Sonography & Sonohysterography of the Non-Gravid Uterus - HD

Introduction

Hi, I am Dr. Peter Dubay, professor of radiology at Harvard Medical School, and Senior Vice Chair of Radiology at Brigham and Women's Hospital in Boston.

I will be lecturing today on sonography and sonohysterography of the non-gravid uterus.

I will be discussing sonography and sonohysterography of the non-gravid uterus with sonography.

We have a two-dimensional probe in the uterus, examining the uterus as seen here with sonohysterography.

As we'll see, the difference is that we have a catheter here coming in through the vagina and cervix into the uterus, instilling fluid.

And that, as we'll see, gives us a very detailed look at the endometrium as the fluid outlines the endometrium.

Some of the topics that we'll consider include normal anatomy of the uterus, some congenital malformations, and their diagnosis by ultrasound, ultrasound of myometrial lesions, including fibroids, adenomyosis and others, and spend a good part of the time talking about the endometrium, ultrasound of the endometrium, and uterine cavity.

One of the key topics there is the topic of postmenopausal bleeding and especially diagnosis of endometrial cancer, as well as a number of other topics.

Imaging Planes in Conventional and 3D Ultrasound

With respect to the endometrium, the imaging planes that we typically get with conventional ultrasound where we have the conventional transvaginal ultrasound include a sagittal view as seen here.

That's the cervix, the body of the uterus, the fundus of the uterus up here, and we can see the endometrium in the middle.

We also, with conventional sonography get a view that is cutting across the uterus.

It's actually transverse to the uterus, though it's coronal to the woman's body.

So in a view like this, we see the endometrium in the middle, the myometrium around it, and we can either call it a transverse view, it's transverse of the uterus or a coronal to the woman's body.

With 3D ultrasound, we can get a third view.

And in some situations, this is the most useful view.

This is coronal view to the uterus.

We get it by 3D reformatting.

We are able to reformat in a plane that cuts across like this, which is a plane that you cannot get via conventional 2D ultrasound, and we'll see soon why that or when that view is extremely important.

Here you can see a coronal image of the uterus, coronal plane to the uterus.

And we are seeing as in this diagram here, the brown area around the outside in this diagram is the myometrium, the endometrium in the middle.

The uterine cavity is typically collapsed, so we don't see it on ultrasound unless fluid is instilled in there.

Diagnosis of Uterine Congenital Malformations

We'll now look at how ultrasound is used to diagnose uterine congenital malformations.

The American Fertility Society, or which is now named the American Society of Reproductive Medicine, has classified uterine congenital malformations into seven classes or seven types.

The main ones that we are diagnosing on ultrasound include didelphys, bicornuate, or bicornuate uterus versus a septate or a subseptate uterus.

We'll also talk a little bit about arcuate uterus and unicornuate uterus, and their diagnosis by ultrasound.

Methods of diagnosing congenital malformations of the uterus by imaging include 2D ultrasound, which can give you some idea, but as we'll see shortly, 3D ultrasound in the coronal plane gives is much better suited to diagnosing uterine congenital malformations.

In fact, the 3D ultrasound with coronal reconstruction is so good that I think it's fair to say that magnetic resonance imaging is not needed for this purpose.

Magnetic resonance imaging or MRI is a lot more expensive than ultrasound, so there's really no reason, at least if you have 3D ultrasound capabilities to ever resort to magnetic resonance imaging or MRI to diagnose uterine congenital malformations.

Uterine Duplication Anomalies

What do uterine duplication anomalies look like on ultrasound?

Well, before we get into the ultrasound, let's take a look at what those malformations are with a septate or a subseptate uterus, we have a fibrous septum dividing either partway down the endometrium or all the way down the endometrium to the cervix.

If it goes all the way down, it's called a septate uterus.

If it goes partway down, like in this diagram, it's a subseptate uterus with a septate or subseptate uterus that not only is there a fibrous band, but the fundus of the uterus is normal in configuration, and that is part of what distinguishes it from another uterine duplication anomaly, that bicornuate or didelphys uterus with the bicornuate or didelphys uterus, you get a separation of the endometrium into two parts, but it's different than the septate uterus because the division is not caused by a fibrous band.

The division is caused by a dipping of the fundus down into and separating the endometrium.

And what separates them is instead of a fibrous band, actually myometrium, so there's no fibrous band, there is myometrium dipping down.

