Ultrasound of the Uterus and Endometrium - HD

Introduction and Objectives

My name is Vicki Feldstein.

I work in the ultrasound section of the Department of Radiology in the University of California San Francisco.

My lecture is about ultrasound and the evaluation of the uterus and endometrium.

The objectives are to recognize normal ultrasound appearance of the endometrium in pre and postmenopausal women.

Be able to identify common endometrial lesions associated with abnormal bleeding and understand the role and recognize findings on sonohysterography.

In the course of the lecture, we'll talk about the differential diagnosis of abnormal bleeding, demonstrate normal findings in pre and postmenopausal women, discuss how to appropriately measure the endometrium, recognize normal anatomy and common forms of endometrial pathology, and review the role of sonohysterography.

This material will be discussed based on specific cases demonstrating these findings.

Scope of the Problem

As for the scope of the problem, abnormal uterine bleeding is a common clinical situation.

About 30% of GYN visits are related to abnormal bleeding, and about 70% of all visits during the peri and postmenopausal period are related to abnormal bleeding.

In general in the US, about one in 20 premenopausal women will have menstrual disorders each year.

The frequency of this problem prompted a recent practice bulletin issued by the American College of Obstetricians and Gynecologists discussing the workup of abnormal uterine bleeding in reproductive aged women.

Differential Diagnosis of Abnormal Uterine Bleeding

It's worth considering the differential diagnosis of abnormal uterine bleeding.

And for this information, I want to credit the contributions of my colleague, Dr. Mindy Goldman.

Many women who present with abnormal bleeding do so because of hormonal problems in particular anovulation.

And the distribution of these is shown on this chart.

We are involved in the workup of anatomic causes of abnormal bleeding.

In particular, ultrasound plays a role in evaluating uterine etiologies.

Cervical and vaginal processes may also present with abnormal bleeding.

Infectious causes are on the list of the differential diagnosis, and again, uterine processes would be the place for ultrasound to have a role.

And in neoplastic causes.

Ultrasound is used in particular to evaluate uterine abnormalities more than cervical or vaginal.

It's worth remembering that non gynecologic causes may also result in abnormal bleeding in the clinical evaluation of women who present with abnormal bleeding.

It's worth reiterating that a pregnancy test is crucial.

The workup and the evaluation by ultrasound of bleeding in women who have a positive pregnancy test is different from those who are not pregnant.

Remembering that the differential diagnosis in those instances include ectopic pregnancy, spontaneous abortion, or possible molar pregnancy, presuming that the pregnancy test is negative.

Additional History

Additional detailed history would include discussion of the following, a careful description of the bleeding, any symptoms of ovulation, a discussion of whether there are associated features such as pain, fever or discharge, consideration of the relationship of bleeding to a menstrual period, whether the bleeding is between periods or heavy bleeding with periods, any personal or family history of bleeding disorder, prior history of such conditions associated medications and association with sexual activity.

When discussing the bleeding history and obtaining a detailed pattern.

The terminology and considerations include inter menstrual or post-coital bleeding, which would make one think of cervical processes.

Menorrhagia heavy menstrual bleeding, which would make one think of fibroids or adenomyosis or menometrorrhagia.

Heavy bleeding with irregular bleeding between periods associated with a variety of conditions listed here.

Physical Examination

Beyond a careful clinical history, a physical exam plays a role prior to the evaluation by ultrasound.

This examination would include a general assessment of the patient's skin color, looking for pallor or bruises, measurement of vital signs, evaluation of the abdomen, looking for palpable masses, a careful pelvic physical exam, looking for vaginal lesions or cervical abnormalities, prolapsing fibroids or uterine enlargement, and a rectal exam to determine that the bleeding is not rectal and truly vaginal.

If a careful assessment, including all of that evaluation, clinical assessment, detailed history, physical exam is done, and patients are pre-screened, based on that, the yield of ultrasound can be significantly enhanced.

