|Year : 2021 | Volume
| 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 Submission||20-Mar-2021|
|Date of Decision||28-Mar-2021|
|Date of Acceptance||30-Mar-2021|
|Date of Web Publication||17-Apr-2021|
9-1-192, St Marys Rd, Madhuranagar, Kummari Guda, Shivaji Nagar, Secunderabad, Telangana 500003
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Deenadayal M. Understanding the endometrium at menopause: A sonologist's view. J Mid-life Health 2021;12:66-78
| Introduction|| |
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|| |
- 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.
| Technique|| |
- 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
- Trace from the endocervical canal
- The angle of insonation between the endometrium and the ultrasound beam should be 90° to optimize image quality ,if possible
- Enhanced sonography by instilling saline or gel
| The International Endometrial Tumor Analysis (IETA)|| |
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.
| Study of the Endometrium in Menopause IETA Guidelines:|| |
Thickness of the endometrium-visible, interuppted, invisible
- Uniform-homogeneous, hyperechogenic, isoechogenic or hypoechogenic
- Non-uniform-homogeneous with regular or irregular cysts, heterogeneous with or without cysts.
- Pattern-three-layer or monolayer pattern.
- Endometrial midline-linear, non-linear, irregular or not defined
- Bright edge-A bright edge is the echo formed by the interface between an intracavitary lesion and the endometrium.
- Endo-myometrial junction-regular, irregular, interrupted or not visible.
- 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
- single dominant vessel with or without branching
- multiple vessels of focal or multifocal origin,
- scattered flow
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|| |
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|| |
Endometrial echogenicity and pattern
| Endometrium at reproductive stage, at menopause and postmenopause|| |
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|| |
- 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 %
Do not measure the endometrium if you do not see it Plan a sonohysterography
| Approach to Postmenopausal Endometrium|| |
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|| |
- Endometrial polyp
- Submucus myoma
- Hyperplasia endometrium
- Endometrial carcinoma
Endometrial hyperplasia and endometrial carcinoma (EC) are histological diagnosis
how to recognize on sonography?
FOLLOW THE IETA RULES
| What are Focal Lesions?|| |
WHEN ENDOMETRIUM >5 mm No focal lesions at SIS
Decreases the odds of pathology 30 times
Decreases the odds of cancer 20 times
Irregular focal lesion is a strong sign of malignancy
| Features of a Benign Polyp|| |
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|| |
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|| |
AN INTRACAVITARY MYOMA
Myoma should not be included in the measurement of endometrial thickness
IF INTRACAVITORY PATHOLOGY PRESENT
The total endometrial thickness including the lesion should be recorded.
| Fluid in the cavity|| |
Fluid in the cavity in post menopausal uterus always exclude malignancy particularly if associated with a focal irregular lesion
| Understanding Endometrial Thickness in Postmenopausal Bleeding|| |
- < 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
| Understanding Endometrial Thickness in Asymptomatic Women|| |
In an asymptomatic early postmenopausal woman, an endometrial thickness of >11 should prompt an endometrial biopsy
| Endometrial hyperplasia|| |
- Thick endometrium
- Possibly cysts in the endometrium
- Midline echo present
- No feeding vessel
- No polyp at hydrosonography
| Simple Hyperplasia without Atypia|| |
| Complex hyperplasia with Atypical hyperplasia|| |
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|| |
Interrupted endo myometrial junctional zone
High color score > or equal to 3-4 - Malignant
Multiple and densely packed irregular branching vessels
| Endometrial Carcinoma|| |
Thickened endometrium with heterogenous echotexture
loss of endomyometrial junctional zone
Color score 3-4
Random dispersed not arising from EMJ
| EC Limited to Endometrium in an Asymptomatic Postmenopausal Woman|| |
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
INVASION LESS LIKELY
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.
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