terms, definitions and measurements to describe the

Ultrasound Obstet Gynecol 2010; 35: 103112Published online 15 December 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.7487

Terms, definitions and measurements to describe thesonographic features of the endometrium and intrauterinelesions: a consensus opinion from the InternationalEndometrial Tumor Analysis (IETA) group

F. P. G. LEONE*, D. TIMMERMAN, T. BOURNE, L. VALENTIN, E. EPSTEIN,S. R. GOLDSTEIN**, H. MARRET, A. K. PARSONS, B. GULL, O. ISTRE,W. SEPULVEDA***, E. FERRAZZI and T. VAN DEN BOSCHDepartments of Obstetrics and Gynecology, *Clinical Sciences Institute L. Sacco and Childrens Hospital, Buzzi, University of Milan,Milan, Italy, Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium, Department of Obstetricsand Gynaecology, Imperial College London, London, UK, Departments of Obstetrics and Gynecology, Malmo University Hospital andLund University Hospital, Lund University, Lund and University of Goteborg, Sahlgrenska University Hospital, Goteborg, Sweden,Departments of Obstetrics and Gynecology, **New York University School of Medicine, New York, NY, University of South Florida,Tampa, FL and Harvard Medical School, Boston, MA, USA, Service de Gynecologie, Centre Hospitalier Universitaire Bretonneau,Tours, France and ***Department of Obstetrics and Gynecology, San Jose Hospital, University of Santiago de Chile, Santiago, Chile

KEYWORDS: diagnosis; endometrial disease; endometrial neoplasms; endometrium; myoma; sonography; terminology;ultrasonography; uterus

ABSTRACT

The IETA (International Endometrial Tumor Analysisgroup) statement is a consensus statement on terms,definitions and measurements that may be used to describethe sonographic features of the endometrium and uterinecavity on gray-scale sonography, color flow imagingand sonohysterography. The relationship between theultrasound features described and the presence or absenceof pathology is not known. However, the IETA termsand definitions may form the basis for prospective studiesto predict the risk of different endometrial pathologiesbased on their ultrasound appearance. Copyright 2009ISUOG. Published by John Wiley & Sons, Ltd.

INTRODUCTION

Over recent years transvaginal sonography has signifi-cantly improved our ability to accurately diagnose andmanage intrauterine abnormalities. In women with post-menopausal bleeding a simple measurement of endome-trial thickness can reliably discriminate between womenwho are at low or high risk of endometrial cancer,with an endometrial thickness of 4 mm or less decreas-ing the likelihood of endometrial cancer by a factor often both in users and non-users of hormone replacementtherapy16. In the high-risk group of women, i.e. those

with an endometrial thickness of 5 mm or more, an eval-uation of endometrial morphology and vascularizationusing gray-scale and Doppler ultrasound imaging with orwithout the added use of sonohysterography (instillationof saline or gel into the uterine cavity during scanning)can be used to further refine the estimation of risk ofpathology and, in particular, the risk of endometrialcancer710. The usefulness of an ultrasound examina-tion of the endometrium in premenopausal women withbleeding problems is much less obvious11,12. Most studiesreporting on ultrasonography of the uterine cavity aresmall, and the results are sometimes conflicting, espe-cially those with regard to sonohysterography. It is likelythat many discrepant results can be explained by differ-ences in the definitions and terms used to describe theultrasound findings. They may also be explained by thesample sizes being small, which means that study pop-ulations are likely to differ. Results of small studies aretherefore not generalizable. The lack of standardizationof terms and definitions used to describe ultrasound find-ings of the endometrium and the uterine cavity makesmeta-analysis of small studies meaningless. Large mul-ticenter studies are needed to clearly define the role ofdetailed ultrasound assessment of endometrial morphol-ogy and vascularization both before and during sono-hysterography in order to discriminate between different

Correspondence to: Dr T. Van den Bosch, Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Herestraat 49,3000 Leuven, Belgium (e-mail: [email protected])

Accepted: 26 October 2009

Copyright 2009 ISUOG. Published by John Wiley & Sons, Ltd. CONSENSUS STATEMENT

104 Leone et al.

types of endometrial pathology and other intracavitarypathology.