Normal Ultrasound Findings in Premenopausal Women

Before we discuss the findings ultrasound in those patients who present with abnormal bleeding, it's worth reviewing expected normal findings, paying attention to the evaluation of the endometrium, its symmetry, morphology, thickness, and detailed measurement in a premenopausal woman.

The appearance of the endometrium will change in the course of the menstrual cycle.

Remember that the endometrium is composed of two layers.

The basal layer, which is a thin, bright echogenic line at the periphery of the endometrium, and an inner functional layer, which changes in thickness and echogenicity in the course of the menstrual cycle.

If a young woman is evaluated immediately following menses, what we will see is a uniform thin echogenic line.

As shown here early in the menstrual cycle, that inner functional layer starts to thicken and appears hypoechoic resulting in what's been termed a triple line sign.

The white line down the middle is where the front and back walls of the endometrium are opposed, and the endometrial thickness would be measured as shown here.

Here's an axial view of the proliferative, normal endometrium in the first half of the menstrual cycle and the triple line shown on this cine clip in the axial plane.

Later in the month following ovulation, that inner functional layer starts to become thicker still, and increase in echogenicity.

Eventually in the late secretory phase appearing homogeneously echogenic the white line down the middle, no longer evident sometimes in the late secretory phase, deep to the thick echogenic endometrium, posterior acoustic enhancement may be seen.

We will discuss later detailed measurement technique.

For now, it's worth knowing that on average endometrial thickness in the course of the menstrual cycle ranges from about one to four millimeters in the immediate postmenstrual phase, about four to eight mid cycle and up to 18 millimeters in the late secretory phase.

Case Examples: Endometrial Polyp

Starting with our first case, oftentimes our requisitions are vague and say something as broad as rule out pathology.

The correct history in this instance was a patient with abnormal bleeding ultrasound images shown here.

Sagittal endo vaginal sweep through the endometrium demonstrates a focal echogenic structure identified within the otherwise normal appearing proliferative endometrium.

The triple line sign is evident this focal endometrial abnormality would be described in this way.

Small focal echogenic solid lesion.

The most likely explanation for this finding would be an endometrial polyp.

I wanna return to the discussion of the timing of these exams.

Remember that in the immediate postmenstrual phase, the endometrium is uniform and thin.

In the late secretory phase, the endometrium is thick and bright, making it much harder to identify a small focal lesion such as a polyp.

Case in point, a patient came for evaluation of abnormal bleeding.

What we saw was a thick, bright, and secretory endometrium, a normal appearance.

However, as we reported, given reported history of inter menstrual bleeding, suggest repeat pelvic sonogram best done in the immediate postmenstrual phase.

So in those patients in whom an endometrial polyp is suspected based on clinical history of inter menstrual spotting, it's worth reinforcing that those exams are best done in the immediate postmenstrual phase when a small focal polyp such as this would be most evident.

Again, this image now shows what we couldn't see on the earlier study of small focal lesion indicating an endometrial polyp.

Endometrial polyps are typically echogenic focal thickening, sometimes with an associated vascular stalk demonstrated on color Doppler interrogation.

They're typically benign tumors of the surface endometrium with centrally positioned blood vessels, occasionally sessile, more often, pedunculated usually solid occasionally with cystic components.

Rarely these lesions have a pre-malignant potential, particularly when large and seen in older patients, they're associated with intra menstrual spotting and are treated with hysteroscopic resection when symptomatic.

Fibroids (Myomas)

Another patient presented with abnormal bleeding.

In this instance, the patient had known myomas a few words about fibroids or myomas.

They're the most common benign solid tumor in women and the main indication for hysterectomy in the US Approximately 20 to 40% of women have symptomatic fibroids.

Those symptoms typically being bleeding, pelvic pressure or pain, and about half of fibroids are asymptomatic.

For reasons not well understood.

There have increased incidence in African American women.

Fibroids are known to respond to hormonal stimulation, so may increase rapidly in early pregnancy and tend to decrease in size after menopause.

