1. Ultrasonographic features of endometrium in pre- and postmenopausal women
C. Tracy Suit, MD
Cornelia de Riese, MD
Samuel Prien, PhD
Kelsey Kelso, BS

2. Background The endometrium is a dynamic tissue Menstrual cycle
Postmenopausal
Exogenous hormones

3. Transvaginal US Non-invasive Relatively inexpensive
Good safety profile
Readily available

4. Normal endometrium Menstrual phase Proliferative phase Secretory phase
Days 1-5
<4 mm
Proliferative phase
Days 6-14
4-8 mm
Secretory phase
Days 14+
Up to 16 mm
Thickest about day 21 of the cycle

5. Normal endometrium
In the follicular phase, the endometrium becomes relatively hypodense
As the cycle progresses the endometrium becomes more hyperechoic
Hyperechogenicity is due to an enlargement of the spiral arteries and and increase in glycogen in the glands

6. Normal endometrium Ovulatory period = trilaminar endometrium
Echogenic basal layer
Hypoechogenic functional layer
Echogenic line
Usually disappears 48 hours after ovulation
During the ovulatory period, the endometrium takes on a trilaminar appearance.
The echogenic line represents the endometrial cavity

7. 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
Fluid is never considered normal if there are echoes suggestive of blood or debris: associated with CA

8. Premenopausal—Differential Diagnosis
Often due to normal proliferation under hormonal influences
Can include:
Polyps
Polypoid growths
Hyperplasia or cancer
Submucosal fibroids D

9. Important distinction: symptoms Exogenous hormones
Postmenopausal
Important distinction: symptoms
Exogenous hormones
If patients are symptomatic (ie, PMB) they are MUCH more likely to have hyperplasia or cancer

10. Postmenopausal—differential diagnosis
Polyps
Hyperplasia or cancer
Fibroids
Fibroids are less likely in the postmenopausal period, as they atrophy after menopause
If fibroids or polyps are suspected, sonohysterography can be used to further elucidate these lesions

11. Associated sonographic findings
Polyps: cystic spaces
Hyperplasia: regular/homogeneous echotexture
Cancer: irregular margins, indistinct borders between the endometrium and myometrium, heterogeneous echotexture, complex fluid

12. Study objective
To evaluate the predictive value of endometrial thickness and descriptive sonographic appearance on pathology in pre- and postmenopausal women

13. 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

14. 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

15. 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

16. 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

17. Statistics
Endometrial descriptors were compared with pathology using a Chi-Square analysis
Endometrial thickness and age were compared using a Student’s t-test

18. Results Overall: N=367 Postmenopausal group: N=76
Benign: 69
PreCA/CA: 7
Premenopausal group: N=291
Benign: 267
PreCA/CA: 24

19. 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 mm to 37 mm

20. 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 : mm
p<0.05

21. Results: Postmenopausal group
Descriptive terms
No difference between groups

22. Results: Postmenopausal group

23. 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

24. 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

25. 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)

26. Results: Premenopausal women

27. 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
The average endometrial thicknesses were significantly elevated in each group, however,

28. Conclusions
In the postmenopausal group, complex hyperplasia and cancer were diagnosed with an endometrial thickness of 3 and 5 mm, respectively

29. Conclusions
In premenopausal women, the average endometrial thickness in women with pathology was still in the normal range for secretory endometrium

30. 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

31. 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.

32. Conclusions
One weakness of the study is the low rate of pathology

33. Conclusions DO THE EMB in symptomatic women
High risk women – even very young
Postmenopausal women
High risk women include those with menorrhagia or intramenstrual bleeding, anovulatory pattern

34. 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.