And note again, the fundus of the uterus is indented or concave with a bicornuate uterus.

The indentation is partial, so you get part separation of the endometrium with a unicornuate or a didelphys uterus.

The concavity or the dipping down completely divides.

It would come all the way down to the cervix and sometimes even divides the cervix itself.

A third uterine configuration is what's called the arcuate uterus.

This one, the myometrium dips down a little bit into the endometrium, but the outer contour of the fundus of the uterus is normal.

It's normal convex upwards.

Instead of concave downward, like with the bicornuate uterus, the arcuate uterus is actually considered to be a normal variant.

It's not really pathological. These two are abnormal.

Now, why do we really care about diagnosing uterine duplication anomalies?

Well, one reason that we do care is that if a woman has a septate or subseptate uterus, she is at risk for having fertility problems, difficulty either getting pregnant or difficulty remaining pregnant.

And the reason for that is because with a septate or subseptate uterus, pregnancy may implant on the septum on a fibrous band.

And that is not useful that the fibrous band is implantation will lead to very poor provision of oxygen and nutrients to the developing baby when it implants on or near the septum.

So it's important to diagnose.

Ultrasound Appearance of Duplication Anomalies

So what does it look like on ultrasound?

Well, on ultrasound, if we're doing a 2D ultrasound and we take a transverse view of the uterus like this, or this line, or this line, all of these look very similar and often indistinguishable on 2D ultrasound transverse view.

So if we cut across this one, we're gonna go from side to side, from side to side, but we hit the endometrium twice, so we get double endometrium.

But the same is true for a bicornuate or didelphys uterus.

And the same may be true for an arcuate uterus, depending where we're cutting.

So 2D ultrasound with a transverse view of the uterus can be useful to determine that there's some sort of duplication going on, but not to distinguish between a septate bicornuate or arcuate uterus.

And here are three different ultrasounds on three different women.

In each case we're transverse to the uterus.

Notice. In each of them, you see duplicated endometrium on transverse view.

Here's one, two, and this one.

Here's one, two, and this one, again, there's one, two.

So we know there's something going on, but we don't know what's going on.

And the way that we can find out what's going on is to do 3D ultrasound with a true coronal reconstruction of the uterus.

And here, this one with a on the coronal view of the uterus from 3D, we can see it's a septate uterus.

You can see the septum coming down.

There's no indentation of the fundus of the uterus in this case.

When we do the coronal view, you can see that there's a major indentation.

The cervix would be down here.

This is bicornuate uterus, no fiber septum.

There's myometrium all the way around.

And in this case, when we do the 3D reconstruction, we see nice, normal fundus, just a little exaggerated, dipping down of the myometrium, partially separating the fundal aspect of the endometrium.

No big deal. This is a normal variant.

So 2D didn't tell us what was going on.

3D with coronal reconstruction did, and that's why it's so useful.

Here is yet another case in which we can see when we look sagittal to the right, sagittal to the left, we see endometrium, endometrium.

On the video clip, we can see this is a transverse view video clip.

We can see the two separate parts of the endometrium.

But from this view alone, we can't tell whether it's a bicornuate at a septate or even an arcuate uterus.

When we do a 3D ultrasound, this dotted green line shows us the plane of reconstruction.

And here is the reconstructed uterus.

That's the fundus of the uterus. Cervix is down here.

You can see very clearly a septum separating the two parts of the endometrium.

So the 3D told us that the anomaly that we could tell was there by 2D, but we couldn't characterize it, characterize it as a septate uterus.

This woman for some reason actually went on to have an MRI.

You can see the MRI is almost exactly the same in appearance as the 3D reconstructed uterus.

So this was really totally unnecessary.

We already knew from the 3D ultrasound, the woman had a septate uterus.

Here's another nice example of a coronal reconstruction of the uterus, and you can see that there's only one horn.

There's the endometrium here. Fundus is up here.

You can see one horn, the endometrium angling towards one horn, but none on the other.

And another 3D reconstruction in the coronal plane.

That's the fundus of the uterus.

And you can see the configuration of the endometrium is like a t.

This is a so-called T-shaped uterus, which is sometimes seen in the offspring of women who were taking diethylstilbestrol or DES during pregnancy.

Myometrial Lesions

Fibroids (Leiomyomas)

Okay, well, let's move from congenital abnormalities to myometrial lesions, including leiomyomas or fibroids and others.