Transabdominal views of this enlarged uterus by convention, the myomas are included when reporting the overall uterine dimension.

So long axis, AP and transverse dimensions of this uterus shown here, and endo vaginal views, we see an anterior left fundal subserosal myoma and a submucosal myoma.

The terminology would a suggested terminology would be several myomas, including a centrally positioned likely submucosal myoma distorting the endometrium.

Such a myoma can be associated with abnormal bleeding.

Here is a Netter diagram and a pathologic correlate demonstrating the different locations and terminology for myomas involving the uterus.

These terms can be helpful when describing what is seen on ultrasound as these locations may be associated with differences on physical exam.

Were regarding clinical history and bleeding patterns, the bleeding associated with fibroids is usually menorrhagia, heavy menstrual bleeding, occasionally bleeding between periods, menometrorrhagia particularly if those fibroids are submucosal or intracavitary.

Some women present with pressure symptoms, dysmenorrhea or pelvic pain.

Adenomyosis

Another patient who presented with abnormal bleeding and an enlarged uterus on exam demonstrated this on ultrasound, the uterus is enlarged, but unlike the last case, it has a globular and smooth configuration rather than discrete focal myomas, which could be measured, the entire myometrium is heterogeneous and altered in echogenicity.

This enlarged globular uterus with heterogeneous echo texture and tiny myometrial cysts is a manifestation of adenomyosis.

It's worth remembering. This is different from myoma involvement and is managed differently clinically it's worth thinking of this condition as endometriosis of the myometrium with ectopic endometrial tissue involving the muscle.

If it is unclear on ultrasound, this diagnosis can be pursued by means of pelvic MR scan.

This condition is treated medically, not surgically.

Large Myoma Reporting

Yet another case presented with abnormal bleeding, also with an enlarged uterus.

On exam, these views demonstrate the uterus with the caliper placed demonstrating uterine size long axis, AP and transverse, and it's worth realizing that this patient who had a very large myoma shown here on images which no longer demonstrate that the uterus posterior to the bladder would be described as such.

The uterine dimensions given initially do not include this large dominant exophytic subserosal myoma arising off the fundal aspect of the uterus.

It's worth making clear in a report while the convention is to include the uterine myomas in an overall dimensions of the uterine size.

There are times when it's a clearer, more clearly understood when described in this way an exophytic myoma measured and reported separately.

These details are important to the gynecologist making decisions regarding clinical management of symptomatic fibroids.

The surgical treatment for fibroids is myomectomy.

The approach hysteroscopic laparoscopic or transabdominal is determined in large part by the size and location of the fibroids.

We see other management options include uterine artery embolization or hysterectomy.

Another patient with abnormal bleeding and known myomas presented for an ultrasound.

And on these two endo vaginal images, you'll see there's a subtle solid mass, nearly isoechoic with adjacent myometrium centrally positioned outlined on these views, this centrally positioned solid mass suggests the submucosal myoma.

An appearance such as this would often prompt an additional evaluation by means of sonohysterography, sometimes referred to as saline infusion sonohysterography, a maneuver by which fluid is instilled into the uterine cavity and additional ultrasound images obtained.

Sonohysterography

The indications for this procedure include abnormal bleeding in the pre or postmenopausal patient, a suspected abnormality as in this patient with what appears to be a submucosal myoma, or in those instances where imaging of the endometrium on conventional views is inadequate.

The questions pursued by this maneuver include is there an endometrial lesion, is it a focal or diffuse one?

And based on these findings, the next step is determined random biopsy, DNC or hysteroscopy listed.

Here are the items needed for performing these procedures.

It's very much like doing a hysterosalpingogram.

The difference being that the catheter is instilled with fluid, not contrast, not air, and additional endo vaginal images are obtained.

The technique involves a preliminary bimanual exam to identify the location of the cervix and always a preliminary endo vaginal ultrasound assessment.

On occasion, patients are pre-medicated.

