Ultrasound
of the
Endometrium
Michelle Melany, MD
Chief of Women’s Imaging - Cedar-Sinai Imaging
Vice Chair of Imaging – GLA VA
Ultrasound of the Endometrium
statistics, terminology, technique
normal versus abnormal
premenopausal
postmenopausal
tamoxifen
HRT
abnormalities on EVUS
saline infusion sonography
Ultrasound of the Endometrium:
The STATS on Endometrial Cancer
10% of post menopausal women bleed
10% of those Î endometrial CA (EC)
10% EC occurs in women < 50
EC most common GYN malignancy
~ 39K cases/year in USA
4th most common cancer in women
only 15% of cancer deaths
Ultrasound of the Endometrium:
The STATS on Endometrial Cancer
• lower survival rate among black women
with EC when compared to white women
Obstetrics & Gynecology 1996;88:919-926
• race/ethnicity or income (not both) is
associated with advanced-stage disease
• African American ethnicity, advanced age,
aggressive histology, poor tumor grade Î
increased risk for death from EC
American Journal of Public Health 2004; 94:2104-2111
Ultrasound of the Endometrium:
Terminology
menorrhagia: heavy, prolonged, > 7 days
metrorrhagia: bleeding between menses
menometrorrhagia: heavy at irreg. intervals
DUB: excess bleeding, usually endocrine
PMB: bleeding more than 6-12 months after
last menstrual cycle
AUB (abnormal uterine bleeding): all of above
Ultrasound of the Endometrium:
Technique
• endovaginal: empty bladder, sagittal plane
- thickest portion: exclude inner myometrium
- double thickness: exclude fluid
- visualize entire endometrium
obscured = inadequate (5-10%)
indistinct = inadequate (potential sign of EC)
• “Midline echo could not be described as
normal or abnormal in 24% during [EVUS]”
Kazandi. Am J Obstet Gynecol 2003
Ultrasound of the Endometrium:
Technique
“Attention to the little details is
the foundation of excellence.”
- John Wooden
Ultrasound of the Endometrium:
Technique
endovaginal ultrasound
32 yo w/ metrorrhagia on OCPs
LMP 2/9/08
44 yo with anemia
Sag Midline + 17.2 cm
x 10.4 cm
importance of
endovaginal ultrasound
Trv Midline
+ 12.2 cm
Ultrasound of the Endometrium:
Measurement Technique
exclude hypoechoic inner myometrium in PMP
+ 1.1 mm
Ð
Ï
23 Jan 08
don’t confuse
with the
“triple line sign”
Ó
Ò
LMP
11 Jan 08
hypoechoic
inner
myometrium
Ó
Ò
Ultrasound of the Endometrium:
Measurement Technique
if fluid present, measure each wall separately
and sum, don’t include the fluid
+
+
+
+
Ultrasound of the Endometrium:
Technique
sweep the entire endometrium
Ô
Ultrasound of the Endometrium:
Technique
+
+
“Just because you can put calipers
on it doesn’t mean you should”
Ultrasound of the Endometrium:
Technique
12 Feb 08
+
+
+ 4 mm
51 yo with PMB and pelvic pain
Ultrasound of the Endometrium:
Technique
12 Feb 08
+ 4.2 cm
x 2.4 cm
don’t accept indeterminate endometrium
Ultrasound of the Endometrium:
Technique
visualize entire endometrium
+ 8 mm
12/2007: 48 yo with metromenorrhagia on tamoxifen
12/2007 US dx: intracavitary myomas?
2/2008: EMB - complex EH with mild atypia
Ultrasound of the Endometrium:
What is abnormal endometrium?
Premenopausal
• appearance changes throughout cycle
• follicular = proliferative phase
• luteal = secretory phase
• upper normal in late secretory phase:
12 - 16 mm – a “soft” threshold
Normal Endometrium:
Premenopausal
22 Jan 08
+ 2 mm
follicular = early proliferative phase
(immediately post menses or PMP)
Normal Endometrium:
Premenopausal
follicular = late proliferative phase
+
+
+ 8.5 mm
“ triple line sign ”
Normal Endometrium:
Premenopausal
follicular = late proliferative phase
+ 6.5 mm
Normal Endometrium:
Premenopausal
luteal = early secretory phase/ periovulatory
+
+
+ 11 mm
Normal Endometrium:
Premenopausal
luteal = late secretory phase
20 Sep 07
+ 10 mm
LMP 8/31/07
What is abnormal endometrium:
Premenopausal
+ 17 mm
15 mm is not a perfect threshold !!!