Fibroids are very common, benign tumors of smooth muscle and connective tissue in the myometrium, very common.

As I mentioned, approximately 20% of women over the age of 35 have fibroids.

They're more common in blacks than in whites.

They're usually multiple, and they're often estrogen dependent.

That means that they enlarge or infarct or occasionally infarct during pregnancy.

And because they are often estrogen dependent, they may decrease in size after menopause.

So what do they look like on ultrasound?

On ultrasound, you will see single or multiple heterogeneous, highly attenuating masses.

By highly attenuating means that they partially shadow behind them.

In many cases, they may be calcified, and if they're calcified, the calcification may be internal within the fibroid or on the rim of the fibroid.

And if it's necrotic, there may be some anechoic areas within them.

Here are a couple of examples of fibroids.

This is on a transabdominal scan.

There's the fundus of the uterus, the woman's bladder.

And you can see a focal, well-defined mass seen here in the anterior myometrium.

This is typical appearance of a fibroid on a transabdominal scan.

Here is a fibroid on a transvaginal scan.

Here is the cervix.

You can see the endometrium coming up towards the fundus of the uterus, which is up here.

And on the posterior aspect of this uterus, there's a fairly large but well-defined mass, very typical of a uterine fibroid.

This is an example of a fibroid with rim calcification.

So this is the uterus, two different views of the uterus on transvaginal ultrasound.

And you can see calcification around the rim seen here on the sagittal view here on the transverse view.

And in fact, because there's so much calcification in the rim, you really get totally shadowed out.

You don't get a look at the fibroid, but you can tell that one must be there because of this calcification, actually, this woman went on to have a CT scan.

And here in her uterus, you can see the rim calcification all the way around the fibroid on both of these views.

Another kind of fibroid or location of fibroid is a submucosal fibroid.

Submucosal fibroid is one that indents into the endometrium.

It is actually arising from the myometrium, but because of its location, it projects into the endometrium.

And here you can see this same fibroid, the same submucosal fibroid, right?

Here it is again, this is a coronal reconstruction.

There's the fundus of the uterus, endometrium seen here.

And this structure, which has the same echogenicity as the myometrium, or at least similar to it, is projecting into bulging into the endometrium in this submucosal fibroid.

Or they can be subserosal as seen.

Here they are projecting out from the peripheral aspect of the uterus or the serosal aspect.

Here's a large fundal subserosal fibroid.

And here's a much smaller subserosal fibroid in a different patient.

It's actually surrounded by a little bit of fluid in the woman's pelvis.

There's the fundus, and it's in the anterior uterus, in this case, near the fundus.

Another location for fibroids.

Occasionally the fibroids can be on something of a stalk and projecting into the cervix.

So this is a fibroid prolapsing through the cervix.

You can see the stalk here.

Or in another view, this is the stalk and the fibroid.

When we turn color doppler on, we can see color doppler extending along the stalk and into the fibroid, which is prolapsing through the cervix here.

Uterine Leiomyosarcoma

Another type of myometrial mass is a uterine leiomyosarcoma.

This is a malignant tumor. It's a rare tumor.

But it can occur.

And when it does, we wanna make the diagnosis if possible.

And we'll see in a minute that it's not so easy to diagnose.

We don't usually do it.

It's thought to sometimes arise from a preexisting fibroid or it may arise de novo or on its own.

Now, the problem with diagnosing leiomyosarcomas, the reason that we do it is pretty rare to diagnose it before surgery.

If surgery is done, is because the presentation on ultrasound or the appearance on ultrasound is similar to that of fibroids.

So when would you ever see a myometrial mass and diagnose a leiomyosarcoma or say that you're worried about a leiomyosarcoma?

Well, the one situation where you would see a myometrial mass and say, I think that may be a leiomyosarcoma instead of just a fibroid, is in the situation where you have a growing myometrial mass in a postmenopausal woman.

So if a woman who is postmenopausal has an ultrasound at one point in time, and you see a myometrial mass, you're gonna call it a fibroid.

That's what it almost certainly is.

If she comes back, let's say, six months or a year later, two years later, and it's grown, that's rare for fibroids.

As I mentioned earlier, fibroids tend to be estrogen independent postmenopausally, estrogen levels are extremely low.

So fibroids rarely grow after menopause, if you see one that grows on sequential scans, that's the situation.

You have to be worried that it may be a leiomyosarcoma.