We visualize and cleanse the cervix, insert the catheter flushed with saline to avoid injection of air bubbles, remove the speculum, insert the transducer, and during continuous ultrasound visualization, instill sterile saline into the lumen of the uterus.

We document this maneuver typically with cine clip images.

Here is a normal uterus shown by sonohysterography in the sagittal and transverse planes, uniform thin endometrium and fluid instilled into the normal uterine cavity.

Back to the case that prompted this conversation about sonohysterography.

We see now that fluid partially surrounds this solid mass, which protrudes into the uterine cavity, representing a submucosal, predominantly intracavitary myoma, the reason for the patient's abnormal bleeding.

Another example, similar in appearance, unconventional views.

We see a solid centrally positioned mass when fluid is instilled into the uterine cavity by means of sonohysterography, that mass is nearly surrounded by the instilled sterile saline indicating a predominantly intracavitary myoma, and that's how it would be worded, predominantly intracavitary solid lesion myoma greater than 50% intraluminal.

The reason that these details are important is that it informs the decision regarding possible hysteroscopic resection of the myoma.

This maneuver works well with intracavitary myomas that are less than five centimeters in diameter, and at least 50% intracavitary.

Various gynecologic methods are used to excise the lesion, and sometimes following a hysteroscopic myomectomy endometrial ablation may be performed.

Again, crediting Dr. Mindy Goldman, my colleague in the gynecology department at UCSF.

Here's an example of a procedure being performed excising a predominantly submucosal intracavitary myoma.

This device is morcellating the myoma, removing it and leaving an otherwise normal thin endometrium.

This in this way, treating the cause of her persistent abnormal bleeding.

One other comment about sonohysterography and the findings made these endo vaginal views are somewhat difficult to interpret obtained during the performance of a sonohysterogram.

In such instances, it may be helpful to take an additional transabdominal view and realize that what is demonstrated here is a very large transmural anterior myoma with fluid now instilled into the uterine cavity.

Endometrial Thickness in Abnormal Bleeding

We pay particular interest to endometrial thickness in patients with abnormal bleeding, but sometimes it's hard to see the endometrium well, and my suggestion is if the endometrium is not well visualized on conventional views, don't guess or force a thickness onto the images.

If bleeding persists and the endometrium is not reliably assessed by ultrasound, sonohysterography plays a role in this instance.

And a guess at an endometrial thickness was obtained and it became clear following installation of sterile saline that there is a large heterogeneous intracavitary mass.

In this case, a polyp better appreciated when it was surrounded by fluid.

Another instance where sonohysterography can prove useful is when the endometrial biopsy findings and the ultrasound findings are discordant.

This endometrial thickness appeared thick, however, the biopsy result obtained revealed atrophy that discordance prompted a sonohysterogram, and it was clear when fluid was instilled that the thickness was due to an endometrial polyp, which was missed on random biopsy.

Evaluation of Postmenopausal Bleeding

In those patients who present with abnormal bleeding, it's worth considering whether the step obtained should be an endometrial biopsy or endo vaginal ultrasound.

This comes into particular play when evaluating women with postmenopausal bleeding.

Remember that most causes of postmenopausal bleeding are benign, in particular endometrial atrophy, but the differential diagnosis includes other processes including cancer.

In general, according to the literature, the risk of endometrial cancer as a cause of postmenopausal bleeding ranges from seven to 30%.

That risk goes up with patient age, obesity, and a history of diabetes, and you will read different algorithms.

Proponents of initial evaluation by means of tissue sampling versus ultrasound imaging.

When should the endometrial biopsy be done first?

Well, it's considered the gold standard, and in many minds the best first step.

It's performed in all patients with postmenopausal bleeding unless there's a recent initiation of hormone replacement therapy.

That's the guideline proposed by the gynecologists with whom we work.

It's also performed in women 35 to 40 years old with the persistent irregular bleeding, meaning more three months or more of symptoms, and sometimes in younger women if there's increased risk in particular obesity or chronic anovulation.

