Ultrasound of the Endometrium

Numeric Summary for Endometrial Thickness

Remember five millimeters.

If you're postmenopausal and bleeding, you're 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 Routine Transvaginal Ultrasound

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 stock heading into it there.

And then fibroids. We've all seen a million of these, hypo coic with that hyper coic 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, a 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 his picograms.

The only time that we do them now is to assess tubal patency, fill and spill for in the infertility population.

But his picograms 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 is the dilatation in cure, 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 DNC 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 with a 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 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.

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 trans vaginal had an abnormal SIS.