And here's an example.

This is a woman who had an ultrasound.

She was postmenopausal.

We see this focal mass posteriorly here on the sagittal view here on the transverse view.

You can see that it's measuring about 11 and a half by nine by nine centimeters.

We diagnosed a fibroid.

She then came back five months later, but now it's much bigger.

It's measuring 13 by nine and a half by 11, quite a bit bigger than this, and it has some fluid or necrotic areas within it.

But most importantly, there's been quite marked growth five months later.

That growth of a is not what you would expect to see in a fibroid.

You have to be worried that this, the reason for the growth is that this is not a fibroid, but instead, a malignant version or a leiomyosarcoma, she had surgery, and this did prove to be a leiomyosarcoma.

Adenomyosis

Another myometrial lesion is adenomyosis of the uterus.

And adenomyosis is the situation where you have endometrial tissue that is situated within the myometrium.

It's actually a form of endometriosis because it's endometrial tissue in an abnormal location.

It may be difficult to distinguish from a fibroid, but you should suspect adenomyosis.

If you see a lesion in the myometrium that either involves the entire uterus or has very ill-defined margins, fibroids usually have pretty well-defined margins, and also suspect adenomyosis.

If the lesion that you're seeing is hypoechoic or echogenic with cysts and shadowing, like you see, in this case, the whole uterus is enlarged and bulbous looking here, sagittal here, coronal or transverse.

So it is a diffuse lesion.

No margins to it.

Also, it's full of these shadows that are emanating from it.

And as you look carefully, you can see multiple small cysts here, here, here, and again, shadowing.

So a lesion like this with cysts and shadowing and no well-defined margins to it, is pretty typical for adenomyosis.

The that one was diffuse. This one is localized.

The bottom half of the uterus is seen here, and the top half, the top portion here, the top portion is actually looks normal on the sagittal and coronal view or transverse view, this is normal, but we see markedly thick and posterior myometrium.

See, in both cases, both sagittal and coronal views.

And you can see multiple areas of shadowing little cysts within it.

This is localized adenomyosis.

Endometrial Evaluation

Okay, well, let's now move, spend the rest time talking about the endometrium.

And some of the findings here on ultrasound, or some of the topics that we can talk about include fluid in the endometrial cavity, and what does that mean?

Uterine synechiae or scars, and some endometrial lesions, the most important of which is endometrial carcinoma, which we'll talk about in a little more detail, as well as localization of intrauterine devices or IUDs.

Fluid in the Endometrial Cavity

So if you see fluid in the endometrial cavity, what causes should you consider?

And I do put a little footnote here.

Trace amount of fluid in the endometrial cavity, or the uterine cavity is usually completely normal and not something that we worry about.

So when I talk about causes of fluid in the endometrial cavity, what I'm really talking about is a significant amount of fluid, not a trace amount.

You can obviously get fluid in the endometrial cavity during pregnancy, normal pregnancy or abnormal pregnancy with malignancies, including cervical cancer or endometrial cancer.

You may see fluid in the endometrial cavity.

You can also get fluid with congenital obstruction, such as vaginal atresia and other causes of obstruction, or iatrogenic obstruction after surgery.

There may be obstruction in the cervical canal or after irradiation.

So when we see fluid, we have to think of these causes and try to figure out what which one it is.

This is an example of a lot of fluid in the cavity.

Here. You can see on a sagittal and coronal view, there's a lot of fluid filling the cavity, and actually into the cervical canal.

Here, you can see there's swirling of fluid.

This one proved to be due to cervical stenosis.

Here in the cervix, there's fluid in it.

And the there was stenosis at about this point.

Uterine Synechiae

Another endometrial or uterine cavity abnormality is a synechia or a scar.

And this wouldn't really show up on a regular ultrasound.

Here is a regular transvaginal sagittal view of the uterus, looks completely normal.

But when fluid was instilled with a sonohysterogram, you can see that the fluid outlines this linear band within the uterine cavity.

This is a scar or a synechia, and these sometimes lead to fertility problems.

The benefit of diagnosing them is that they can be removed or resected.

Postmenopausal Bleeding

So now let's move to one of the important, one of the more important topics of ultrasound of the uterus, namely ultrasound of postmenopausal bleeding.

And we will explore that a little bit over the next several minutes.

So what are the causes of postmenopausal bleeding?

And postmenopausal bleeding is a fairly common presenting symptom of women to their doctors.

