The Endometrium - HD

Introduction to Endometrial Evaluation

Thank you very much.

This is an area which is has always been a great interest to me because it is so variable during the month that it's very important to look at the endometrium very carefully and correlated with the time of the month that the patient is at, or whether or not she's pre or postmenopausal, because it will tell you a lot.

Scanning Techniques for the Uterus

First of all, how many of you still fill fetal fill bladders for these patients? Anybody? A few. Please don't. It's unnecessary. It's torture. Nowadays you really then you can't even see anything when the bladder's that full.

We really do not fill the bladder. We do an abdominal scan just to see if there's anything up above the uterus, and then we do the transvaginal scan that shows us the uterus.

And so it is unnecessary to fill the bladders. So, and averted retroverted. You can see here the endometrium is well seen. And there is this line in the middle right here that indicates that there's absolutely nothing in the cavity. This is where the mucosa meets the mucosa, and there's nothing in there.

Here you don't see it quite as well because we're a little bit further away from the ultrasound beam.

Endometrial Changes During the Menstrual Cycle

But during the menstrual cycle the endometrium goes through a series of changes. And in the middle of the cycle when you ovulate this is pretty much what you have is the trilaminar appearance. And again, this line is very important 'cause it shows you that there's no polyp and or no fibroid inside the cav. And again, here, here it is. And that's an important line to look at.

Now, as you go on, after ovulation the lute luteal phase, the myo, the endometrium thickens up and actually becomes very, very thick and sometimes even a heterogeneous. And so you really can't measure it, or you can measure it, but you it doesn't mean anything to measure the my the the endometrium after ovulation. And in fact, it really doesn't mean much to measure it at all on premenopausal patients.

Part of looking at the endometrium is looking at the endocervix and the endocervical canal. At the same time, you also get to see the cul-de-sac and anything that's going on down there. But you see very well here the anterior posterior lip of the cervix and post anterior fornix, posterior fornix right in here. And the endo, cervical canal, the canal, the the cervix, and probably stops here, but it's very difficult to tell exactly where the cerv the uh, internal os is compared to where the rest of the uterus starts. And I don't think there's much of a reason to try and struggle to do that.

Normal Endometrial Width and Evaluation

So there's always a question of what the normal width of the endometrium is. And in premenopausal patients, there is no number. It there is absolutely no number. What you need to look at is the pattern of the endometrial echo. Is it heterogeneous? Does it have something in it like a polyp or a fibroid? Does it have cystic areas in it? But the actual number itself does not matter. And it may be thinner if the patient's on birth control pills, but still, I wouldn't get hung up on a number.

Now, if the patient is postmenopausal it that changes a little bit. And it depends greatly on whether the patient is bleeding or not. If the patient is coming in for postmenopausal bleeding, the number that the most accepted number is less than four. There is some data out there, less than five. We have switched to less than four because that's a predominance of the data right now. But anything greater than four requires their mutual biopsy or further evaluation.

If the patient is not bleeding, there is no number. Again, there is no number. If the patient is not bleeding, some people have put out eight, 10, whatever. Again, look at the endometrium, and if you're concerned about the texture of the endometrium, do a sono histogram, and we'll talk about that in a minute. That's really the easiest thing to do rather than trying to get hung up on a number.

So the postmenopausal endometrium most of the time is very thin. You can see we've measured the anterior posterior aspects of the endo endometrium. There's a little bit of fluid inside the cavity that's very common. That's normal. Doesn't mean anything. In fact, it's very useful when there's a little bit of fluid because it can outline whatever might be in there like a little polyp. So this is completely normal.

Here's a postmenopausal patient with a small uterus. You can see the uterus is very small, and you can see there's a little bit of fluid in the endometrium. Again, that's normal. Now, be careful that when you look at the endometrium, you have to look at the entire endometrium. You can't just see part of it, measure it, and give that number and not have seen the entire part because the other side of it may contain something. So if you don't see the entirety, then I report it as not well seen. And that's really important. Don't be overconfident.

Identification of Polyps and Abnormalities

Now polyps are usually pretty well seen. Even when there's no fluid in there, you can actually see a different texture echo texture of the polyp itself. And if you add some color it'll even enhance it even more because you'll actually see the feeder vessel going into the polyp. And sometimes even if you don't see the feeder vessel, we still call a polyp, although it could be a little clot at that point. But the echo texture of the endometrium is really important.

