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 Table of Contents 
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 66-78  

Understanding the endometrium at menopause: A sonologist's view

Department of Infertility, Mamta Fertility Centre, Secunderabad, Telangana, India

Date of Submission20-Mar-2021
Date of Decision28-Mar-2021
Date of Acceptance30-Mar-2021
Date of Web Publication17-Apr-2021

Correspondence Address:
Mamata Deenadayal
9-1-192, St Marys Rd, Madhuranagar, Kummari Guda, Shivaji Nagar, Secunderabad, Telangana 500003
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-7800.313985

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How to cite this article:
Deenadayal M. Understanding the endometrium at menopause: A sonologist's view. J Mid-life Health 2021;12:66-78

How to cite this URL:
Deenadayal M. Understanding the endometrium at menopause: A sonologist's view. J Mid-life Health [serial online] 2021 [cited 2022 Oct 6];12:66-78. Available from:

   Introduction Top

Pathology of the endometrium is common, the presentation and management of the disease depends on a woman's age, her menstrual history, reproductive history, co-morbidities and use of medications. It is important to distinguish benign from malignant premalignant conditions.

The most common and first line used imaging modality for evaluating the endometrium is pelvic ultrasound with transvaginal and transabdominal

This pictorial review depicts the normal and abnormal appearance of the endometrium at post menopause

   Timing and Method Top

  • Transvaginal is an ideal method. A transabdominal scan may be needed in cases of large fibroids, a globally enlarged uterus, virgins, amd is vaginismus or secondary vaginal stenosis. Transrectal -If transabdominal is inconclusive and is acceptable to the woman
  • In a postmenopoausal woman not on hormone therapy or on a continuous combined regime endometrium is assessed by a transvaginal scan, on any day when on cyclic combined regime 5–10 days after the last progestin pill[1].

   Technique Top

  • Start with the identification of the bladder and cervix
  • The position of the uterus is noted and measurements taken.
  • The uterus is scanned in the sagittal plane from cornu to cornu and in the (oblique) transverse plane from the cervix to the fundus.
  • In cases of difficulty to trace endometrium

    1. Trace from the endocervical canal
    2. The angle of insonation between the endometrium and the ultrasound beam should be 90° to optimize image quality ,if possible
    3. Enhanced sonography by instilling saline or gel

   The International Endometrial Tumor Analysis (IETA) Top

The International Endometrial Tumor Analysis (IETA) group was formed in Chicago at the World Congress of Ultrasound in Obstetrics and Gynecology in 2008 with the aim of agreeing on terms and definitions to describe ultrasound findings in the uterine cavity. A consensus opinion from the International Endometrial Tumor Analysis (IETA) group was developed on the terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions[2].

   Study of the Endometrium in Menopause IETA Guidelines: Top


Thickness of the endometrium-visible, interuppted, invisible


  1. Echogenicity

    1. Uniform-homogeneous, hyperechogenic, isoechogenic or hypoechogenic
    2. Non-uniform-homogeneous with regular or irregular cysts, heterogeneous with or without cysts.

  2. Pattern-three-layer or monolayer pattern.
  3. Endometrial midline-linear, non-linear, irregular or not defined
  4. Bright edge-A bright edge is the echo formed by the interface between an intracavitary lesion and the endometrium.
  5. Endo-myometrial junction-regular, irregular, interrupted or not visible.
  6. Intracavity fluid.


The Color-Doppler score is a subjective assessment of the amount of color, reflecting the vascularity, and is scored as

a.1 (no color), b.2 (minimal color), c.3 (moderate color) d. 4(abundant color).

The vascular pattern may be a

  1. single dominant vessel with or without branching
  2. multiple vessels of focal or multifocal origin,
  3. scattered flow
  4. circular


In fluid-instillation sonography or enhanced ultrasonography, fluid is instilled into the uterine cavity transcervically to provide enhanced endometrial visualization during transvaginal ultrasound examination. The technique improves sonographic detection of endometrial pathology, such as polyps, hyperplasia, cancer, leiomyomas, and adhesions. Endometrial thickness of both endometrial layers.