The most common cause of postmenopausal bleeding is something that's actually not pathological at all, but is just a normal physiologic state, namely endometrial atrophy.

The endometrium normally, or typically atrophies after menopause.

And the atrophic surface of the endometrium is prone to some degree of bleeding.

So by far, the most common cause of postmenopausal bleeding is not pathological at all, but physiologic state, namely, atrophy, at least 50% of all cases of postmenopausal bleeding occur as a result of endometrial atrophy.

Now, then the other causes are pathological.

And the most important pathological endometrial cause of bleeding is endometrial cancer.

It's estimated that roughly 10% of women with postmenopausal bleeding have carcinoma, although there's wide variation from study to study as low as 1% of women with postmenopausal bleeding, having cancer to up to 15%, or occasionally even higher than that, endometrial polyps or hyperplasia can also cause bleeding.

And occasionally you can get vaginal bleeding in a postmenopausal woman because of submucosal fibroid.

The main reason that we have to be concerned that a physician has to be concerned when a patient presents with postmenopausal bleeding is the possibility that the bleeding is due to cancer.

And our evaluation is focused on deciding whether the woman with bleeding has cancer or not.

A American College of OBGYN committee put out an opinion in 2009 that said, any woman with postmenopausal bleeding requires prompt and efficient evaluation to diagnose or exclude cancer.

And that is because that is obviously such a critical diagnosis and bleeding indicates a risk of approximately 10% of having cancer.

Role of Ultrasound in Postmenopausal Bleeding

So in a woman with postmenopausal bleeding, what is the role of ultrasound?

Well, the key questions are, number one, is there any sonographic finding that indicates that in a woman with postmenopausal bleeding, that the likelihood of significant pathology, especially that the likelihood of cancer is so low, that biopsy is unnecessary.

And secondly, can ultrasound help if a woman is gonna have a biopsy for postmenopausal bleeding because of the concern for cancer?

Can ultrasound help identify the appropriate biopsy technique?

So let's to answer those questions, let's start by considering what are the ultrasound features of the endometrium and how do they relate to endometrial pathology?

Well, with endometrial atrophy, the ultrasound feature is uniformly thin endometrium with an endometrial polyp.

The ultrasound appearance is a focal area of thickening, often with a feeding vessel seen on color doppler.

Occasionally there are cystic spaces, and if there's fluid in the uterine cavity with a polyp, there will be projection of tissue into the fluid filled cavity with endometrial hyperplasia.

The ultrasound appearance is a homogeneously thickened endometrium with endometrial carcinoma.

Typical appearance is a heterogeneous endometrium with unclear margin or markedly thickened endometrium.

And with a submucosal fibroid, you'll see a hypoechoic lesion indenting the endometrium.

And here are a few examples.

This is a typical appearance of endometrial atrophy.

Postmenopausally. You can see a very thin line of the endometrium measuring about 1.6, measuring 1.6 millimeters, 0.16 centimeters.

This is an example of a polyp.

You can see the a focal echogenic lesion in the center of the uterus.

There is one feeding vessel into it, very typical appearance of a polyp.

This is an example of endometrial hyperplasia.

You have a thickened endometrium, very prominent endometrium, but it's very homogeneous and well defined.

Margins is an example of endometrial cancer, very thickened, extremely thickened, and very poor margins.

In some places, it's somewhat heterogeneous, darker area here, brighter area here, and a very unclear margin down posteriorly at that point.

Another example of cancer where the endometrium is extremely thick, but it also has fluid in the uterine cavity.

And a irregular endometrial surface outlined by that fluid.

Also seen to be irregular here.

So, as we've seen on the previous few slides, there are some ultrasound features that are typical for various kinds of endometrial pathology.

However, they're not, in most cases, predictive enough to be able to make allow you to make a clear or definitive diagnosis.

In fact, I think it's fair to state the following that in a woman with postmenopausal bleeding, the only sonographic feature that's definitive enough to eliminate the need to perform a biopsy is endometrial thickness.

Measuring Endometrial Thickness

So we since endometrial thickness is used or can be used to say biopsy is not necessary, and we'll see in a minute, we have to have a very careful technique when we are measuring the endometrium.

So we want to measure it via a sagittal image on a transvaginal ultrasound, transvaginal in a woman with postmenopausal bleeding to get the best definition of the endometrium to measure it, we take a double thickness measurement, including the anterior and posterior endometrium.

