ultrasonographic features of endometrium in pre- and postmenopausal women c. tracy suit, md cornelia...
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Ultrasonographic features of endometrium in pre- and postmenopausal women
C. Tracy Suit, MDCornelia de Riese, MDSamuel Prien, PhDKelsey Kelso, BS
Background
The endometrium is a dynamic tissue Menstrual cycle Postmenopausal Exogenous hormones
Transvaginal US
Non-invasive Relatively inexpensive Good safety profile Readily available
Normal endometrium
Menstrual phase Days 1-5 <4 mm
Proliferative phase Days 6-14 4-8 mm
Secretory phase Days 14+ Up to 16 mm
Normal endometrium
In the follicular phase, the endometrium becomes relatively hypodense
As the cycle progresses the endometrium becomes more hyperechoic
Normal endometrium
Ovulatory period = trilaminar endometrium Echogenic basal layer Hypoechogenic functional layer Echogenic line
Usually disappears 48 hours after ovulation
Normal endometrium
Postmenopausal women Averages < 5 mm If on exogenous hormones, < 8 mm is
considered normal A small amount of fluid may be
considered normal
Premenopausal—Differential Diagnosis
Often due to normal proliferation under hormonal influences
Can include: Polyps Polypoid growths Hyperplasia or cancer Submucosal fibroids
Postmenopausal
Important distinction: symptoms Exogenous hormones
Postmenopausal—differential diagnosis
Polyps Hyperplasia or cancer Fibroids
Associated sonographic findings
Polyps: cystic spaces Hyperplasia: regular/homogeneous
echotexture Cancer: irregular margins, indistinct
borders between the endometrium and myometrium, heterogeneous echotexture, complex fluid
Study objective
To evaluate the predictive value of endometrial thickness and descriptive sonographic appearance on pathology in pre- and postmenopausal women
Methods
1903 gynecologic ultrasounds of the endometrium were performed between January, 2004 and January 2009
Stratification: Of these, 367 had pathology performed within 3 months of the ultrasound
The patients were then divided into either pre- or post menopausal after review of the chart
Methods
Each US was critically evaluated for: Endometrial thickness Descriptors of the endometrium
Hyper- or hypoechoic Heterogeneous Regular or irregular Ill-defined Secretory Presence of polyps, fluid or fibroids
Exclusion criteria
No corresponding pathology (EMB, curettage, or hysterectomy) within 3 months of the US
No measurement of the endometrial thickness or distortion by fibroids so that the endometrium could not be meaningfully evaluated
Patient less than 18 years old
Methods
Pathology was classified into groups: Benign: proliferative or secretory,
atrophic, or chronic endometritis Precancerous or cancerous: simple
hyperplasia with or without atypia, complex hyperplasia with or without atypia, endometrial cancer
Statistics
Endometrial descriptors were compared with pathology using a Chi-Square analysis
Endometrial thickness and age were compared using a Student’s t-test
Results
Overall: N=367 Postmenopausal group: N=76
Benign: 69 PreCA/CA: 7
Premenopausal group: N=291 Benign: 267 PreCA/CA: 24
Result: Postmenopausal group
Of the 7 women with pathologic findings: 1 with complex hyperplasia without atypia 6 women with cancer
Average endometrial thickness 20.3 mm Range 13.63 mm to 37 mm
Results: Postmenopausal group
Age Benign: 54 PreCA/CA: 62 There was a trend toward older age with
precancer or cancer Endometrial thickness
Benign: 9.7 mm PreCA/CA : 17.9 mm p<0.05
Results: Postmenopausal group
Descriptive terms No difference between groups
Results: Postmenopausal group
Results: Premenopausal group
Of the women with preCA/CA: 18 with simple hyperplasia
Ranged from 1 mm to 29 mm Average endometrial thickness 11.6 mm
6 with endometrial cancer Average endometrial thickness 24 mm
Results: Premenopausal group
Age: Benign: 39 preCA/CA: 43 Trend toward older age with diagnosis of
hyperplasia or cancer Endometrial thickness:
Benign: 8.9 mm preCA/CA: 15.0 p<0.01
Results: Premenopausal group
Descriptive terms If the endometrial stripe was described as
heterogeneous or irregular, the patients were significantly more likely to have hyperplasia or cancer (p<0.01)
Results: Premenopausal women
Conclusions
Confirmed that endometrial thickness is increased in pathological conditions such as hyperplasia and cancer
But hyperplasia was diagnosed often within the “normal” ranges, especially in the premenopausal women
Conclusions
In the postmenopausal group, complex hyperplasia and cancer were diagnosed with an endometrial thickness of 3 and 5 mm, respectively
Conclusions
In premenopausal women, the average endometrial thickness in women with pathology was still in the normal range for secretory endometrium
Conclusions
In addition, no simple hyperplasia was diagnosed in the postmenopausal group—when pathology was found, it was much more likely to have become frank cancer
Conclusions
Heterogeneity and irregularity in echo pattern were significantly more likely to be associated with hyperplasia or cancer in the premenopausal group. It may have not reached significance in the postmenopausal women due to the smaller sample size.
Conclusions
One weakness of the study is the low rate of pathology
Conclusions
DO THE EMB in symptomatic women High risk women – even very young Postmenopausal women
OUTLOOK
What can the sonohysterogram add? We need to correlate findings to
ethnicity, metabolic and exogenous as well as endogenous hormonal influences to further define high risk scenarios.