No period
for 1 year
RT trans
PCOS
LT sag
What is abnormal endometrium:
Premenopausal
42 yo with metrorrhagia and anemia
Ô
Ô
Ultrasound of the Endometrium:
What is abnormal endometrium?
avoid false positives: scan in proliferative phase
path = secretory endometrium
What is abnormal endometrium?
Postmenopausal Bleeding
• double thickness > 5 mm
Smith-Bindman. JAMA 1998 and Goldstein. JUM 2001
Risk of EC with ET < 5 mm is < 0.5 - 1% - Timmerman 2003
• focal endometrial abnormality
• indistinct endometrium
• non-diagnostic - myomas, etc (5-10%)
What is abnormal endometrium?
Postmenopausal Bleeding
• most common cause of PMB is atrophy
• “Up to 80% of women with PMB and
ET > 5 mm have endometrial pathology”
Epstein 2001
• an abnormal test does not mean the
woman has cancer!
Polyps, hyperplasia, fibroids… and most EC readily
treatable
What is abnormal endometrium?
Postmenopausal Bleeding on HRT
• when to scan?
- 4 - 5 days after completion of cyclic bleeding
in patients on sequential HRT
- any time in patients on continuous HRT
• keep 5 mm threshold
- no data to support widely quoted 8 mm
- same sensitivity but accept more FP
• problem going away with HRT…
What is abnormal endometrium?
Postmenopausal Bleeding on HRT
52 yo on continuous HRT 5 yrs PMP (pt request)
+
+
+ 2.2 cm
path = benign endometrium (HS)
What is abnormal endometrium?
Postmenopausal but NOT Bleeding
• ET > 11 mm Îbiopsy (cancer risk 6.7%)
• ET < 11 mm Îno biopsy
- Smith-Bindman. Ultrasound Obstet Gynecol 2004.
• “No consensus on the usefulness of regular
scans in PMP women [without sx’s] or cut-off
that should trigger further investigations…”
- Jurkovic. Ultrasound Obstet Gynecol 2005.
• but… many Gyn-Oncologists recommend
further work-up if ET > 11mm
What is abnormal endometrium?
Tamoxifen
• halves the risk of breast cancer recurrence
• stimulates endometrium: long term use
increases risk EC 7x after 5 yrs
• strong overall benefit to tamoxifen
• ET increases with increasing duration of use
at 0.75mm/ yr and, after discontinuing drug,
ET decreases at rate of 1.27 mm/ yr.
- Fishman M. JUM 2006.
What is abnormal endometrium?
Tamoxifen
• asx on tamoxifen should NOT be screened
• cancer is rare, low grade and typically bleeds
• most on tamoxifen have ET > 5 mm
• can’t tell tamoxifen changes from true path
• problem going away with newer drugs:
- raloxifen, letrozole, anastrozole, exemestane
Ultrasound of the Endometrium:
What is abnormal endometrium?
Summary:
premenopausal: > 15 mm*
postmenopausal, bleeding: > 5 mm
postmenopausal, bleeding, on HRT: > 5 mm*
postmenopausal, NOT bleeding: > 11 mm*
tamoxifen: > 5 mm* (don’t scan asx!)
* lots of controversy about these values
Goldstein. JUM 20: 1025-1036, 2001
Ultrasound of the Endometrium:
Endometrial atrophy
+ 2 mm
Ultrasound of the Endometrium:
Endometrial polyp
Ultrasound of the Endometrium:
Endometrial polyp
Post menopausal on HRT
image courtesy R. Goldstein, MD
Ultrasound of the Endometrium:
Tamoxifen
path = endometrial polyp at EMB
Ultrasound of the Endometrium:
Tamoxifen
Path: endometrium with cystic change (HS)
Ultrasound of the Endometrium:
Endometrial cancer
65 y.o. with intermittent spotting. Grade 1 adenocarcinoma
image courtesy of R. Goldstein, MD
Ultrasound of the Endometrium:
Endometrial cancer in a polyp
+ 19 mm
42 yo with metrorrhagia
lesson: focal masses are suspicious –
we cannot perform tissue characterization!
