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Abnormalities of the endometrium

Because of its improved resolution, transvaginal sonography is better able to image and depict subtle
abnormalities within the endometrium and clearly define the endometrial myometrial border.
Knowledge of the normal sonographic appearance of the endometrium allows for earlier recognition of
pathologic conditions manisfested by endometrial thickening with well defined or poorly defined or
irregular margins. Many endometrial pathologies , such as hyperplasia, polyps and carcinoma, can cause
abnormal bleeding, especially in the postmenopausal patient. All these conditions can have a similar
sonographic appearance. A hyperechoic line partially or completely surrounding the endometrium has
been described as a sign of a focal intracavitary process, likely caused by the interface between the
intraluminal mass and the surrounding endometrium or the endometrium itself.

Sonohysterography has been shown to be of great value in further evaluating the abnormally thickened
endometrium. SHG can distinguish between focal and diffuse endometrial abnormalities and help
determine further management. If the abnormalities is diffuse, a blind, non directed biopsy can be done,
but a focal process requires hysteroscopy with directed biopsy or excision. SHG may also be able to
distinguish benign from malignant endometrial processes. Patients with endometrial cancer may have
poorly distensible endometrial cavities, despite successful cervical os cannulation.

With the reconstructed coronal view, 3D sonography also has been a valuable addition to standard
transvaginal ultrasound in patient with suspected endometrial abnormalities and in those with an
endometrium greater than 6 mm.

Postmenopausal endometrium

Postmenopausal bleeding is considered to be any vaginal bleeding that accurs in a postmenopausal

women other than the expected cyclic bleeding with sequential HRT. Because the prevalence of
endometrial cancer is low, the negative predictive value of a thin endometrium is high; therefore a thin
endometrium can be reliably used to exclude cancer. Several studies have shown that in patient with
postmenopausal bleeding who have had endometrial sampling, an endometrial measurement of 4 mm or
less or 5 mm or less can be considered by an atrophic endometrium. In 1168 women with postmenopausal
bleeding, in whom 114 endometrial cancers were found, no women with endometrial cancer had an
endometrium measuring less than 5 mm.

A meta-analysis of 35 published studies that included 5892 women showed that an endometrial thickness
greater than 5 mm detected 96% of endometrial cancer and 92% of any endometrial disease. Using this
meta-analysis, a multispecialty consensus conference sponsored by the society of radiologists in
ultrasound to discuss the role of sonography in women with postmenopausal bleeding concluded that an
endometrial thickness of greater than 5 mm is abnormal.

Transvaginal assessment of endometrial thickness has been shown to be highly reproducible, with
excellent intraobserver and good interobserver agreement. If the endometrium cannot be visualized in its
entirety or its margins are indistinct, the examination should be considered non diagnostic and lead to
further investigation. The consensus conference also addressed when SHG or hysteroscopy should be
used in the evaluation of postmenopausal bleeding, agreeing that either is appropriate if a focal
abnormality is suspected on transvaginal sonography, and that sonohysterography is more sensitive than
transvaginal sonography alone in detecting focal abnormalities in women with postmenopausal bleeding.
Some recommend that all women with postmenopausal bleeding should undergo SHG, even if the
transvaginal sonogram is normal. Found 30% of 111 healthy asymptomatic postmenopausal women with
a normal transvaginal sonogram had SHG detected endometrial abnormalities. The important question is
whether finding and treating these benign conditions improves the patients quality of life, morbidity , and
survival; further investigation is warranted.

Other studies have assessed the endometrium in asymptomatic postmenopausal patients and concluded
that an endometrium of 8 mm or less can be considered normal. Most of these report have included a
mixed group of patients, with some undergoing HRT and some not undergoing HRT. In a theoretical cohort
of postmenopausal women age 50 years or older who were not bleeding or receiving HRT. Recommended
that biopsy should be considered if the endometrium measures greater than 11 mm, because the risk of
cancer is 6,7% (similar to that of a postmenopausal woman with bleeding and endometrial thickness >
5mm). if the endometrium measures 11 mm or less, biopsy is not needed because the risk of cancer is
extremely low. Using this cutoff provides an acceptable trade off between cancer detection and
unnecessary biopsies prompted by an incidental finding.

Postmenopausal patient may be receiving HRT, because estrogen replacement decreases the risk of
osteoporosis and relieves menopausal symptoms. However, unopposed estrogen replacement is
associated with an increased risk of endometrial hyperplasia and carcinoma. Therefore, estrogen therapy
is frequently combined with progesterone in continuous combined or in sequential regiment. Patients
receiving sequential HRT have a changing endometrial appearance on sonography similar to the
premenopausal endometrium. If noncyclic bleeding occurs, endometrial hyperplasia, polyps, and
malignancy must be considered. In these patients, sonography should be done 4 to 5 days after
completion of the cyclic bleeding, when the endometrium is thinnest.

A small amount of fluid within the endometrial canal, detected by transvaginal sonography, may be a
normal finding in asymptomatic patients. Larger amounts of fluid may be associated with benign
conditions, most often related to cervical stenosis, or with malignancy. The fluid should be excluded when
measuring the endometrium. Because the fluid allows better detail of the endometrium, it is extremely
important to access the endometrium carefully for irregularities and polypoid masses.

Hydrometrocolpos and hematometrocolpos

Obstruction of the genital tract result in the accumulation of secretions and blood in the uterus (metro)
and/or vagina (coplos), with the location depending on the amount of obstruction. Before menstruation,
the accumulation of secretions in the vagina and uterus is referred to as hydrometrocolpos. After
menstruation, hematometrocolpos result from the presence of retained menstrual blood. The obstruction
may be congenital and is usually caused by an imperforate hymen. Other congenital causes include a
vaginal septum, vaginal atresia , or a rudimentary uterine horn. Hydrometra and hematometra may also
be acquired as a result of cervical stenosis from endometrial or cervical tumors or from post irradiation

Sonographically, if the obstruction is at the vaginal level, there is marked distention of the vagina and
endometrial cavity with fluid. If seen before puberty, the accumulation of secretions is anechoic. After
menstruation, the presence of old blood result in echogenic material in the fluid. There may alsi be
layering of the echogenic material, resulting in a fluid level.
Acquired hydrometra or hematometra usually shows a distended, fluid filled endometrial cavity that may
contain echogenic material. Superimposed infection (pyometra) is difficult to distinguish from hydrometra
on sonography, and this diagnosis is usually made clinically in the presence of hydrometra.

Endometrial hyperplasia