Ultrasound of the Endometrium - HD

Introduction

My name is Tom Winter.
I'm from the University of Utah,
and we're gonna be talking about
ultrasound of the endometrium.
This is downtown Salt Lake City.
You can see the western front
of the Rocky Mountains in the background.
We'll divide the talk up into several sections.
We'll talk about why we worry a little bit on terminology
and technique, what's abnormal in four
or five different clinical scenarios.
We'll talk about abnormalities seen on transvaginal
ultrasound, the utility of other diagnostic modalities.
And then we'll have a talk within a talk
discussing saline infusion
sonohysterography.

I'm a big fan
of quotes, and I like this one.
I think this is very important in medicine,
but this is a quote from Louis Pasteur talking about
how in the fields of observation,
which is our business chance favors only the prepared mind.
And then as a counterpoint to that,
you think this could come out yesterday,
but this was published over a century ago
by Sir William Osler.
I could never get into the medical school
with the proposed new standards.

Why We Worry

Rough rule of tens, about 10%
of postmenopausal women will bleed.
It's one of the most common indications for
seeing a gynecologist in the United States.
Of the 10% of women who bleed, 10%
of these women will have endometrial cancer.
And then remember that even though we think
of endometrial cancer as a disease of older women, five
to 10% of endometrial cancer occur in women
under the age of 50.
It's the most common GYN malignancy about 40,000 cases per
year in the United States.
And it's the fourth most common cancer in women
following only breast, lung, and colon cancer.
But it makes up a minority
of the cancer deaths despite its prevalence,
because it presents early and
because we have reasonable treatments for it.
And just to scare us all, this is a case from
last month where you can see a 35-year-old patient.
And on her ultrasound you can see this large echogenic mass
filling the endometrial cavity.
And on the MR, it's invading almost to the serosa.
So again, endometrial cancer is generally disease
of postmenopausal women, but there are exceptions.

Terminology and Technique

In terms of the terminology, this took me years
to figure out here, and you can look at the handout there,
but kind of a generic term that's nice is just AUB
or abnormal uterine bleeding.
That kind of covers all of the above subcategories there.
John Wooden, the most famous basketball coach in history,
had a great quote.
He was a wonderful life coach,
but he used to say attention
to the little details is the foundation of excellence.
And I think that's totally important in medicine.

How to Measure the Endometrium

So how do we measure the endometrium?
It's a transvaginal measurement,
obviously with an empty bladder.
It's sagittal plane, it's the thickest portion.
It's a double thickness measurement.
So if there's fluid in the cavity, you exclude it
and you have to visualize the entire endometrium.
This is something that's often forgotten,
but five to 10%
of the time you're not gonna see the entire endometrium.
And that's totally okay.
We wanna test that when we say it's normal,
we're a hundred percent or close
to a hundred percent sure that it's normal.
So up to one in 10 times,
you're just gonna say there's a fibroid.
The uterus is in a funny position,
I don't see the entire endometrium, so we need
to do something else there.
And so here's just an example from Ruth's wonderful paper on
this, talking about, obviously transvaginal ultrasound is
better than transabdominal.
You want to exclude the hypoechoic, inner myometrium,
the junctional zone there.
So your measurement is only the hyperechoic center.
And if there's fluid in the center,
this kind of makes sense.
Just exclude it, measure both walls and add them together.
And then again, we have to see the entire endometrium.
It's so easy just to find a white line,
put cursors on either side of it and measure it.
But here you can see in the top left
image there, it looks normal.
But as you sweep to the side, Sally,
and in the bottom we see a cine sweep coronal right there,
there is a stage one adenocarcinoma not
seen on the initial images.
And again, remember five to 10%
of the time the exam is indeterminate.
It's just hard to see things right there.
So here's an example of a bunch of fibroids right there.
Sure you can find a little bit of endometrium
and put cursors on it,
but there was a stage two B endometrial cancer hiding
behind one of those fibroids there.
And don't accept indistinct endometrial margins.
Endometrial cancer can be infiltrating.
And this example here is pretty obvious there,
but you can see just this ill-defined gradient
of tissue going off into the myometrium right there.
And that turned out to be an endometrial cancer.

What's Abnormal

Now let's talk about what's abnormal.
And we'll go into four different categories here.