50 y.o. with
PMB
visualize entire
endometrium
Stage IIb
endometrial CA
Alternative procedures:
Hysterosalpingogram
• poor for evaluation of endometrium
• 40% with normal HSG had synechiae,
polyps, myomas at hysteroscopy
• 1 in 3 women with filling defect on
HSG have normal cavity at hysteroscopy
Alternative procedures:
Dilatation and Curettage (D&C)
• decreasing popularity with US, EMB, HS
• only samples 10-20% of endometrium
• sensitive for EC (but EMB = D&C)
• not good for polyps & other focal lesions
• D&C misses the diagnosis in 10 - 25%
Alternative procedures:
Endometrial Biopsy
• thin suction catheter, office procedure
• accuracy for EC ~ 95%
• (+) EMB Î no need for further imaging
of endometrium
• 10% with (-) EMB had CA or complex EH
• only samples ~15% of endometrium
• sens for polyps 4% (EMB) vs 100% (SIS)
(Hahn 2003)
Ultrasound of the Endometrium:
Saline Infusion Sonography (SIS)
• always perform conventional EVUS first
• not a difficult study to perform
• no difference in accuracy b’t NP, PGY2
PGY4, and fellows (Parker 2004)
• “Routine use of this method, even in
non-expert hands implies a low number
of undiagnosed lesions” (Dueholm 2001)
Saline Infusion Sonography
Is SIS Overkill? Is EVUS Alone Adequate?
Saline Infusion Sonography
Is SIS Overkill? Is EVUS Alone Adequate?
Saline Infusion Sonography
Is SIS Overkill? Bulk of literature: NO!
• “[EVUS] alone left 1 in 5 polyps undiagnosed in
referred pts with abnormal bleeding” (Dueholm ‘01)
• “Accuracy of [SIS] was significantly better than
[EVUS] considering all intrauterine path. (Ragni ‘05)
• “Midline echo could not be described as NL or ABN
in 24% of patients during [EVUS]” (Kazandi ‘03)
• “added info [from SIS lead to] improved dx
confidence [esp for…] dx & location of submucous
myomas & focal endometrial lesions. (Becker‘02)
• “29.7% of pts w/nl EVUS had abnormal SIS (Neele ‘00)
Saline Infusion Sonography
Indications
• abnormal pre- or postmenopausal bleeding
• evaluation of thickened, irregular, immeasurable,
or poorly defined endometrium on EVUS
• ET > 5 mm, sampling Î atrophic endometrium
• irregular-appearing endometrium with EVUS in
women on tamoxifen
• presurgical evaluation of intracavitary myomas
• infertility evaluation, RPOC, C-section scar, …
Saline Infusion Sonography
Scheduling
Schedule day 4 - 7 (2 - 5 days after menses stops)
• precludes scanning during pregnancy
• fewer ovarian cysts
Goldstein and Timor-Tritsch. JUM 2005;24:255
• avoid endometrial false positives - secretory phase
• in women with AUB, scan any time in cycle:
use cath tip to distinguish clot from real pathology
Saline Infusion Sonography
False Positives and Problems
• air bubbles
• balloon obscures LUS
• misinterpretation of small irregularities as
polyps (Kazandi 2003)
• mechanical shearing of endometrium
• poor timing in menstrual cycle
Saline Infusion Sonography
Endometrial Polyps
• most common focal lesion: 30% of PMB
• well defined, homogeneous, echogenic with
narrow base of attachment
• less common: broad base, cystic, heterogeneous
• surgical lesion: treat sx’s, can’t exclude CIS, CA
• SIS: accurate size, location and number Î
increases success rate of HS resection
Saline Infusion Sonography (SIS):
Endometrial Polyp
+ 1.14 cm
Saline Infusion Sonography
Fibroids
• 77 % prevalence; 25% symptomatic
• 10 % of PMB
• hysteroscopic resection possible if >50%
intracavitary extension
• SIS: broad based, hypoechoic, more heterog. than
polyps, thin rim of endometrium = submucosal origin
• can be difficult to distinguish pedunculated and
even more typical fibroids from polyps
Saline Infusion Sonography (SIS):
Intracavitary Myoma
+ + 1.6 cm
x 1.3 cm
+ + 1.4 cm
Saline Infusion Sonography (SIS):
Intracavitary Myoma
Ô
Ô
Ô
Saline Infusion Sonography
Endometrial Hyperplasia
• 6% of PMB
• spectrum: simple, no atypia Î severe atypia
• severe atypia: 20% risk of EC
