Ultrasound of the Endometrium

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.

Primary Goal

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 in terms of technique, if you like military metaphors for medical procedures, four star patent set, a pint of sweat will save a gallon of blood.

Preparation

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.

Why Day Four to Seven?

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 lithium cyst that make you worry.

Doctors Goldstein and Timor, Trish, 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 of one of these could be a polyp or cancer.

And then you bring your back 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.

Handling Abnormal Bleeding

Another issue though is that if somebody has abnormal bleeding, they may not know when their period is.

And so your secretary's like, well come back on day five 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.

Risks

What are the risks? The main one that people experience is some cramping right there, just because you're descending 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 upstaging.

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 to 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 right there.

They're theoretical risks.

So we go ahead and we have very good data, historically and also this or study showing that we're not upstaging endometrial cancer, okay?

Equipment

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 in 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 oh three eight glide wire right there.

Choosing the Correct Speculum

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 catheters 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 catheter is a good choice.

Inserting the Speculum Correctly

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 Val Salva, 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 site picture right here.

Spend your time getting this shot.

A lot of the flails that I've seen over the years are when people get a shot like this and the internal loss 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 flail.

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.

Getting the Catheter Through the Cervix

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.

What to Do with a Stenotic Cervix

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 oh three eight 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 mein 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 flail, 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.

Insertion Tips

Again, don't jab the funnel endometrium upon catheter insertion right there.

Slowly descend 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 minis.

Remember that the last thing that you did on a double contrast barium minimum 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.

Alternative Balloon Placement

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 used 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.

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.

But bottom line, remember, a 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.