And now we have instruments in our ultrasound machines that are so good that we can actually tell a lot about looking at the endometrium, just looking at the texture rather than getting hung up on a number we do a lot of 3D for the endometrium. And in this case, we knew there was a polyp. This shows you exactly where it is. What we do now a lot is we include this picture in the report to the referring physician so that the referring physician knows exactly when they do the hysteroscopy, where to go and where the polyp is.

So here is a 67-year-old patient with po postmenopausal bleeding. She has a thick endometrium. It's heterogeneous. Clearly there's some fluid in the endometrium. It's dirty fluid, sort of, it's echo you know got echogenic material in it. You can see that this is sort of a mass inside here. There's a lot of color. There's a lot of blood flow. Color is very important. This is great to endometrial carcinoma.

And what's important about the endometrial carcinomas when you see them, is how invasive are they? We decided that this was not terribly invasive because we could still see portions of the endometrium here. And we didn't we saw some pretty good thick myometrium. And so less than 50% invasion indicates that the patient won't need chemotherapy and will be cured by a hysterectomy, a greater than 50% invasion through the myometrium. They will need further treatment.

Here's a polyp. And this was a polyp that you couldn't really tell. It was a polyp just looking at this. But then we turn on the color, and you can see that there's a single feeder vessel, which suggested that this was all one entity. It was a polyp. There was a lot of blood flow here. Turns out that this was an adenocarcinoma of the of inside the polyp in a patient that was bleeding. So polyps can contain cancer. Obviously they don't spread quite as as we as much, which is good. But if there's bleeding the polyps have to come out.

Here's a 63-year-old with postmenopausal bleeding. And here this is a little more problematic. Now the back here looks pretty good. Okay? There's certainly a mass in the uterus. It's echogenic, there's a lot of color. This is bad. This is cancer of the endometrium, but you're missing the borders of the front here, of the anterior wall of the of the endometrium. And that's worrisome here. And this was, in fact, a 90% invasion with nodes. And so that's bad news for this patient. She will need some further treatment after her hysterectomy.

The Role of 3D Ultrasound in Gynecology

So 3D as I said, is very, very important. In gynecology we do a 3D on every gynecologic patient that we scan. And I think that it replaces MRI in many situations when we wanna look at the shape of the endometrial cavity certainly for mullerian duct abnormalities and the like. And how many of you do 3D in your GYN scans? So great quite a few of you. I think it's very important to just do it and get used to doing it because as you take your volume and your three orthogonal planes come up your third plane here, your Z plane is the money plane, where you will see a reconstructed view of the endometrium that you otherwise don't see.

Postmenopausal Bleeding and Polyps

Now, going on to spending more time on patients with postmenopausal bleeding, here was a postmenopausal patient. You can see very thin endometrium. By the way, don't just measure it here. You gotta measure it over here, because again, you'd be misleading if you measured it somewhere here. This is not very well seen so that you really can't put your caliper here. But the measurement is not what counts here. What counts is that there's something inside the endometrial cavity. And so you have to really look and see what it is. And it was a little polyp right here inside the endometrial cavity.

Fibroids and Cycle Timing

Now, here's a submucosal fibroid, and if you bring them in at a time when after ovulation in the luteal phase of the cycle, the endometrium will be thick enough so that it will act as a contrast and it'll outline the fibroid for you. So you don't even have to put any fluid in. And so we do that a lot when patients come in for locate localization of fibroids. How much of it is submucosal? We have 'em come in, in the latter part of the cycle as opposed to the early part.

Here's another fibroid. It looks completely intracavitary here but in fact, it's not totally intracavitary. It's probably, I would say 75% intracavitary. But this is the picture that the surgeon wants. This will tell the surgeon how much they'll be able to shave off hysteroscopically.

Sonohysterography Procedures

Now one thing that is extremely useful when looking at the endometrium is the sonohysterography. We do, I would say, an average of three to four a day. And they're very, very easy to do. You thread a little insemination catheter up in the endometrium, and you just put a little bit of saline and you outline the cavity, and it shows you if there's any question about whether there was some lesion in the endometrium. It just it shows it to you so much better. Then you take your volume, you take a couple of quick volumes, and then you can save the volume and you can go back and re-scan after the patient's gone. 'cause you've got the entire picture. You don't have just a few snapshots of the the fluid going in.