In the presence of an intracavitary lesion, look for extent, type of localized lesion, echogenicity, outline, color score and vascular pattern.

   Endometrium-Implementation of IETA Top

Quantitative Assesment

Endometrial thickness : how should it be measured?

The endometrium should be measured where it appears to be at its thickest.

When intracavitary fluid is present, the thickness of both single layers is measured in the sagittal plane and the sum is recorded.

If the endometrium is thickened asymmetrically, the anterior and posterior endometrial thicknesses should also be reported separately.

   Qualitative Assesment Top

Endometrial echogenicity and pattern

Endometrial midline

"Bright edge"

Endo-myometrial junction

   Endometrium at reproductive stage, at menopause and postmenopause Top

Normally the menopausal endometrium is thin Sometimes it is difficult to see and measure as in upright position, vascular calcifications and calcified fibroids

   Post Menopausal Uterus Top

  • Smaller in size <7.5 cm
  • Uterine body to cervix 1;1
  • Calcified arcuate vessels – elderly post menopausal women

Median endometrial thickness 2.9-3mm

Not measurable /not visible 10 %

>5 mm 7-24%

<5 mm 76-93 %[3]

Do not measure the endometrium if you do not see it Plan a sonohysterography

   Approach to Postmenopausal Endometrium Top

Asymptomatic - Pathology discovered incidentally on scan

Symptomatic - Scan on indication


To understand the cause of bleeding

To estimate risk of endometrial cancer

In women with cancer to asses the tumor invasion

To determine the optimal biopsy procedure

   Thickened Endometrium Differential Diagnosis Top

  • Endometrial polyp
  • Submucus myoma
  • Hyperplasia endometrium
  • Endometrial carcinoma

Endometrial hyperplasia and endometrial carcinoma (EC) are histological diagnosis

how to recognize on sonography?


   What are Focal Lesions? Top

WHEN ENDOMETRIUM >5 mm No focal lesions at SIS

Decreases the odds of pathology 30 times

Decreases the odds of cancer 20 times[4]

Irregular focal lesion is a strong sign of malignancy

   Features of a Benign Polyp Top

Uniform hyperechogenic

Bright edge

Undefined midline echo

May or may not have cysts

Regular endomyometrial junctional zone

Single vessel without branching

Color score 2-3

   Polyp with Malignant Change Top

48 years post menopausal spotting

Polyp large occupying the entire cavity

The 'bright edge' echo formed by the interface between an intracavitary lesion and the endometrium

Marked increase in vascularity with chaotic vascularity

   Measuring Endometrium with an Intracavitory Lesion Top


Myoma should not be included in the measurement of endometrial thickness


The total endometrial thickness including the lesion should be recorded.

   Fluid in the cavity Top

Fluid in the cavity in post menopausal uterus always exclude malignancy particularly if associated with a focal irregular lesion[5]

   Understanding Endometrial Thickness in Postmenopausal Bleeding Top

Endometrial thickness

  • < 4 mm low risk cancer risk- Endometrial sampling if rebleed or at high risk for EC
  • > 5 mm High risk - Endometrial pathology 80%, Uterine malignancy 25%
  • Endometrium >4.5 mm saline sonography to determine focal or non focal

Normal looking polyp will have a malignant or premalignant potential of 6%

Unmeasurable not necessarily thin beware of cancer 5 % always perform hydrosonohysterography

The sensitivity for detecting EC at 3mm is 98%, at 4mm is 95%, and at 5 mm is 90%. However, using a low threshold is associated with a high false-positive rate.