It's also suggested that biopsy be performed if there is persistent abnormal bleeding despite medical therapy.

When and why might endo vaginal ultrasound be used instead?

Well, ultrasound evaluates the thickness of the endometrial stripe directly.

It can be used in those settings where the cervix is stenotic and biopsy cannot be performed, and it can be helpful for anatomic lesions like those I showed earlier, polyps or submucosal myomas, which may result in false negative or misleading endometrial biopsy results.

A conventional ultrasound may be followed by sonohysterography when using ultrasound in the workup of postmenopausal bleeding.

It's worth remembering that an endometrial thickness less than five millimeters virtually excludes endometrial cancer, and in that way, we play a role in the evaluation.

Ultrasound is not as helpful in evaluating premenopausal or perimenopausal women with abnormal bleeding.

Keep in mind the utility of the appropriate timing of the exam.

We will discuss tamoxifen later.

Worth mentioning here that ultrasound is often not useful for evaluating women on tamoxifen, and we were reiterating if the results are negative on biopsy and ultrasound, but a patient has persistent bleeding, she needs additional workup.

Normal Postmenopausal Endometrium

If we are going to use ultrasound to evaluate postmenopausal bleeding, we have to review first the normal appearance of the postmenopausal endometrium.

Once women have stopped cycling, the endometrium should be a consistent uniform thin echogenic line, less than eight, usually less than five millimeters in AP diameter.

If there is a small amount of intrauterine fluid, it should not be included in the measurement reported.

In those instances, a single layer can be seen that should be no thicker than three millimeters.

These measurements are best done on an endo vaginal rather than a transabdominal view.

Pitfalls in Endometrial Measurement

And a few words about potential pitfalls in this measurement.

The image obtained from which the endometrial thickness is measured by convention is the sagittal plane.

What should be measured and reported is the site of maximal endometrial thickness, usually near the fundus.

The thickness involves both the front and back layers, a bilayer thickness not to include the inner myometrium, which is usually hypoechoic compared with the echogenic endometrium.

As I said, if there is intrauterine fluid, it should not be included in the measurement, and it might interest you to know that the intra observer variation in these numbers is about 1.5 millimeters.

Here are four sagittal endo vaginal views of women with abnormal bleeding in which the endometrial thickness is measured.

Keep in mind that the uterus is broader than it is in the AP plane.

Thus, if different thicknesses are obtained, it is possible that rather than scanning in the pure sagittal plane, some coronal images were obtained.

Also, focal endometrial abnormalities may result in different numbers in the course of the exam.

While we don't measure the endometrial thickness on the axial view, some images in that plane are helpful to recognize those possibilities.

We were a center that reviewed endometrial thickness measurements performed at a bunch of different centers across the US and in our review of those exams, we realized that a common technical error was inappropriate depth settings when measuring the endometrium.

The depth of the image should be appropriate for the size of the uterus to ensure optimal visualization and most reliable measurement of the endometrium.

We also participated in a meta-analysis looking at the reliability of the cutoff for endometrial thickness and came up with this message based on that review.

For a postmenopausal woman with vaginal bleeding, with a pretest probability of cancer of approximately 10%, an endometrial thickness of five millimeters or less by ultrasound resulted in a post-test probability of cancer of 1%, significantly reducing the risk by seeing a uniform thin endometrium less than five, and as is often seen in these women with postmenopausal bleeding, a markedly thin endometrium, an atrophic endometrium measuring only 1.4 millimeters associated with postmenopausal bleeding.

Advantages of Ultrasound

The advantages of ultrasound in this regard is it's less invasive than endometrial biopsy.

It's nearly pain-free and well tolerated in women even of advanced age.

It can obviate the need for biopsy if normal, if thin, as was the case here.

Importantly, it's diagnostic in women with cervical stenosis who cannot undergo effective biopsy.

The accuracy is similar to that reported for endometrial biopsy and the cost compares favorably.

Sometimes we encounter women in whom a biopsy has been performed or attempted, and in those instances, it's worth remembering that there will be some intrauterine blood making the ultrasound less reliable.