The other reason to do 3D is because unless you use a balloon catheter, if you use a little insemination catheter, the the the um, fluid will come come out, come pouring out as you put it in, so that you'll have to keep putting saline in in order to get all your pictures. Whereas if you're doing it with 3D, you put your burst of saline, you take a couple of quick volumes, and then you're done. And you don't have to blow up a balloon, which is tends to be more painful to the patient.

So here's a patient that clearly has an abnormal endometrium, and again you can measure it if you want. It's not gonna mean anything unless she's post-menopausal and bleeding, but you still want to find out what's going on in here. And so the way to do it is to put some fluid in. So we put the fluid in, and sure enough, you don't really need the 3D in this case. We we do it to archive everything. But you can see the polyp right there, and there's a couple of several polyps. The advantage to doing 3D is that you can get all your polyps um photographed all at once, then you can go back and measure them at your leisure without having to keep put putting fluid in. But nonetheless, this shows you what what is going on in here, rather than trying to guess.

And by the way, if they do an endometrial biopsy here, they probably won't get anything because most of the time when there were polyps the endometrial biopsy is negative because they missed the polyp. So it's very important to be able to tell that the referring physician, these are polyps. You better go in there with a scope because otherwise you're gonna you're not gonna get a piece of whatever this is.

All right. Now, can you measure the endometrium and the postmenopausal patient? Well, you might say, sure, I can measure it right here, but that's not good enough because up here, you can't tell what's going on. So in this case, even though you can measure it in certain places, I would say, no, I can't measure it. So you put a little fluid in, and lo and behold, look at what we see here. A little a little um, whoops, a little polyp right here. So we have very low threshold for putting a little bit of fluid. It's really easy to do. And it it'll outline whatever's going on here.

Here's another patient, 43-year-old with men metro. Here's the endometrium. Can we see it? Well, sort of a little bit but we we really can't. Now, let me just show you. Go go back and you you see here don't invent the endometrium and put a to put a caliper on it, just you know a little bit of fluid will really tell you what it is.

You can get fancy with it. If you wanna send a nice picture the to the referring physician, this really goes a long way. If you send these nice pictures and they'll send you more patients, which is always very nice. And if you take a 3D, you can even make it look like an MRI if um, if you want, by um, giving, by turning your 3D into a um um uh, uh, slices uh, like a uh other cross-sectional imaging techniques. These are all techniques to display. Once you have the 3D, you can display it in lots of different ways. You can display it like this. You can display it uh, surface rendering of the polyp. You can display it um, in one volume. You can display it in these two different ways, depending on how you wanna manipulate your volume. So this is very, very useful.

Patients on Tamoxifen

Alright, now here's somebody 55-year-old on Tamoxifen. And she was sent in because another radiologist felt that the endometrium was thick. Well you know, what are you gonna do here? You're gonna measure it from here to there, from here to here, or from out over there to over here. Well, you can't measure it. You you can't measure it. And not only that, but patients with uh that are on tamoxifen you know, they they have an increased incidence of and um, of polyps and endometrial cancer, but they also have uh sub endometrial cysts that can confuse the issue. So the only thing to do here is to put in some fluid. And actually, the endometrial is normal. These are all sub endometrial cysts. And we were able to tell the patient that uh the referring physician, that the endometrial was entirely normal and she doesn't even need an endometrial biopsy.

Fibroids and Prolapsing Fibroids

If you put some fluid, you'll outline uh, fibroids. And I I don't want to get in too much to fibroids uh because I know that uh, Mary just just spoke about them. But the fibroid can sometimes try to deliver itself. It can be very painful to the patient. Here's a fibroid trying to get out of the through the cervix. And you can see that um uh, there's a stalk here, and if you turn on the color, you will see uh uh uh the blood flow going down uh, from where the origin of this uh uh, fibroid is uh, trying to get out. And here is this stalk. They can be quite vascular, but this is a prolapsing fibroid.

Infertility Evaluations and Sonosalpingography

Okay, now going on to what you can do uh, as uh for infertility patients. I know that many of you do um uh, hy of SAP picograms. We have we do not do them anymore. We do osei, which um, I'm not gonna try and say what SSI stands for 'cause it's written down here if you are interested in reading reading it. But what it is basically is putting some fluid in the endometrium, doing a sono histogram, but then um, you blow up a little balloon and then you can um, put a little bit of air. We've used air because contrast wasn't available, and air works really well. You put a little bit of air in the cavity and then it goes out the tubes and it demonstrates the tubes.