The International Endometrial Tumor Analysis (IETA)group was formed in Chicago at the World Congress ofUltrasound in Obstetrics and Gynecology in 2008 withthe aim of agreeing on terms and definitions to describeultrasound findings in the uterine cavity, and to developrecommendations for a standardized measurement tech-nique for both endometrial thickness and intracavitarylesions. The terms, definitions and measurement tech-niques were discussed based on representative images ofthe uterine cavity and agreed upon by all members of theIETA group.

The IETA statement is a consensus statement on terms,definitions and measurements that may be used to describethe sonographic features of the endometrium and uterinecavity at gray-scale sonography, color flow imagingand sonohysterography. The relationship between theultrasound features described and the presence or absenceof pathology is not known. However, the IETA terms anddefinitions may form the basis for prospective studies topredict the risk of different endometrial pathologies basedon their ultrasound appearance.

EXAMINATION TECHNIQUE

In most women the endometrium and uterine cavityshould be scanned transvaginally. A transabdominal scanmay be required in the presence of large fibroids or aglobally enlarged uterus. When a transvaginal scan isconsidered inappropriate (e.g. virgo, vaginismus or sec-ondary vaginal stenosis) or if the transabdominal scanis inconclusive, a transrectal ultrasound examinationshould be considered. Before the menopause, a sono-graphic examination should preferably be performed inthe early proliferative phase (cycle day 46), and inpostmenopausal women on cyclic hormonal replacementtherapy 510 days after the last progestin tablet13,14.

Every assessment of the uterus should start withidentification of the bladder and the cervix. The positionof the uterus is noted and measurements taken. Theuterus is scanned in the sagittal plane from cornu tocornu and in the (oblique) transverse plane from thecervix to the fundus. Having established an overview ofthe whole uterus, the image is magnified to contain onlythe uterine corpus. The magnification should be as largeas possible, focusing on the area of interest. In generalthe endometrium is easy to visualize. However, difficultiesmay arise from variations in uterine position (particularlywhen axial) or with uterine rotation (endometriosis orprevious surgery-related adhesions). This problem maybe overcome in some cases by pressing on the abdomenwith the non-scanning hand, or by filling the bladder.Further problems may be encountered when the cavityis distorted by coexisting benign pathology such asadenomyosis or fibroids. Endometrial cancer may distortthe endometrialmyometrial interface and should be

90

Figure 1 Schematic diagram illustrating ultrasound assessment ofthe endometrium; if at all possible, the angle between theendometrium and the ultrasound beam (the angle of insonation)should be 90 to optimize image quality.

considered as a possible explanation when the endometrialcavity is poorly defined.

When the endometrium is difficult to visualize, it maybe helpful to trace it from the endocervical canal. Ifat all possible, the angle of insonation between theendometrium and the ultrasound beam should be 90to optimize image quality (Figure 1). If the endometriumcannot be seen, saline or gel instillation often addssubstantial information on endometrial appearance.

UNENHANCED ULTRASOUNDEXAMINATION OF THE UTERINECAVITY

Quantitative assessment of endometrial thickness,intrauterine lesions and intracavitary fluid

The endometrial thickness is the maximum measurementin the sagittal plane and includes both endometrial lay-ers (double endometrial thickness). The calipers shouldbe placed at the level of the two opposite endome-trialmyometrial interfaces in an appropriately magnifiedimage, and the endometrium should be measured whereit appears to be at its thickest perpendicular to theendometrial midline (Figure 2a). The measurement ofthe total double-layer thickness should be reported inmillimeters, rounded up to one decimal point. Whenintracavitary fluid is present, the thickness of bothsingle layers are measured and the sum is recorded(Figure 2b). If the endometrium is thickened asymmet-rically the largest anterior and posterior endometrialthicknesses should also be reported separately. Whenthe endometrium cannot be seen clearly in its entirety, itshould be reported as non-measurable and no attemptmade to measure it. The proportion of cases in whichthe endometrium cannot be measured may be as high as10%15.