• risk factors: obesity & unopposed estrogen,
nulliparity, HTN, DM
• classically diffuse; focal forms mimic polyps
• interface between base of polyp/focal EH Î
if distorted or poorly seen, increased risk of CA
Saline Infusion Sonography (SIS):
Endometrial Hyperplasia
40 yo with
infertility:
indistinct
endometrium
path = EH with mild atypia
Saline Infusion Sonography
Tamoxifen
• SIS avoids further intervention in 14% on
tamoxifen with ET > 8 mm by showing normal
ET or endometrial cysts (Hann 2001)
• SIS better than EMB for polyps in tamoxifen pts
– 100% sensitive vs 4% (Hann 2001)
• most tamoxifen assocociated polyps are benign
• literature confusing about role of SIS in tamoxifen
• most agree no role for SIS in asx pt on tamoxifen
Saline Infusion Sonography
Endometrial Cancer
• most common gyn cancer, 4th in women
• how much you see depends on practice patterns
• if pts go to EMB first, you’ll see few cases at SIS
• wide variety of presentations:
- large, broad based (up to most of lining)
- heterogeneous lesions worrisome
- look at base of attachment for irregularity
- incomplete distension worrisome
Saline Infusion Sonography
Endometrial Cancer
• “ The risk of malignancy was increased 7x
in women with distension difficulties [at SIS]..”
• “… 2/3 of women with poorly distensible
uterine cavity had a malignant diagnosis…”
(Epstein 2001)
• make sure to use good technique: NO LEAK!
Saline Infusion Sonography (SIS):
Endometrial Cancer
image courtesy Ruth Goldstein, MD
Saline Infusion Sonography (SIS):
C-section Scar
Summary:
Endometrial Measurement
• endovaginal, sagittal plane
• thickest portion, exclude inner myometrium
• double thickness, exclude fluid
• must visualize entire endometrium
if fibroids obscure = inadequate exam
(“it is what it is”… it’s not you!!!)
if endometrial margins are indistinct
= inadequate (potential sign of EC)
technique is critical…
pay attention to fine detail!
Summary
• ET < 5 mm reliably excludes EC
• ET > 11 mm ET asymptomatic PMP ÎEMB (?)
• Tamoxifen controversial:
- don’t screen asymptomatic pts with EVUS or SIS
- problem going away?
• HRT: use same threshold for ET, accept more FP’s
- problem going away?
• premenopausal: ET > 15 - 16 mm is soft threshold
- timing of scan is critical to avoid FP
Summary
• SIS easy to perform,
short learning curve,
valuable tool
• indications: discordance
(ET > 5mm, (-) EMB),
pre-op eval myomas, AUB,
abnormal endo on EVUS
• intracavitary masses are
surgical lesions: can’t reliably
make tissue diagnoses!
“I Bought a
Sonogram Machine”
Ultrasound of the Endometrium
statistics, terminology, technique
normal versus abnormal:
premenopausal
postmenopausal
tamoxifen
HRT
abnormalities on EVUS
saline infusion sonography
Thank you!!
Ultrasound of the
Endometrium
Michelle L. Melany, MD
Cedars-Sinai Medical Center
Department of Imaging
Summary:
Ultrasound of the Endometrium: Technique
“Attention to the little details is the
foundation of excellence.
- John Wooden
Saline Infusion Sonography
Technique
Preparation:
“A pint of sweat will save a gallon of blood”
General George Patton
•Schedule between day 4 and 7
(2-5 days after menses stops)
•NSAID 30 minutes before
•Psychological “warmth”
•Other: PID/doxycycline, IUD, SBE prophylaxis
Saline Infusion Sonography
Primary Goal
• focal (surgical) vs. diffuse (medical) disease
• one cannot reliably distinguish malignant from
benign disease (Epstein, et al. 2001)
• we’re pretty good at fibroids vs. polyps, and most
polyps are benign (but still usually come out)
WE CANNOT RELIABLY MAKE
TISSUE DIAGNOSIS!
Saline Infusion Sonography
Color Doppler and focal lesions
• polyps typically contain a single feeding vessel
• fibroids usualy have several vessels arising from
the inner myometrium
• broad overlap; not pathogomonic
Ultrasound of the endometrium
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