.
We wanna be very careful and look for any kind
of mass within the endometrium.
So you're gonna look for focal mass, you're gonna look
for diffuse thickening.
You're gonna look for cystic spaces
to suggest hyperplasia, a polyp.
You may or may not see a stalk.
It might be broad-based endometrial cancer.
It won't just be the thickening of the endometrium,
but also loss of the endometrial myometrial interface
in a woman with abnormal.
This is a nice study on a thousand women
who were asymptomatic postmenopausal
and they found endometrial fluid in 12% of these women.
Very, very common. They attempted a biopsy in 131
and cervical stenosis precluded sampling in 12.
So you can assume that cervical stenosis
was the cause of the fluid.
And an additional 32 had some degree
of cervical stenosis.
So again, maybe a third
of these patients have cervical
stenosis contributing to their fluid.
In the patients that they were able to biopsy,
they found two polyps, one cystic hyperplasia,
one adenomas hyperplasia, and one carcinoma.
So again,
they ended up sampling a little bit more
than a hundred patients.
They found one carcinoma.
So when you see endometrial fluid, you wanna look very,
very carefully, for any underlying lesion.
But the overwhelming likelihood is,
that you won't see anything
and that it will be due to cervical stenosis.
I love the title of this, talk, paper written
by Steve Goldstein.
Postmenopausal Endometrial Fluid Collections Look at the
donut rather than the whole.
So in this case, we've got a donut,
a thin surrounding endometrium fluid in the endometrium.
Notice these arcuate vessel calcifications.
You can ignore this if the rest
of the endometrium looks good,
but in this case, this endometrium doesn't look so bad.
But in this case, this endometrium doesn't look bad.
But we can actually see a lesion off to the side here
that's invading the myometrium.
And this is a very early cancer.
This is what you wanna look for
when we think about women with endometrial bleeding,
postmenopausal women
and they have biopsies about three quarters come back
atrophy and about a quarter come back with a lesion.
Hyperplasia, polyps or cancer
and ultrasound can be very,
very helpful in triaging these patients
because obviously you don't need
to biopsy everyone with atrophy.
And a lot of studies have looked at this and this.
Number four, some people use less than five, less than
or equal to four comes up a lot
because it turns out that if you use four millimeters
as your threshold, the likelihood of missing cancer is very,
very, very low.
So this study, over a thousand women
atrophy four millimeter mean thickness cancer,
21 millimeter mean thickness,
no malignant endometrium was less than five.
This study, 361 women
163 were less than four millimeters.
There was one cancer, there was recurrent bleeding in 6%
and they had increased endometrial thickness
on followup in 8%.
So again, we can't get rid of that diagnosis
of cancer in women who are bleeding.
And the reason is cancer needs to start somewhere.
It starts out as a microscopic lesion and then it grows.
We're not a microscopic technique,
but usually by the time the cancer is big enough
to cause bleeding
and to cause symptoms,
the endometrium will be greater than four millimeters.
So postmenopausal thick endometrium
hormone use will depend on the hormone regimen.
Don't forget about that
sequential estrogen and progesterone.
But this endometrial myometrial interface is really
important because if it's intact,
there's not an invasive cancer.
Now I didn't spend a long time on fibroids.
I assume, the people listening
to this lecture know what fibroids look like.
Shadowing, they can be csol
or undulated, iso coic, hypo coic, very rarely echogenic.
If they're intramural, they're gonna have
that classic appearance.
If they're submucosal,
they can disrupt this endometrial myometrial interface.
And when you look at this chart, it's only a fibroid
or a cancer that can do that.
So if you can't define where the endometrium begins
and ends, figure out if it's a fibroid or not.
If it's not a fibroid, you have to worry about a cancer
Hyperplasia can cause diffuse
or irregularly thickened endometrium.
But it can also be focal polyps can have a variety
of different appearances.
They can have smooth margins, they tend to be echogenic.
You might see the vessels going in and branching,
but they might be Cecile and very broad based
and look like focal hyperplasia or cancer.
But again, the endometrial myometrial
interface should be intact.
With cancer, you'll get an irregularly thickened endometrium
that looks heterogeneous,
but early cases can be tough to see.
Once it becomes invasive, it should disrupt
that endometrial myometrial interface.
So this is looking at the sonographic appearance.
Let's now look at some images.
Classic fibroid in the endometrium.
It's got shadowing
and this can make the endometrium very thick
because it's draped around this fibroid.
But the fibroid can be a cause of bleeding.
In postmenopausal women
here are polyps echogenic lesion Within the endometrium
here we're singing a single vessel
inside this echogenic mass.
And here this polyp is
so big it's descending the entire uterus.
Lots of big cystic spaces. But this was all a polyp.
Hyperplasia we tend to see in per and postmenopausal women.
The endometrium diffusely, thickened here.
Some cysts, it can be focal. This is focal hyperplasia here.
Look at this thin endometrium here.
If you see a lesion like this,
of course you're gonna recommend a biopsy and cancer.
I have no idea where this endometrium begins and ends.
I'm gonna be very worried about this appearance in
a postmenopausal woman.
Here, this endometrium looks very thin, very thin.
Here's the fluid. And then here is this invasive mass.
This is not a fibroid, this is a cancer.