Premenopausal

The first is premenopausal.
And we have the different phases of the cycle right there,
rough limit there is 15 millimeters is the upper limits
of normal depending who you read right there.
Here's just two
or through various stages of the endometrium.
This could be a postmenopausal patient,
but it turns out to be a 20-year-old on OCPs who's day four.
And the endometrium looks totally atrophic.
Then we start to get into the proliferative
or follicular phase.
Those are synonyms there,
and you start to see some architecture in the stripe.
Then as we get closer to mid cycle there,
you get this trilaminar appearance to the stripe
where you see three layers to it right there.
These are two different patients here.
Then as we move on into the luteal
or secretory phase, we lose the trilaminar appearance
and instead we have just a thick homogeneous mass right there.
And remember that in a premenopausal patient,
15 millimeters is not a perfect threshold right there.
This is a two and a half centimeter endometrium,
but your GYN friends are gonna laugh at you if you call this
abnormal because she's 29 years old.
She's totally asymptomatic with normal cycles,
normal periods there.
So one of the key things
to learn from this is we always want
to do all our non-emergent pelvic ultrasounds on day five
to 10 of the menstrual cycle there,
and then we won't run into these issues.
So again, look at this one here.
We have a lumpy, bumpy appearance to the endometrium.
We do an SIS here
and you can see kind of a lumpy, bumpy appearance there.
But if you did this on day five to 10,
it would be totally normal.
The endometrium does not hypertrophy homogeneously.
Instead it hypertrophies in a lumpy, bumpy fashion.

Postmenopausal with Bleeding

Second scenario, and by far
and away the most important is
what should the endometrium look like in a postmenopausal
patient with bleeding?
And we use five millimeters. ACOG uses four millimeters.
There's arguments back and forth somewhere in there.
If there's a focal endometrial abnormality
that's abnormal though.
So if it goes 1, 1, 4, 0.9,
4.9, 1, 1, that's abnormal
and indistinct appearance of the lining, as we saw before,
and again, remember
that this is gonna be non-diagnostic in five
to 10% of the cases.
Remember
that an abnormal test doesn't mean the woman has cancer.
We don't wanna scare grandma if she comes in and is bleeding
and her stripe is over five millimeters.
It's incumbent on us to rule out cancer,
but there are certainly a bazillion other causes
that could give her bleeding right there.
So bottom line, we just need to say you need to see A GYN
and get another test there.

Postmenopausal on Hormone Replacement Therapy

Third scenario, postmenopausal bleeding on hormone
replacement therapy there.
Stay at five millimeters.
Don't go to the eight millimeter threshold
that you see tossed around.
There's no data to back that up.
Bottom line, we're gonna have a higher false positive rate.
But again, we want specificity.
We want to test that when we say it's negative,
grandma does not have cancer there,
and there are enough cancers in the five
to eight millimeter range that we don't want to use that.
So just stay at five millimeters.
And here's a 55-year-old on unopposed estrogen
for five years after menopause, kind
of against her doc's wishes there.
And she had this 1.6 centimeter endometrium
that turned out to be benign.
So again, an abnormal ultrasound doesn't mean cancer,
it just means we need to deal with it.

Postmenopausal but Not Bleeding

Next scenario, this one's very controversial,
postmenopausal but not bleeding.
How thick is too thick?
So the most important thing to remember from this is
that we are not advocating a screening program.
Nobody out there is saying
that we should offer asymptomatic women ultrasounds
to look for endometrial cancer there.
But what if you're doing it for a fibroid
or for diverticulitis for 50 million?
Other reasons? This is probably the best paper out there.
And it's a meta-analysis published by the group at UCSF
and they say over 11 millimeters offer biopsy
if you're post-menopausal
but not bleeding, cancer risk is around 5% there.
You can argue all these things,
but most of our GYNs seem comfortable
with that number right there.

Tamoxifen

Okay, last scenario, Tamoxifen.
There this selective estrogen receptor
modulator has the risk of breast cancer recurrence,
but it is an estrogen agonist in the uterus and an antagonist elsewhere.
So it increases the risk of hyperplasia, polyps, and cancer.
If you do the math though, the number
of lives saved from preventing breast cancer far outweighs
the morbidity and mortality from endometrial cancer.
So it's a good thing there
because it's an estrogen agonist
and the endometrium, most women on estrogen,
their endometrium looks abnormal.
So bottom line here, don't ask, don't tell.
We don't want to do ultrasound
in patients on tamoxifen if they're asymptomatic,
and then if they're bleeding, they're gonna
go ahead and do a D&C.
And so here's just a patient
who had a 16 millimeter cystic endometrium on Tamoxifen,
and these turned out just to be polyps and not cancer there.
And most of the gynecologists,
and certainly all the GYNs know this,
they're not sending us ultrasounds in patients on tamoxifen
who are asymptomatic there,
but still some of our mid-level providers are sending us these ultrasounds
and then we're kind of stuck because everything looks
abnormal and we don't know what to do with it.
So we just don't wanna look.
Here's another one right here
with a classic tamoxifen endometrium appearance.
And here's a big one. Look at this.
It was three centimeters
and then went up to five centimeters a year later.
But when they finally got around to doing a D&C,
this was just benign polyps here.