The nice thing about the SSI is that, first of all, there's no radiation, there's no dye. You can certainly uh, differentiate uterine shape abnormalities um uh, easily. But uh, in addition to the cavi uh the intracavitary lesions, you can see the ci rosa. It's very important to see the outside of the uterus when you're trying to figure out what um to correlate what the inside looks like. Plus all you can assess the ovaries uh, the tubes, the the whole thing. So it's really it's a lower cost. It's a full pelvic examination uh that doesn't have any radiation. So there's absolutely no reason not to do these. We do about two a day uh, of these.

And here is a little bit of air uh being injected in the cavity right here. You can see a little puff of air, and you can see the air going down the tube right here. Now, it's a quick thing, and you have to have a sonographer that knows what uh, he or she is doing to snap the video right at the right time. Because it's it just is a width of uh, air, but it does show you the patency of that tube.

Let's see if I can go on to the next slide. It's somehow it's not being, how do you go to the next slide? Oh, here, great. Thank you.

So if you're lucky, you can actually see both tubes at the same time. Here we were getting fancy, but usually you have to do one tube at a time. But in this case uh, things were lined up well enough, so you could see the patency of both tubes. When the when the tube is blocked um it will well up in here and the patient will be very uncomfortable, will have a lot of cramping. And um, and so uh uh, sometimes you you you'll see patency in one tube and not the other. It doesn't mean that the tube that's you're not seeing is not patent um and uh, you just can't demonstrate it. But what you can do is either call patency or uh, if there is no fluid, no air going in uh, anywhere, then you can uh, call the blockage of the tubes. And this is very consistent uh, in accuracy with the hysterosalpingogram.

Post-C-Section Evaluations

Another thing you can do uh here is a patient who's had a prior C-section. And patients with prior C-sections have a lot of um uh bleeding because they have this niche uh in the c-section scar here that collects uh, blood. And uh, and there's a a a clot that sits there sometimes. And so um, you put in some fluid and here's the clot, you can see it and you can flush it out. And then you can really examine the um the niche without the clot. And this shows you why a lot of patients that have had histor um uh, cesarean sections uh, have um these uh clots that sit in those places. And they have inter menstrual bleeding during the month. It's very common for people with uh, cesarean section scars to have uh, have this this problem.

Unique Diagnostic Cases

Now this is probably one of the most remarkable cases I've ever seen. Last year, 68-year-old patient with abnormal uterine discharge, unresponsive antibiotics. The only prior history was that she had bout of diverticulitis six months before, here's her endometrium. And here we are measuring, trying to measure. That's not very good. I wouldn't put those uh, measurements in the report. But what is this? Is this calcium? We were looking at it and started moving. So then I thought, ah you know, this must be air. So then uh, started looking at the uh the adnexa and what do we have here? OSI in a 68-year-old. And so there's here in the fallopian tube. So based on this, I actually made the diagnosis of uh colon to fallopian, two fistula from diverticulitis was which was actually repaired. And she she she was fine. So uh fluid in the fall uh air in the fallopian tube, very, very helpful uh to make some of these diagnoses.

IUD Placement and Evaluation

Now, going on to the location of IUDs. We have a lot of IUDs now because we have the Mirenas that um uh deliver some hormones. And so now they're back in fashion. And 3D is really, really helpful to determine where the IUD is. Patients who have an abnormally placed or slid down IUD have uh, pain and bleeding, and we've documented that so that when you see it um you know, there there's a benefit to replacing uh taking it out, replacing. And these IUDs can be hard to find. The shaft of the IUD is pretty obvious here. We couldn't find the arms, and that's because the arms were down instead of up. This was an anchor, this was upside down. I don't know how they got upside down, but whatever it is, that's um, a lot easier to find if you can get a volume and just see the whole thing together.

Now, here um is a type of scan where you say, well it's in the right place. Here's the shaft, and here are the arms. Well, the trouble with this is that you don't really know where the endometrium is. And if you do the 3D, you'll see that the right arm is totally embedded uh in the myometrium. And that's because the uterus is not big enough. And we have found um and shown data that uh, NIUs patients don't have a uterus that's big enough uh, to um, support the IUD. And so that's um uh, the uh, study that we did looking at this uh, led the companies to come up with the S Skylar, which is the smaller IUD for people who have a small uterus.