When intracavitary pathology is present the totalendometrial thickness including the lesion should berecorded. However, if an intracavitary myoma is clearlyidentified, the myoma should not be included in themeasurement of endometrial thickness. Intracavitarylesions should be measured in three perpendicular

Copyright 2009 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2010; 35: 103112.

Ultrasound definitions for endometrium 105

(a)

(b)

Figure 2 (a) Diagram and accompanying ultrasound image showingmeasurement of the endometrial thickness in the absence ofintracavitary fluid; the endometrium should be measured where itappears to be at its thickest. (b) When intracavitary fluid is present,the thickness of both single layers is measured in the sagittal planeand the sum is recorded. The measurement should be taken wherethe endometrium appears to be at its thickest. If the endometrium isthickened asymmetrically, the anterior and posterior endometrialthicknesses should also be reported separately.

diameters in millimeters, rounded up to one decimalpoint. The volume of the lesion may be calculated fromthe three orthogonal diameters using the formula for aprolate ellipsoid (d1 d2 d3 0.523). In myomas, thedistance from the back of the myoma to the serosa shouldalso be measured if a surgical resection is considered.

The amount of intracavitary fluid is defined by itslargest measurement in the sagittal plane.

Qualitative assessment of the endometrium

An evaluation of endometrial morphology includes anassessment of endometrial echogenicity, the endometrialmidline and the endometrialmyometrial junction.

The echogenicity of the endometrium is describedas hyperechogenic, isoechogenic or hypoechogenic com-pared with the echogenicity of the myometrium. Theendometrial echogenicity should be defined as uni-form, if the endometrium is homogeneous and with

symmetrical anterior and posterior sides. This defini-tion includes the different appearances seen through-out the menstrual cycle and the monolayer pat-tern found in most postmenopausal patients. A uni-form endometrium includes the three-layer pattern,as well as the homogeneous hyperechogenic, hypo-echogenic and isoechogenic endometrium (Figure 3).The echogenicity is defined as non-uniform if theendometrium appears heterogeneous, asymmetrical orcystic (Figure 4).

The endometrial midline is defined as linear, if astraight hyperechogenic interface within the endometriumis visualized, as non-linear if a waved hyperechogenicinterface is seen, and as irregular or as not defined inthe absence of a distinct interface (Figure 5).

The bright edge is the echo formed by the interfacebetween an intracavitary lesion and the endometrium(Figure 6)16.

In some patients the endometrial interface is betterdetected by gently pushing the transvaginal probe againstthe uterine corpus, which makes the two endometrialsurfaces slide against each other (i.e. the sliding sign).This technique may also be used to help characterizepathology, as small amounts of fluid in the cavity mayhelp delineate structures in the cavity.

The endometrialmyometrial junction17 should bedescribed as regular, irregular, interrupted or notdefined (Figure 7).

Synechiae are defined as strands of tissue crossing theendometrium (Figure 8). Congenital anomalies are notcovered in this document.

Intracavitary fluid is described as anechogenic orof low-level echogenicity, ground glass or of mixedechogenicity (Figure 9).

Color and power Doppler assessment

The color and power Doppler box should includethe endometrium with the surrounding myometrium.Magnification and settings should be adjusted to ensuremaximal sensitivity for blood flow (ultrasound frequencyat least 5.0 MHz, pulse repetition frequency 0.30.9 kHz,

(a)

(c) (d)

(b)

Figure 3 Uniform endometrial echogenicity: three-layer pattern (a), hypoechogenic (b), hyperechogenic (c) and isoechogenic (d).


106 Leone et al.

wall filter 3050 Hz, color power Doppler gain shouldbe reduced until all color artifacts disappear).

The color content in the endometrium may be scoredusing the International Ovarian Tumor Analysis (IOTA)color score applied previously to ovarian masses18. The

(a)

(b)

(c)

(d) (e)

Figure 4 Non-uniform endometrial echogenicity: homogeneousbackground with regular cystic areas (a), homogeneousbackground with irregular cystic areas (b), heterogeneousbackground without cystic areas (c), heterogeneous backgroundwith regular cystic areas (d) and heterogeneous background withirregular cystic areas (e); black color denotes cystic spaces.

color score is a subjective semiquantitative assessment ofthe amount of blood flow present: a color score of 1 isgiven when no color flow signals reflecting blood flowcan be found in the endometrium, a score of 2 when onlyminimal color can be detected, a score of 3 when moderatecolor is present, and a score of 4 when abundant color isdetected (Figure 10).