So numeric summary, basically remember five millimeters.
So if you're postmenopausal
and bleeding your postmenopausal bleeding
and on hormones, you're on tamoxifen,
we're using five millimeters.
The idea being that if it's less than five,
it's almost never gonna be cancer.
If it's over five, it doesn't mean it's cancer,
but we need to do something else.
And then postmenopausal patients who aren't bleeding,
we use 11 millimeters and premenopausal, we use a centimeter
and a half, but take that with a grain of salt.

Abnormalities on Transvaginal Ultrasound

Okay, so what are the abnormalities we can see on just
routine transvaginal ultrasound?
And number one is atrophy.
60% of the patients who come in
with postmenopausal bleeding have atrophy.
Remember, 10% of the postmenopausal population comes in
with bleeding, and 60%
of those are gonna have atrophy as we see here.
Some are gonna have polyps.
Here's a nice transvaginal
appearance of a polyp right there.
This one's kind of cool.
You can see the uterus kind of peristalsing, if you will,
trying to push this polyp out here.
There's the solitary vascular stalk heading into it there.
And then fibroids. We've all seen a million of these,
hypoechoic with that hypoechoic cap,
and then endometrial cancer.
She had intermittent spotting. This looks like a polyp here.
And unfortunately as you section this, it's benign, benign,
benign, benign cancer, benign, benign, benign, benign.
So there was an article in the Green Journal a couple years
ago, making the point that
what we were taught in medical school
that polyps are always benign, is not true.
And depending whether you're premenopausal
or postmenopausal, there's a two to 4% risk
that any polyp taken out will have a small
focus of cancer in it.
It's really not that big a deal
because you're gonna take the polyp out anyways
because of the symptomatic issues there.
And then here's another one 58-year-old with heavy bleeding.
And where is the endometrium?
There's just no stripe there whatsoever.
And in the operating room, nearly every surface
of the endometrial cavity was involved with cancer.
So endometrial cancer tends to be kind of big
and bulky most of the time.
Here's another one, white here, an 83-year-old
with vaginal bleeding.
And you can see the endometrial thickness of
however many millimeters that is right there.
And there's cystic change in it.
And this turned out to be endometrial cancer.

Other Diagnostic Modalities

What are the other diagnostic
modalities that we compete with?
Well, in the old days, we used to do HSGs of cell picograms.
The only time that we do them now is to assess tubal patency, fill
and spill for in the infertility population.
But HSGs are awful for the endometrium.
Here are two different patients that we did.
One of these turned out to be a polyp.
One turned out to be a cancer,
but it turns out that these are have many false positives
and many false negatives there.
So a lot of women with true pathology have normal HSGs.
Many women with masses like this turn out
to have no cancer there.
So this has gone the way of the dodo.
Another technique has the dilatation and curettage,
or as my mother-in-law called it dust and clean.
This is now only being used as a therapeutic modality.
We're not doing this for diagnostic purposes anymore.
And even when you're doing it therapeutically,
you're only sampling a subset of the endometrium.
So you can miss focal abnormalities,
whether they're cancer or polyps.
The diagnostic D&C has been replaced
with the endometrial biopsy right here.
There's a bazillion different types out there.
This is pretty good for endometrial cancer.
It's not perfect, but most papers say it has a pretty good sensitivity right there.
But again, you're only sampling a small subset
of the endometrium there.
So in Lucy Han's study, you're only picking up 4%
of proven polyps.
So this is a good test, but not perfect for cancer.
It's awful for focal benign abnormalities there.
And it hurts more than an SIS
The gold standard is hysteroscopy.
You can do this diagnostically in the office
or in the operating room.
In the office, there's about a 10%
failure rate right there.
You can just like virtual colonoscopies.
Sometimes SIS is better diagnostically there.
But obviously the advantage of hysteroscopy is
that if you find something,
you can do something about it there.