Usually you can't separate them, but if there is fluid in the endometrial cavity or in the uterine cavity, you have to measure the anterior and posterior component separately and add them together to get the endometrial thickness measurements.

We wanna sweep through the uterus to find the area of maximal thickness.

And if you don't see the endometrium well enough to get an accurate measurement in a woman with postmenopausal bleeding, it's important to interpret the scan as being non-diagnostic.

As far as endometrial thickness goes, if you can't see the endometrium clearly in its entirety, and this is how you measure it, criteria were put forth by an international endometrial tumor analysis group in 2010.

You wanna pick the region of maximal thickness as in this diagram, and if there's fluid in the cavity, separating the anterior and posterior portions, you wanna measure each separately and add them together.

So here is a good example of why you wanna look at the area of maximal thickness.

Initially you might think that you were measuring an endometrium here, and it is, looks like it's just about four millimeters.

However, what you can see when we sweep through, as in this image here, and stop at the area of maximal thickness, it's not four millimeters, it's 8.7 millimeters, which is, as we'll see soon, abnormally thick.

So again, it's important to sweep through, pick the area of maximal thickness and measure there.

When there's fluid in the cavity, you can see a little thin band of fluid.

The right way to measure it is to measure the anterior part and the posterior part.

You can see two measurements here.

We add them together to determine a endometrial thickness here of 4.8 millimeters.

Incorrect would be to measure the whole thing, even though there's fluid in the middle.

And you would, if you do that, get an incorrect measurement of 6.5 millimeters as seen here.

So when there's fluid measure, anterior and posterior parts separately.

Significance of Endometrial Thickness

So what's so important about the endometrial thickness?

Well, a number of studies, a fairly large number of studies have looked at the relationship between endometrial thickness and endometrial cancer.

In particular, they have looked at what the diagnosis is in a patient with a thin endometrium.

What do we mean by a thin endometrium?

Well, there's a little bit of variability in these studies, but typically using either four or five millimeters as the definition as the cutoff for a thin endometrium.

And I highlighted in green these two columns.

They're the ones that we wanna focus on.

So the first column, this one, endometrial cancer looks at what is the likelihood or what is the incidence of endometrial cancer in a woman with postmenopausal bleeding who has a thin endometrium?

And you can see it's exceptionally low. It's very, very low.

In fact, in most studies, no one 0% of women with postmenopausal bleeding had cancer if their endometrium is thin.

So a thin endometrium comes pretty close to ruling out uterine and endometrial cancer.

What was the diagnosis? It was almost always atrophy.

The vast majority of patients with a thin endometrium have endometrial atrophy.

Not all of them, but the large majority.

And in some studies, all patients with a thin endometrium had atrophy, in other words, a thin endometrium.

According to one consensus conference, the Society of Radiologists in Ultrasound Consensus Conference called it thin if it was less than or equal to five millimeters.

The American College of OBGYN Committee said it's thin if it's less than or equal to four millimeters.

In fact, in my own department, what we do is, we say if the endometrium is four millimeters or less, it is normal thin in a woman with postmenopausal bleeding.

If it's four to five millimeters, it's borderline.

And if it's above five, it is thick.

So a thin endometrium indicates an extremely has an extremely low false negative rate for endometrial cancer.

In other words, the likelihood of endometrial cancer in a woman with postmenopausal bleeding and a thin endometrium is somewhere between zero and 2%, very low.

The and the false negative rate of zero to 2% is actually lower than the false negative rate of an endometrial biopsy.

So, a thin endometrium means an extremely low likelihood of endometrial cancer.

It also means a very high likelihood of endometrial atrophy, above 90% in most studies.

So if this is a woman with postmenopausal bleeding, we measure the endometrium looks thin.

It is thin, it's just over one millimeter.

This is a thin endometrium and a woman with postmenopausal bleeding, which means by those studies that she has a very high likelihood of endometrial atrophy and extremely low likelihood of endometrial cancer.

So, biopsy is unnecessary because of the low likelihood of endometrial cancer.

Sonohysterography and Biopsy Techniques

Now, one of the questions is, if a woman is gonna have a biopsy, can ultrasound help pick the best biopsy technique?

And the answer here is, yes, a sonohysterogram and a woman, if a woman has a thickened endometrium and is gonna have a biopsy, a sonohysterogram can help select the appropriate biopsy technique.