If women undergo a biopsy, I would recommend you wait at least a week before performing an endo vaginal ultrasound to assess the endometrium.

Consensus Guidelines

The Society of Radiologists in Ultrasound convened a consensus panel several years ago, addressing several questions related to the evaluation of women with postmenopausal bleeding.

The take home message from that panel included this statement, either ultrasound or biopsy could be used safely and effectively as a first diagnostic step.

And there are different approaches even within our own institution to this evaluation.

When looking at a cost effective decision making, one again could start with biopsy or ultrasound.

It's worth incorporating into that assessment, the pretest probability of cancer and patient's risk factors.

If the prevalence of endometrial cancer based on risk factors was over 15%, then biopsy was the most cost effective first step.

And alternatively, based on risk factors, if the prevalence of cancer was less than 15%, ultrasound first most cost effective.

A more recent opinion has been issued by the American College of Obstetricians and Gynecologists.

In that report, it was suggested that four millimeters rather than five be used as a cutoff.

I've shown here the results by using the different threshold measurements, and it is incumbent upon any particular institution to decide together which number they would use.

At UCSF, less than five millimeters in the evaluation of postmenopausal bleeding is still considered a reliable means by which to exclude cancer.

Case Examples in Postmenopausal Bleeding

Sometimes we encounter patients such as this postmenopausal bleeding presented to a gynecologist and endometrial biopsy was attempted, though was inadequate that prompted an ultrasound, which shows this a trace of fluid in the uterine cavity.

The presence of this fluid indicates some degree of cervical stenosis trace intrauterine fluid suggesting cervical stenosis, thus explaining why the biopsy was difficult to perform.

The presence of the fluid however, allows us to better visualize the endometrium and we see a uniform thin endometrium, single layer thickness measuring one millimeter.

No additional evaluation would be necessary for that patient.

In this patient also with postmenopausal bleeding, attempted biopsy, which was inadequate, and ultrasound was performed as the next step, this patient had fibroids limiting the visualization of the endometrium, and oftentimes cases such as this would be read as inadequate visualization of the endometrium due to the myomas limiting the ability of ultrasound to assess the patient's cause of bleeding.

However, in this instance where we could see the endometrium, it measured over five millimeters, in fact, seven millimeters.

So in this postmenopausal patient with abnormal bleeding, while the visualization of the endometrial stripe was limited due to the myomas where seen it measured seven millimeters prompting additional evaluation.

And in this instance, endometrial cancer was found at surgery.

Another postmenopausal patient presented with bleeding, had had a biopsy which was deemed adequate and reported benign, but had persistent bleeding.

And as I said earlier, that would prompt an additional evaluation.

In this instance, the patient had an ultrasound marked thickening of the endometrium was seen well over the cutoff values.

In fact, over 15 millimeters, it measured 20 millimeters and maximal AP diameter additional tissue sampling was performed, and this was found to be endometrial cancer.

Endometrial Cancer

Endometrial cancer is the fourth most common cancer in women.

The most common GYN cancer typically presents in the postmenopausal patient.

Median age 61 a quarter occur before menopause.

The main risk is increased circulating estrogen.

So women who early menarche and late menopause, luckily it tends to present in the early stage and almost always presents with vaginal bleeding.

The diagnosis is made by endometrial biopsy, which is fairly sensitive and specific.

Occasional false negatives occur due to small cancers arising in a polyp or localized area of the endometrium.

The treatment is surgical with hysterectomy and salpingo-oophorectomy.

Tamoxifen Effects

We are asked to use ultrasound to evaluate patients who have breast cancer or at increased risk for breast cancer, some of whom are being treated with tamoxifen.

The requisition might come to evaluate the ovaries, but in so doing, we would see the endometrium and might encounter an endometrial appearance such as this, a thick endometrium, heterogeneous echo texture with multiple cysts.