Saline Infusion Sonohysterography (SIS)

So now let's move into a talk within a talk
on saline infusion sonohysterography right here.
We'll have an overview, we'll talk about technique
and then we'll have a whole bunch of examples in there.
If you like etymology,
there's a bazillion different terms for this right here.
And it's kind of a hybridization of both Latin and Greek.
That means literally writing on the uterus
with sound right there.
Primacy is always difficult to determine in medicine,
but the first study that I could find was
about 30 years ago.
And there's still quite a bit of literature on this.
We've averaged about 70
or 80 a year for the past 10 years, right there.
One of the most important points I wanna make is
that this is not a difficult study to perform.
There was a really nice study
where they compared nurse practitioners,
second year residents, fourth year residents
and fellows found no difference right there.
So that's what makes this such a good test.
You may have a test that works for somebody from Harvard
who's brilliant and does nothing but ultrasound,
but that's not gonna help us in rural Montana trying to help
the 300 million
or a hundred, 200 million women in America right there.
We need a test that works well in non-expert hands.
And that's what this test is.
Now, we're not gonna talk about it,
but remember to always do a conventional transvaginal
ultrasound, look at the uterus for fibroids,
look at the ovaries and all that stuff.
And one point, particularly in this era
of cost containment that people bring up is SIS overkill.
Is transvaginal ultrasound alone good enough?
And here's an ultrasound MR.
And hysteroscopy on a fibroid in the uterus.
Here's another one.
It's maybe a little bit subtle,
but there's an obvious endometrial mass right there.
You put fluid in
and there's the endometrial polyp right there.
So you might say, well,
is it really good enough or is it too much?
But look at this case right here.
There's a sagittal midline view of the uterus on the left,
and then here's a sweep through the uterus from left
to right, showing you that I'm not cheating,
I'm showing you everything right there.
And I would never call anything on this
test, but she was bleeding.
And then let's go ahead and look right here.
And there's an obvious polyp right there.
So transvaginal ultrasound,
we don't see anything right there.
And then on SIS obvious polyp, so the overwhelming,
overwhelming bulk of the literature says
that transvaginal ultrasound is not good enough.
And just picking one paper kind
of randomly from the list there, a quarter of the women
with a normal transvaginal had an abnormal SIS

Indications for SIS

What are the indications?
Basically anything whatsoever to do with the endometrium.
Discordance is a big one here.
Here's a woman who had perimenopausal with irregular bleeding.
The stripe was 17 millimeters,
her endometrial biopsy was negative.
But remember, endometrial biopsies have a 4%
sensitivity for polyps.
And then we do the SIS
and there's a four centimeter polyp in there.
So our primary goal is
to determine whether something is surgical or medical.
Is it atrophy or is there a focal bump
that needs something right there?
And although we're pretty good, we want
to be careful about not getting too cocky about
distinguishing malignant from benign disease