The vascular pattern within the endometrium isreported with respect to the presence or absence ofdominant vessels or of other specific patterns. Dominantvessels are defined as one or more distinct vessels (arterialand/or venous) passing the endomyometrial junction(Figure 11). The dominant vessel may show branchingwithin the endometrium, which may be described aseither orderly or disorderly/chaotic. Dominant vesselsmay present as a single vessel (formerly referred to asthe pedicle artery sign)19 with or without branching.Multiple dominant vessels may have a focal origin atthe endometrialmyometrial junction or may have amultifocal origin. Other vascular patterns within theendometrium include scattered vessels (dispersed colorsignals within the endometrium but without visible originat the myometrialendometrial junction) and circularflow (Figure 11).

Figure 6 Bright edge, the echo formed by the interface between anintracavitary lesion and the endometrium.

(a)

(c) (d)

(b)

Figure 5 Endometrial midline: linear (a), non-linear (b), irregular (c) and not defined (d).



(a)

(b)

(c)

(d)

Figure 7 Endometrialmyometrial junction: regular (a), irregular (b), interrupted (c) (dark gray area denotes theendometrialmyometrial halo; in this case the halo is interrupted) and not defined (d).

Figure 8 Synechiae are seen as strands of tissue crossing theendometrium.

ENHANCED ULTRASOUNDEXAMINATION OF THE UTERINECAVITY

Qualitative assessment of endometrial morphology andintrauterine lesions at sonohysterography or when thereis pre-existing fluid in the uterine cavity

Sonohysterography is the instillation of fluid into theuterine cavity to act as a negative contrast agent.Saline instillation sonohysterography or gel instillationsonohysterography may be used2023. Evaluation of theendometrial and intracavitary morphological features atsonohysterography is done using the same definitions asdescribed above.

Uterine cavity distension at sonohysterography isdefined as optimal if the fluid clearly distends the cavity,

(a)

(b)

(c)

Figure 9 Intracavitary fluid: anechogenic or low-levelechogenicity (a), ground glass appearance (b) and mixedechogenicity (c).

suboptimal if the cavity is barely distended and failedif no fluid is seen in the cavity.

The endometrial thickness is measured as describedabove, and its echogenicity is described as outlined above.

The endometrial outline is defined as smooth if theendometrial surface facing the uterine cavity appearsregular, as having endometrial folds (multiple thickenedundulating areas, moguls with a regular profile),or as polypoid if there are deep indentations. The


108 Leone et al.

(a) (b) (c) (d)

Figure 10 Color Doppler assessment of the endometrium: a color score of 1 is given to indicate no color, i.e. no flow (a); a score of 2indicates minimal color, i.e. minimal flow (b); a score of 3 indicates moderate color, i.e. moderate flow (c); and a score of 4 indicatesabundant color, i.e. abundant flow (d).

(a)

(c)

(e)

(d)

(b)

(f)

Figure 11 Vascular patterns: single dominant vessel without branching (a) and with branching (b), multiple vessels with focal origin (twoor more vessels appear to share a common stem) (c) and with multifocal origin at the myometrialendometrial junction (d), scatteredvessels (dispersed color signals within the endometrium but without visible origin at the myometrialendometrial junction) (e) and circularflow (f).

endometrium is described as irregular if the surfacefacing the uterine cavity is cauliflower like or sharplytoothed (spiky) (Figure 12).

The endometrialmyometrial junction is described asoutlined above.

Intracavitary lesions

Anything that protrudes into a fluid-filled uterine cavity iscalled an intracavitary lesion. Intracavitary lesions should

be described as endometrial lesions or as lesions arisingfrom the myometrium.