The differential diagnosis for this appearance in this woman on tamoxifen would include endometrial polyp and cystic endometrial hyperplasia.

The appearance on ultrasound is not specific.

An additional evaluation might be prompted, certainly would be prompted if there is a history of bleeding.

Patients on tamoxifen have been found to have a variety of findings at pathology, and often more than one process.

The differential includes polyps, hyperplasia, and even endometrial cancer.

It's worth recognizing that some of the cysts seen are not actually within the endometrium, but represent changes in the inner myometrium foci of reactivated or degenerated adenomyosis in response to tamoxifen exposure.

So sub endometrial cysts may be seen worth distinguishing from the endometrial cysts and if need be, recognized by sonohysterography to review.

Tamoxifen is used as an adjuvant hormonal therapy for patients being treated for breast cancer.

It has an anti-estrogen tumor suppressive effect in the breast, but has been found to have an agonist estrogen action on the endometrium, particularly in the postmenopausal patient.

Increased incidence of hyperplasia and cancer in these patients.

While ultrasound can be used, it can be quite misleading because of the variable responses of the endometrium to tamoxifen exposure.

There are a high rate of false positives, increased thickness of the endometrium, heterogeneous with cystic changes, not all of which correlate with malignant histology.

The take home message is that in women with abnormal bleeding, ultrasound is not a reliable maneuver, and in those patients biopsy need be performed.

Incidental Findings

On occasion, women are sent to evaluate the ovaries postmenopausal patient, for example, such as this.

There's no history of abnormal bleeding or symptoms related to the endometrium, but in the process of doing the pelvic sonogram, we come across a thicker than expected endometrial stripe.

This thick echogenic, endometrial stripe measuring greater than 15 in AP diameter is certainly unexpected.

In a postmenopausal woman, we would revisit the question about whether there is abnormal bleeding.

However, even in the absence of reported bleeding and endometrium of this thickness in a patient of this age without hormone replacement therapy is unexpected and might prompt one to perform an endometrial biopsy.

In this case, that was what happened, and the biopsy revealed very early stage one endometrial cancer.

That experience prompted us to ask the question, how thick is too thick?

If the endometrium is incidentally noted to be thick in an asymptomatic postmenopausal patient, what if anything should be done?

We reviewed our data asking the question about whether a risk of cancer with different endometrial thickness in patients with and without bleeding, knowing that in patients with bleeding a certain thickness prompts additional evaluation, we would assume that a thicker threshold would prompt biopsy in women without bleeding.

What we found on that review is this, in a postmenopausal woman without vaginal bleeding, if the endometrium measures more than 11 millimeters, a biopsy should be considered because the data revealed that the risk of cancer is approximately 7% similar to the threshold that prompts one to do a biopsy in a patient with bleeding and an endometrial thickness greater than five millimeters.

Again, this is a rare clinical scenario, but a useful exercise, and information worth considering.

Summary

In summary, remember the normal appearance of the endometrium in pre and postmenopausal patients in particular.

Remember that premenopausal women will undergo changes in thickness and appearance of the endometrium in the course of the monthly cycle.

Thus, evaluation of abnormal bleeding in premenopausal women is best done in the immediate postmenstrual phase.

When the stripe is uniform and thin, the technique was reviewed, how best to visualize and measure the endometrium.

That measurement and a description of the morphology should be included in the report because much rides on that description in the evaluation of women with abnormal bleeding and in determining the likelihood and the ability to exclude cancer if the endometrium is well seen and appears thin, if the endometrium cannot be well seen, it should be made clear that the exam is non-diagnostic in the evaluation of abnormal bleeding and more need be done.

The risk of cancer is less than one in patients who have postmenopausal bleeding, whose endometrium is well seen by ultrasound is uniform and thin.

We reviewed the sonographic appearance of polyps and myomas and the ability to delineate those by means of sonohysterography.

And it's worth reiterating that it's important that the ultrasound, the biopsy and the clinical history be consistent.

And if not, to pursue the workup.

Thank you.