Technique for SIS

In terms of technique.
If you like military metaphors for medical procedures for star patents, set a pint
of sweat will save a gallon of blood.
So preparation, preparation, preparation, schedule the study
between day four and seven of the patient's cycle.
Have the patient take some Motrin half an hour
to a couple hours ahead of time.
Be a nice person. There's some minor things
that you want to think about.
We don't do SISs with an IUD and all that,
but take a look at our article there for details.
And more recent data from the National Heart
Association says that we don't need to prophylax for SBE.
Okay? And why are we doing this day four to seven?
Number one, you don't like
to do this when the patient's pregnant,
you lose style points right there.
Number two, remember we said that we do the entire pelvis,
we look at the uterus for fibroids
and we look at the ovaries and you're just not gonna run
into those funky little hemorrhagic corpus luteum cysts that make you worry.
They're so Doctors Goldstein
and Timor-Tritsch had a nice paper saying,
just schedule all your non-emergent studies.
Day four to seven, you most importantly,
you avoid the endometrial false positives
that occur when you're scanning in the late secretory phase
because the endometrium is lumpy, bumpy.
And here's an example.
Look at this endometrium, totally lumpy, bumpy.
Any one of these could be a polyp or cancer.
And then you bring your vacuum and it's totally atrophic.
This was a beautiful paper by MJ O'Neill a
few years back right there.
So schedule days five to 10.
Another issue though is
that if somebody has abnormal bleeding,
they may not know when their period is.
And so you your secretary's like,
well come back on day five to 10
and they're like, I don't know what day five to 10 is.
But once you get the catheter in, you can,
here's two different patients.
You can often find the blood clots, kind of beat 'em up
with the Foley balloon, suck out the fluid,
put in fresh fluid so it takes you longer.
But even when somebody's bleeding,
you can get a diagnostic study.
What are the risks? The main one
that people experience is some cramping right there, just
because you're just distending the uterus, get a little bit
of spotting, have some tampons
and pads in the department
that you can give patients to go home with.
Very rare, knock on wood, I've never had one of these,
but you can have an infection right there.
If you have dilated tubes,
you may wanna put 'em on antibiotics there.
Vasovagal reactions are rare, but they do occur.
So please, when you inflate the fluid in the
balloon, do it slowly.
One very high theoretical concern is endometriosis
because one of the theories for
that is retrograde menstruation.
And here you're putting fluid into the endometrium
and potentially knocking endometrial cells out retrograde into the peritoneal cavity.
Another one is up staging.
If you have endometrial cancer,
because we're doing these in older women, many
of whom have endometrial cancer,
are you seeding the cells right there.
And this was a beautiful study right here
where they put baggies on the end
of the fallopian tube there
and then infused, did an HSG in the operating room
before they did a hysterectomy
and looked at the cells in the fallopian tubes
and bottom line, there were some malignant
cells, but they weren't viable.
So even though endometriosis
and endometrial cancer are risks,
they are not real risks there.
They're theoretical risks.
So we go ahead and we have very good data historically
and also this our study showing
that we're not upstaging endometrial cancer, okay?
Equipment. Here's a tray that we put together with some ring forceps, a tenaculum, some sounds,
and all that kind of stuff.
Like most things in life,
it's the operator, not the equipment.
This was a really nice study
that looked at six different catheters
and 600 plus women,
so about a hundred patients per arm of the study there.
And bottom line, they all worked,
the Foley catheter was the cheapest,
but it was a little bit more difficult to use.
The Goldstein, which is this one in the middle here,
is relatively cheap, works pretty well.
We use the dedicated HSG catheters, which is more
or less just a modified Foley.
You can see here it has a balloon on the end of it.
If you have somebody that has a stenotic cervix,
you can use the patent embryo transfer catheter
or just use a five French catheter over an 0.038 glide wire right there.
Choose the correct speculum for radiologists.
I think this is very intimidating just doing these exams here.
So there are two different types of speculums,
the Peterson and the Graves.
The Peterson has a straight margin.
The Graves is kind of like a ducks bill right there.
Each one of these comes in small, medium
and large sizes there.
A medium Peterson is a good all purpose one there.
I work at a state institution,
so we really have no choice over
what central supply sends up to us.
If you work at a private place,
you can get a little bit more fancy
and get these Lucite speculums
that have the LED lights on the end that are made for this.
They're really, really nice.
But I basically never get to use those.
For a large woman who's had a lot of kids,
a large Graves speculum is a good choice.
Insert the speculum correctly.
This is from Bates Guide to physical diagnosis there.
Lubricate the speculum, warm it with your hands there,
put gel on it right there.
Have the patient perform a Valsalva,
depress the perineal body posteriorly there
and go in at about a 45 degree angle cheating posteriorly
because the anterior vagina where the urethra is,
is more tender right there.
So perineal pressure come in 45 degrees cheat posteriorly.
So there we are going in, then we turn it 90 degrees
and this is what it looks like from the side.
And then we open it up and this is what we want.
We want this side picture right here.
Spend your time getting this shot.
A lot of the fails
that I've seen over the years are when people get a shot
like this and the internal os is down to the left
and at the bottom of the air
and you think, oh, I can sneak