In particular, if a woman with a sonohysterogram, with thickened endometrium has a sonohysterogram, and it shows that the endometrium is diffusely thick, a blind biopsy would be appropriate.

If it's focally thick, a hysteroscopic biopsy would probably be, would usually be appropriate.

And I'll show you some examples shortly.

So how do we do a sonohysterogram?

A speculum is inserted into the vagina catheter is put through the cervix.

A balloon may or may not be used.

We usually use them in our department, but it's optional.

The speculum is removed, transvaginal transducer is inserted.

You scan and insert saline to outline the endometrium.

As in this case, you can see here saline is being instilled into the uterine cavity.

In this normal sonohysterogram, you see a nice thin, uniformly, thin, smooth endometrium all the way around.

So the role of sonohysterography is if ultrasound shows a thick endometrium greater than four millimeters, or it's distorted or unmeasurable on the conventional scan, you can do a sonohysterogram.

And then if it is thin, which is less than or equal to two millimeters, uniformly single layer, which corresponds to a four millimeter double layer, the diagnosis is endometrial atrophy.

If the endometrium is diffusely thick, a blind biopsy would be appropriate, focally thick.

A hysteroscopic biopsy would generally be needed.

And if you see a focal, I mean a submucosal fibroid excising, it would be may be considered a few examples.

This is a conventional transvaginal ultrasound prior to sonohysterogram.

You can see 12.8 millimeter or quite a thick endometrium in this woman with bleeding.

Does she need a biopsy? Yes. What kind of biopsy?

Well, we put saline in, as you can see here, and you can see it's pretty diffusely thick everywhere, all around, which means that a blind biopsy should be appropriate.

On the other hand, here's another woman with a thick endometrium measuring about 10 millimeters.

So it's thick. Does she need a biopsy? Yes.

What kind to answer that when instill saline.

And you can see that the reason it's thick is because there's a pretty large polyp.

So she needs a hysteroscopic biopsy to make sure that the polyp is either biopsied or actually totally removed during the procedure.

So we asked two questions earlier.

Is there an ultrasound finding that indicates biopsy is unnecessary?

The answer is yes, A thin endometrium less than a four millimeters.

Second question, can ultrasound identify an appropriate biopsy technique?

The answer again, is yes, sonohysterography can, depending on whether it's diffuse or focal, indicating a blind biopsy or a hysteroscopic biopsy is needed.

Diagnostic Approaches for Postmenopausal Bleeding

So what the diagnosis of postmenopausal bleeding?

There are really two approaches.

One is ultrasound first, and the other is biopsy first. With the ultrasound first approach, we start out with a woman with postmenopausal bleeding.

The first thing we do in the ultrasound first algorithm is a transvaginal ultrasound.

If the endometrium is thin, we diagnose atrophy.

If it's at least four millimeters or distorted or unmeasurable, do a sonohysterogram and pick the appropriate biopsy technique if needed, based on the sonohysterogram.

So that's the ultrasound first approach.

Another equally good approach is a biopsy first approach.

A woman presents with postmenopausal bleeding.

The first thing that's done is a office biopsy.

If the diagnosis is conclusive, the workup is complete.

And if the biopsy is inconclusive or inadequate, there's an inadequate diagnosis based on it, you do a transvaginal ultrasound and then you proceed as in the prior algorithm, either biopsy first or biopsy.

Uh, either ultrasound first or biopsy first is fine.

The key thing is to use them both in conjunction to reach a diagnosis.

So conclude this part of the talk.

Any woman with postmenopausal bleeding should undergo diagnostic evaluation to diagnose or exclude malignancy.

Either endometrial biopsy or transvaginal ultrasound is an acceptable first test.

If the endometrial biopsy is done and tissue is insufficient for diagnosis, transvaginal ultrasound should be performed.

An endometrial thickness of four millimeters or less, or some use five millimeters on a transvaginal ultrasound indicates a very low likelihood of cancer.

An endometrial biopsy is not needed.

If the endometrial thickness is greater than four millimeters, sonohysterography can identify the best biopsy technique.

And if the initial test is negative and bleeding persists, then additional evaluation is usually indicated.

Conclusion

So I've come to the end of the tour of ultrasound and sonography and sonohysterography of the non-gravid uterus considering congenital anomalies, myometrial lesions, and endometrial pathology.

I certainly hope it's been useful to you. Thank you.