Sonography & Sonohysterography of the Non-Gravid Uterus

Adenomyosis of the Uterus

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 hyperechoic
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 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 thickened posterior myometrium
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 Findings on Ultrasound

Let's now spend the rest time talking about the endometrium.

And some of the findings here on ultrasound are 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 there was stenosis at about this point.

Uterine Synechiae or Scars

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.

Ultrasound of 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.

Causes of Postmenopausal Bleeding

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,
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.