the catheter around the corner.
Sometimes you can and sometimes it turns into a fail.
So just get this shot where it's right in the center,
right there and it's much easier to do.
Okay? That's the hardest part of the exam.
The second most difficult is getting the catheter
through the cervix into the endometrial cavity.
And you're dealing, if you're dealing
with a 35-year-old who's had eight kids vaginally,
it's probably gonna be easy.
If you're dealing with a 90-year-old who's never had kids
or only had c-sections, it's gonna be hard right there.
So what do you do with a stenotic cervix?
Number one is you can use a sound.
I always use the smallest sound.
And remember, we are not sounding the uterus.
You don't wanna perforate the uterus,
you just put this in a couple centimeters right there.
And oftentimes all that's obstructing you is a little piece of saran wrap like stuff.
So just putting in this sound an inch will kind
of break that up, show you which way the cervix is going.
Option number two is to use one
of these specialized catheters.
This is the patent embryo transfer.
You can use a five French wire
or five French catheter on an 0.038 there,
but just slide it up.
You think, oh, I'm gonna
have a lot of leakage there.
And you might, but you're generally only gonna do this in
the setting of a stenotic cervix,
so you're probably not gonna have much leakage.
Number three, you can use a tenaculum.
I've got a lot of very good friends who are GYNs.
They tell me textbooks tell me, oh,
the cervix doesn't have pain sensors,
it just has pressure sensors.
I can tell you that if this is done
wrong, it hurts right there.
So we're not doing surgery.
What we want to do is put the tenaculum at the noon position
on the cervix because the blood vessels are at three o'clock
and nine o'clock and we wanna stay away from those.
Just slowly go down one click
slowly pull it out a little bit right there, just enough
to get the catheter in right there.
And then the fourth thing is to quit.
This is from the literature. There, a gynecologist
who does this day in and day out with office hysteroscopy
and the benefit of a little midazolam
and fentanyl, which we don't have,
is gonna fail 10% of the time.
So we don't want to torture patients.
We want an easy procedure.
And if it turns into a fail, just quit.
We can always go ahead and do hysteroscopy.
So here's just an example of
that egg transfer catheter we tried
and tried, couldn't get anything through.
So you use this skinny slippery little thing
and it slides right in and we get a diagnostic study.
Again, don't jab the fundal endometrium upon catheter
insertion right there.
Slowly distend the balloon,
slowly infuse the saline right there so that it's nice
and slow there because you don't want a vasovagal response.
Another. And then remember those
of you in the room old enough to have done barium enemas.
Remember that the last thing that you did on a double
contrast barium enema was deflate the balloon
and image the rectum to rule out a rectal polyp
that was obscured by the balloon.
We need to do the same thing here.
So deflate the balloon
and pull it out at the end
to clear the lower uterine segment.
Another option, this is from the literature on a paper on
SISs, on HSGs.
But think
of inflating the balloon in the cervical canal there.
As you can see here, now this sounds kind of funny,
but we actually did a paper
and we had all these psychologists involved
and we measured pain and everything.
Turns out that this hurt less than
inflating in the endometrium.
We use less saline
because we didn't have to do pullout imaging.
You're not obscuring the lower uterine segment.
This works really well when you can't get the catheter all
the way up into the endometrium,
but you can get it far enough up into the
cervix to gain purchase.
The only downside is that 10% of the time,
one in 10 times the balloon's gonna pop out
and you have to put the speculum
back in and do it again there.
So I would say when you start out learning these,
put the balloon in the endometrial cavity,
but as you get better, just put it in the cervix failures.
Here's kind of a quick meta-analysis I did from the
literature and the numbers are all over the spectrum there,
depending whether it's OB, whether it's radiology,
whether the patient's postmenopausal
or premenopausal, whether bottom line.
Remember gynecologist fails 10% of the time.
After you've done some of these
and use some of the tricks that we talked about, you'll see
that it's much, much easier there.
You'll just learn little tricks.
What are some false positives and problems?
Air bubbles are the enemy of ultrasounds.
So here we can see an air bubble up towards the
fundus of the endometrium.
Balloon obscuring the lower uterine segment.
So deflate the balloon, grunge that looks like a mass.
You see that thing on the back of the uterus there.
So we deflated the balloon
and then just kind of scooped it around
and sucked the fluid out, put some new fluid in.
And by the time we were done,
we had a beautiful look at the endometrium right there.
Again, blood clots.
You start out here and you're like, wow, that's a polyp.
That's cancer. But you spend five
or 10 minutes putting fluid in, sucking it out,
putting it in, sucking it out,
and you get a nice normal study.
Mechanical shearing of the endometrium.
This has been called a pseudo polyp here.
And you can see you put the catheter in,
you've made a little shelf in the endometrium.
But bottom line, you should not be doing this study in
somebody who's in the luteal phase.
If you do everybody on day five
to 10, you won't have an issue.
Color Doppler, how much does it help?
Classic teaching is one vessel polyp multiple
vessels is fibroids.
That works, but you can't take it to the bank.
3D more and more of us are getting that there.
In reality, all you really need is a cine clip.
Just get a sweep sagittal, sweep coronal, and you're done.
But if you have 3D by all means use it.
Here's a second polyp right there
that we missed on the initial 2D scan.
You can do this kinda CT type imaging right here
and get the C plane so pretty.