The extent of an endometrial lesion is reported onthe basis of the percentage of the total endometrialsurface involved. The percentage is estimated subjectivelyby the sonographer. An endometrial lesion is definedas extended if the endometrial abnormality seems toinvolve 25% or more of the endometrial surface, and aslocalized if the endometrial abnormality seems to involveless than 25% of the endometrial surface (Figure 13). The



(a)

(c)

(d)

(b)

Figure 12 Endometrial outline at sonohysterography or when there is pre-existing fluid in the uterine cavity: smooth (a), endometrialfolds (b), polypoid (c) and irregular (d).

(a)

(b)

Figure 13 Estimation of the extent of an endometrial lesion atsonohysterography or when there is pre-existing fluid in the uterinecavity: localized the base of the lesion involves less than 25% ofthe endometrial surface (a) or extended the base of the lesioninvolves 25% or more of the endometrial surface (b).

type of localized lesion depends on the ratio between thediameter of the base at the level of the endometrium (a)and the maximal transverse diameter of the lesion (b). Itis defined as pedunculated if the a/b ratio is

110 Leone et al.

(a) (b)

a

b

Figure 14 Type of localized lesion at sonohysterography or when there is pre-existing fluid in the uterine cavity: a/b ratio < 1 indicatespedunculated (a) and a/b ratio 1 indicates sessile (b), where a is the maximal diameter of the base of the lesion at the level of theendometrium and b is the maximal transverse diameter of the lesion.

(a)

(b)

Figure 15 Outline of a lesion at sonohysterography or whenthere is pre-existing fluid in the uterine cavity: smooth (a) andirregular (b).

choose to use this approach to reporting their ultrasoundfindings. However, the primary aim of this paper is toproduce a list of terms and definitions that may be used inresearch. Currently it is difficult to compare results fromdifferent published studies because authors use different

(a)

(b)

(c)

Figure 16 Proportion of a myoma protruding into the uterinecavity at sonohysterography or when there is pre-existing fluid inthe uterine cavity: 100%, Grade 0 (a); 50%, Grade 1 (b);


Figure 17 Synechiae at sonohysterography or when there ispre-existing fluid in the uterine cavity are thin or thick strands oftissue crossing the endometrial cavity, usually with an echogenicitysimilar to that of the myometrium; they are attached to bothuterine walls and are not covered by endometrium.

have been used in large multicenter studies and theresults have been validated successfully26; hopefully, themorphological and blood flow descriptors used in theIOTA study will gradually be adopted as the standardlanguage to describe ovarian pathology. We hope thata similar approach to the endometrium will also provesuccessful.

Standardizing terminology will allow comparisonsbetween future studies on the endometrium and facilitatemulticenter studies. At present we do not know whichof the features outlined in the document are relevantin terms of the prediction of pathology. Endometrialthickness is certainly important as a predictor ofpathology, but endometrial morphology may prove justas useful once we can be certain that investigatorsare looking at the same structures and evaluating thesame morphological features. In particular, it might beuseful in premenopausal patients, in whom endometrialthickness has been shown to be of limited value as apredictor of abnormal findings11,12. Future studies willdetermine which features are relevant for the predictionof intrauterine pathology in both premenopausal andpostmenopausal women. Other techniques, such as three-dimensional ultrasound imaging2729 and the evaluationof endometrial peristalsis30, might also prove useful in thediagnosis of endometrial pathology, but in this documentwe have limited ourselves to two-dimensional gray-scaleultrasound and color flow imaging.

In daily practice, an ultrasound report on theendometrium may be less detailed than described inAppendix S1 (IETA data sheet). However, furtherprospective studies will have to demonstrate which are themost important items in reporting on the endometrium

and on intracavitary lesions, before providing guidelinesas to the required essential information.

Not everyone will agree with the terms and definitionsthat we suggest. However, to allow consistent reportingof research results, it is necessary to propose somekind of structure to describe gynecological ultrasoundfindings. We feel we have developed a nomenclaturethat is reasonable. Clinicians in the IETA group fromseveral countries and with an interest in both ultrasoundimaging and operative hysteroscopy have agreed on thisnomenclature. Prospective studies will show if it needs tobe adjusted.

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SUPPORTING INFORMATION ON THE INTERNET

The following supporting information may be found in the online version of this article:

Appendix S1 IETA data sheet.


terms, definitions and measurements to describe the

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