Mullerian Duct Abnormalities

Now, the last area that I want to get into um is the mulian duct abnormalities. If again, you have to bring these patients up in the luteal part of the cycle, because again, you're gonna use the endometrium as your contrast. You can put fluid in it, but uh, it's not necessary. I don't do uh, sono histograms. For mullerian duct abnormalities. You just uh, use the thick uh, endometrium endometrium towards like premenstrually, and then you don't have to put in any any fluid.

So here's your uterus. You take your sweep, and here is your coronal view. That shows you this septum, the sub septum um, and the septum. They want to know a lot of times how deep it goes, how thick it is. This is a very thin septum. It wouldn't be good if a if a pregnancy implanted here because there's not enough blood flow. And this one actually goes all the way down and uh, involves the cervix too. So this is all very important. And we put a lot of pictures in that in in the report uh for these uh referring physicians because they are gonna take these patients to the or. And this is better than MRI because you can really manipulate that volume, so it's exactly the way you want it uh, rather than um you know, just um uh take the picture the way that that it comes.

This is an example of uh, why the HSG is not as helpful as just a plain old 3D ultrasound for Mulan. This is a septate uterus. And you see the sep septum goes down to here. This is the bicornuate uterus, which is much more rare. The bi corneas are rare. The septum is very common, and yet with a hyster of gram these would look exactly the same. And yet, this does not require treatment. This does require treatment because there's a higher incidence of um uh, a miscarriage or early pregnancy loss up to 80, up to 50% uh in patients who have uh, a septum.

This is a unior uterus. Interestingly enough uh, the uterus looks very normal uh in 2D, and it's only in 3D that you realize that half of it's missing. A lot of times there's a rudimentary horns. Sometimes it it connects, sometimes it doesn't connect. Here, it's a rudimentary horn that doesn't connect. These are dangerous because if you get pregnant in here um it's gonna explode and you can't carry the pregnancy in there. So if you have a rudimentary horn and you're in in the infertility group, this has to be removed before you go through um uh any kind of of treatment.

And so what they do when you have a a septum is that they resect the septum down here. They shave it down, and then they send you back the patient to see what's left. And this is a good repair. They always have a little divot here. But that's a good repair of the septum. And then the patient can uh, can try and get pregnant.

This is a delphis. Delphi is basically two completely separate uterine. It's not two separate cavities in one uterus. That would be a septum. It's two separate utero which actually are very hard to image because you have to open your angle 180 degrees in order to catch both sides of the uterus. In the same picture.

Now, we do see infertility patients who have funny shape unusually shaped uterus. This is a T-shaped uterus. These are very stiff utero. Patients with T-shaped uterus are unlikely to get pregnant. Here are two utero that looked very peculiar. I we we I don't know what to call them. That's why I include a picture in the referring physician for the referring physician because I I don't know what this is. This is very, very tubular looking uterus. This one, I don't know whether it's T-shaped or whether it's a bico that fell down. It whatever it is, it's not good. And these patients were not uh, getting pregnant.

And then of course, you have patients who have syne eye who've had multiple DNCs. And unfortunately, when there's a scar like that uh you can see it in in 3D, you don't even have to put any fluid in.

One-Stop Infertility Workup

So the workup for infertility these days is really one stop testing. You look at the shape of the uterus inside and out with 3D, you evaluate the cavity with a sono histogram, you will blow up your balloon just to get a little pressure um, just to put your air in the tubes or osi. And then you look at the ovaries um and si for signs of endometriosis um and deep infiltrating endometriosis. And then you you've really done the whole thing uh, very very easily in one stop.

Conclusion

So the endometrium is a very dynamic portion of the uterus. It changes throughout the cycle. It responds to hormonal changes like a mirror. The endometrial echo is very useful when you do a 3D 'cause you can manipulate it to be uh, to uh make fibroids and polyps stand out. And endometrial cancer is the most common malignancy in the female reproductive tract. It's less lethal than ovarian cancer which is why it gets less press, but it is the most common uh female cancer in in the pelvis.

Thank you very much for your attention.