Pathology Examples with SIS

Okay, and let's finish up in the last 15 minutes with pathology right here.
So SIS
and endometrial polyps there, most polyps are homogeneous
and they're hypoechoic, hyperechoic,
and they have a narrow base of attachment.
Oftentimes they're multiple.
So you wanna describe to your GYN friends how many they are,
where they are, what the base of attachment is,
so they know how to snare them.
Here's another one here.
Just a big polyp totally looks like a polyp,
but remember that literature talking about two to 4% of
supposedly benign polyps will have a small
focus of cancer in them.
And this one had a grade one
adenocarcinoma within the polyp.
So our job is surgical versus medical.
Here's another one right here. Just a pretty polyp.
Again, homogeneous hyperechoic.
Here's another one. This looked like Pac-Man,
that old video game on the left there.
And as we go through, you can see the Pac-Man appearance,
but this again turned out to be a benign endometrial polyp.
Really pathognomonic appearance almost.
And then again, remember the second polyp,
there are multiple here.
The balloon is obscuring the lower uterine segment.
When we deflate the balloon, we see the second polyp there.
Fibroids incredibly common right there.
A nice New England Journal paper a couple weeks ago talking
about the pathophysiology of these.
Here, like most things in life,
there are these obscure staging systems,
but all you need to remember is,
is it more than half in or half out?
Because if it's more in the endometrial cavity,
like the grade zero
and the grade one, you can take them out
hysteroscopically.
If it's more than half in the myometrium,
you have to do surgery there.
That's the information they want
and we're good at giving it to 'em.
This is from MJ's paper.
You can see the classic appearance of a fibroid
with this cap of endometrium
and then the hypoechoic fibroid underneath.
Here's another one on the right cap of endometrium.
Here's another one here.
Hopefully I'd call this,
but on a bad day I might miss it.
But then you do the SIS
and it's totally obvious you get that cap of endometrium
around it there and solitary vessel.
Here's another one, cap of endometrium, hypoechoic.
The vast majority of it's in the endometrial cavity.
These are the easy ones to take out.
Hysteroscopically, here's one.
You can see it transvaginally there you do the SIS though
you see the multiple blood vessels characteristic
of a fibroid, the cap of endometrium.
And again, it's almost all in the cavity.
So it's amenable to hysteroscopic resection.
Here's another one, classic appearance of this thin cap
of hyperechoic endometrium on this exophytic fibroid.
Now we're gonna start moving along
the spectrum toward cancer.
And there's endometrial hyperplasia, which makes up about 6%
of postmenopausal bleeding.
And there's a spectrum of endometrial hyperplasia from
simple without atypia through a few steps to severe atypia,
which is one step short of cancer.
So here you can see at transvaginal.
And then with the SIS we have this kind of uniform lumpy, bumpy appearance to the endometrium.
And this turned out to be simple endometrial hyperplasia.
Here's another one right here.
There's a little bit of a polyp,
but this turned out to be complex endometrial hyperplasia
without atypia within the polyp.
So surgical versus medical disease.
Here's a flat plaque, like one in MJ's paper right there.
This turned out to be mild atypia.
And then finally the point of this whole talk is getting
to endometrial cancer.
And again, this is the most common GYN cancer,
the fourth most common cancer in women.
They tend to be large and broad based.
Is this from our study patient right here, there.
So here is a classic appearance of this irregular, lumpy,
bumpy, partially cystic appearance taking up
much of the endometrium.
Here's another one with a malignant hematometra
with a irregular lumpy, bumpy appearance to the lining.
Here's another one coming in. And we may start.
There's been a change in Europe.
We've been asking the GYNs for years to do MR for these
and they haven't done 'em, they've just taken the OR.
But there's a real sea change out there in Europe
that's starting to hit in the US
The idea being if we can say
that there's only minimal invasion of the uterus,
then the hysterectomy can be done at your local
community hospital.
But if there's major invasion of the uterus,
then you may need to go see a GYN oncologist
with nodal dissection.
So take a stab at grading depth of invasion on your
SIS or transvaginal ultrasound there.
But in reality, MR is gonna be much better.
Another thing to think about is incomplete
distension right there.
Think of linitis plastica and gastric cancer there.
Those of you old enough to have done upper GI there,
the cancer, whether it's a primary gastric
or metastatic breast infiltrates the lining of the stomach
and it's thick like a leather bottle
and you can't distend it.
The same thing often happens in endometrial cancer.
The lining gets stiff and you start putting in fluid
and the fluid just heads out the fallopian tubes
or back leaks around your balloon out the os
but you can't distend it.
And the odds ratio
for cancer is almost an order of magnitude there.
7.3. Here's another example.
We had the balloon in down low
and no matter how much we pushed here,
we just couldn't distend this.
And this whole thing up here turned out
to be endometrial cancer.
And then here's one of our study patients
who obviously didn't complain of pain
after we took her uterus out,
but in this case I put clamps on the fallopian tubes,
inflated the balloon all the way in the endometrial cavity
and put in fluid as much as I could
and I could barely distend.
So think of this stiff endometrium as being a risk factor
for infiltrating endometrial cancer.
Here's another one. This looks totally like a polyp there.
And at path it was benign, benign, benign, benign,
papillary serous endometrial carcinoma, benign,
benign, benign, benign.
And also notice here how we have the single feeding vessel,
kind of the classic appearance for a polyp.
Here's another one here.
You look at this, and this is a classic example of lumpy bumpy endometrium.
I would call this endometrial cancer every single time.
And this turned out to be metastatic breast
cancer to the uterus.
I've seen four cases of this.
Now, tamoxifen, again, don't ask, don't tell.
We just don't wanna look in these situations right here.
But here you can see this weird looking mass in there.
This turned out to have severe atypia in it,
but we really don't even wanna look
because most patients on tamoxifen are gonna look abnormal.
And the bottom line is if they're not bleeding,
we're not gonna do anything.
Here's another one. This turned out to be a polyp
with carcinoma in situ too.