In women with homogeneous and normal morphology, those on MHT, and hypertensive medication, the acceptable combined thickness is 6 mm

A focal increased echogenicity or a diffuse heterogeneity in the endometrium in a thin endometrium -Endometrial sampling[6]

   Understanding Endometrial Thickness in Asymptomatic Women Top

In an asymptomatic early postmenopausal woman, an endometrial thickness of >11 should prompt an endometrial biopsy[7]

   Endometrial hyperplasia Top

  • Thick endometrium
  • Hyperechogenic
  • Possibly cysts in the endometrium
  • Midline echo present
  • No feeding vessel
  • No polyp at hydrosonography

   Simple Hyperplasia without Atypia Top

   Complex hyperplasia with Atypical hyperplasia Top

Thickened endometrium with cystic spaces

Multiple vessels without origin

Intact endomyometrial junctional zone

Color score 2-3 Multifocal linear single vessels crossing EMJ

   Endometrial Cancer Top

Interrupted endo myometrial junctional zone

High color score > or equal to 3-4 - Malignant

Multiple and densely packed irregular branching vessels

   Endometrial Carcinoma Top

Thickened endometrium with heterogenous echotexture

loss of endomyometrial junctional zone

Color score 3-4

Random dispersed not arising from EMJ

Myometrium normal

   EC Limited to Endometrium in an Asymptomatic Postmenopausal Woman Top

49 year old, asymptomatic, family h/o endometrial malignancy, detected during routine screening, endometrium 8 cm,volume 591cc, normal myometrium intact junctional zone marked increased vascularity


Endometrial intraepithelial neoplasia with atypia, few foci of endometroid adenocarcinoma


Echogenity – hyperechogenity

Size – small tumor volume

Regular junctional zone

Thick tumor free myometrium

Low tumor perfusion score 1-2 single /no vessel

Histological grading low

Thickened endometrium 9.5 mm

Loss of endo myometrial junctional zone

Echogenecity – hypo or mixed echogencity

Size - larger tumor volume

High tumor perfusion– score 3 -4

Histological grading - high

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Omodei U, Ferrazzi E, Ramazzotto F, Becorpi A, Grimaldi E, Scarselli G, Spagnolo D, Spagnolo L, Torri W. Endometrial evaluation with transvaginal ultrasound during hormone therapy: a prospective multicenter study. Fertil Steril 2004; 81: 1632– 1637.  Back to cited text no. 1
Leone FP, Timmerman D, Bourne T, Valentin L, Epstein E, et al. (2010) Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol 35(1): 103-112.  Back to cited text no. 2
L. JOKUBKIENE, P. SLADKEVICIUS and L. VALENTIN, Transvaginal ultrasound examination of the endometriumin postmenopausal women without vaginal bleedingUltrasound Obstet Gynecol 2016; 48: 390–396. DOI: 10.1002/uog.15841  Back to cited text no. 3
Epstein E, Ramirez A, Skoog L, Valentin L. Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium >5 mm. Ultrasound Obstet Gynecol. 2001 Aug;18(2):157-62. doi: 10.1046/j.1469-0705.2001.00472.x. PMID: 11529998.  Back to cited text no. 4
Patricia C. Davis, Mary Jane O'Neill, Isabel C. Yoder, Susanna I. Lee, and Peter R. Sonohysterographic Findings of Endometrial and Subendometrial Conditions MuellerRadioGraphics 2002 22:4, 803-816  Back to cited text no. 5
Timmermans A, Opmeer BC, Khalid KS, Bachmann LM, Epstein E, T Justin Clark TJ, et al. Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis. Obstet Gynecol. 2010;116:160-167.  Back to cited text no. 6
Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol 2004;24:558.  Back to cited text no. 7


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  In this article
   Timing and Method
    The Internationa...
    Study of the End...
    Qualitative Asse...
    Endometrium at r...
    Post Menopausal ...
    Approach to Post...
    Thickened Endome...
    What are Focal L...
    Features of a Be...
    Polyp with Malig...
    Measuring Endome...
   Fluid in the cavity
    Understanding En...
    Understanding En...
    Endometrial hype...
    Simple Hyperplas...
    Complex hyperpla...
   Endometrial Cancer
    Endometrial Carc...
    EC Limited to En...
    Endometrial intr...
    Echogenity ̵...
    Size – sma...
    Regular junction...
    Thick tumor free...
    Low tumor perfus...
    Histological gra...
    Endometrial intr...
    Echogenity ̵...
    Size – sma...
    Regular junction...
    Thick tumor free...
    Low tumor perfus...
    Histological gra...
    Endometrial Canc...

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