Sonohysterography

How does sonohysterography play into all of this?
The reason why we might wanna do a sonar histogram,
I mentioned with Tamoxifen
to help us figure out if a blind biopsy can be done
or if you need to do a biopsy under direct visualization.
But it can also help to figure out if a lesion's real.
In this case, we're looking at a very well
circumscribed fibroid.
That's almost completely intracavitary.
And this can actually define how this lesion is going
to be taken out
because if there was a large intramural component,
it might be that it wouldn't be easily removed
during hysteroscopy.
But since this is almost completely intracavitary,
hysteroscopy is gonna be a great way to remove it.
So we use a speculum, we place the catheter into the cervix
or lower uterus, the transducer's inserted,
and then we have some fluid.
And you can see a nice outline of this polyp.
Now you might say you don't need to do a sono histogram.
You know there's a polyp there
and I have to tell you I agree.
So here's a study looking at
postmenopausal women with bleeding.
And they had a thickness greater than
four millimeters after a biopsy.
So these women had a sonar histogram after their biopsy.
And what they ended up finding was that 45 per 45 patients,
56% of the population had an endoluminal mass.
Many of these were undulated, some were Cecile.
And the undulated lesions you can kind
of expect if somebody goes in
and does a blind biopsy, the undulated
lesion might move out of the way.
But Cecile lesions, you would think they would be able
to um, get if they're large enough.
The large majority of the lesions,
were fibroids followed by polyps.
But they also found focal hyperplasia and cancer.
And of course those are the lesions,
that we don't want to miss.

Safety of Sonohysterography

Is it safe? What do we worry about?
If someone has endometrial cancer
and you put fluid under pressure into the endometrial
cavity, we worry that some
of those cancer cells are gonna go out the fallopian tubes
and into the peritoneal cavity.
In this particular rather old study,
they looked at 89 patients with endometrial cancer
who had hysteroscopy.
So an x-ray exam, putting contrast into their uterus
and they looked at patients who had stage one
and two cancer, meaning
that they weren't treated with radiation therapy.
You would think patients with spill,
meaning the contrast went into the uterus
and out the fallopian tubes potentially
carrying malignant cells into the peritoneum would have a
worse outcome than patients with no spill.
But it turns out, they had one death in five years
and 28 patients, whereas in this group with no spill,
six deaths in five years
and 46 patients, so they had a higher incidence
of deaths in the patients with no spill.
Now you could do a power analysis
and say this isn't statistically significantly different.
The bottom line here though, is that from the small amount
of data that we have, we don't see an increased risk.
What I would say is if you know it's endometrial
cancer, don't do the study.
But if you have done a study
and you suspect endometrial cancer,
don't worry too much about it.

Summary of Postmenopausal Endometrial Assessment

So summary slide of postmenopausal endometrial assessment.
We look at the thickness.
Alright, now I'm starting
out saying we look at the thickness.
'cause I assume if there's a solid mass,
you've already described it.
This is a assuming a homogeneous endometrium.
If there's a focal lesion, it needs a biopsy.
And if it's focal hysteroscopic
guidance is the right way to do that.
If the endometrium is less than four millimeters
and the patient's not bleeding, this is a normal finding.
If the patient is bleeding from all the studies
that we've talked about, the patient
probably does not need a biopsy
because atrophy is probably the etiology.
If she continues to bleed,
the gynecologist is probably gonna still do a biopsy.
Let's go to the other end of the spectrum.
Greater than eight millimeters thick.
All right, do you need to go straight to a biopsy?
Sonohysterography might be helpful if you think it
would change what the patient's going to do.
But most of these patients greater than eight
millimeters are gonna go to a biopsy
unless the woman's on sequential hormones.
If she's on sequential hormones, you have to figure out
where she is and re-scan her if needed, earlier
or late in the menstrual cycle.
And if it's still thick, then a biopsy
endometrial thickness in between five to eight millimeters.
This is when it matters if she's bleeding or not.
If she's not bleeding, we're willing
to miss the small focal polyps.
We're willing to miss them. They're not causing problems.
She doesn't need a biopsy.
But if she is bleeding, we're gonna lower our bar, five
to eight millimeters, recommended a biopsy
because we don't wanna miss cancer.
So that's it for the postmenopausal ovaries
and uterus and endometrium.
Thank you very much for your attention.