Other Uses of SIS

There's a whole nother area of using SISs
for infertility right there.
You can see the uterine fusion abnormality here.
Here's a patient who had multiple prior D&Cs.
This was in Asherman's right there.
And then one of the really cool areas coming up
that people are talking about is the only time we're doing HSGs now is
for our infertility patients right there
to see if the tubes fill and spill
because HSG is awful for the endometrium.
Well, what if we could get the information with SIS,
we'll get a much better look at the endometrium
and then we're not gonna get detailed
morphology of the tubes.
We're not gonna see SIN,
but if all we wanna see is tubal fill
and spill, why don't we inject a contrast agent?
And these contrast agents range from the cheap,
just grabbing 60 ccs
of room air and injecting it.
Too expensive. They're kinda like barbershop shaving creams that have little bubbles in them
where you can use Optison or Levovist, whatever.
So there's a lot of work looking at this now
to save women the radiation into procedures there
I retained products, again, we said indications
or anything to do with the endometrium, the air.
So if you have a bunch of transvaginals that are normal
and you're worried about something,
this is from MJ's paper showing
RPOC intervention.
That is the weakness of SIS hysteroscopy.
You can deal with it. I've got a buddy who's an inventor,
he's an REI doc
and he's kind of come up with these
Rube Goldberg contraptions with different balloons
and snares and all that.
But again, this works in his hands
and even in his hands he admits it's really hard.
But for the rest of us, it's never gonna work there.
So bottom line, not a lot of luck with intervention there.
You know, one thing that you can do if you're doing this
for cancer there, you think it's malignancy.
You just suck the fluid out after you're done
and send it for cytology.
And there's a fair amount of recent work just talking about positive cytology
and endometrial cancer there.

How Good is SIS

Okay, how good is SIS Basically it's as good
as diagnostic hysteroscopy under general
anesthesia at detecting things.
So it's like optical colonoscopy versus virtual colonoscopy.
Virtual colonoscopy is probably better at finding
significant lesions there,
but the issue is you can't deal with them there.
But as you do the math, you go through,
here's one paper that said two outta three hot
hysteroscopies can be avoided.
SIS hurts less, requires less medical intervention
and is a lot cheaper than doing ambulatory
office hysteroscopy.

Summary and Take Home Points

So here's what we talked about here.
We talked about why we worry terminology
and technique, what's abnormal
abnormalities seen on transvaginal ultrasound,
other diagnostic modalities like D&C and endometrial biopsy.
Then we had a lecture within a lecture
of saline infusion sonohysterography really emphasizing
technique and how to do it.
And then we showed a whole bunch of different examples
that can be elucidated by SIS.
So the take home points, how to measure it.
Remember John Wooden's quote, attention
to little details is the foundation of excellence.
Less than five millimeters reliably excludes endometrial
cancer in the postmenopausal patient with bleeding,
use 11 millimeters in the asymptomatic postmenopausal
patient take home point SIS is easy to perform,
has a short learning curve.
Works for all of us there.
I don't think it's quite as easy as Tom Cruise
and Katie Holmes right there
where you can buy an ultrasound machine
and use it at home right there.
But it's a really good test
and I'd like to thank these folks for the help with the talk
and we're all done.