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

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Presentation on theme: "Ultrasonographic features of endometrium in pre- and postmenopausal women C. Tracy Suit, MD Cornelia de Riese, MD Samuel Prien, PhD Kelsey Kelso, BS."— Presentation transcript:

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 Days 1-5 <4 mm Proliferative phase Days mm Secretory phase Days 14+ Up to 16 mm

5 Normal endometrium In the follicular phase, the endometrium becomes relatively hypodense As the cycle progresses the endometrium becomes more hyperechoic

6 Normal endometrium Ovulatory period = trilaminar endometrium Echogenic basal layer Hypoechogenic functional layer Echogenic line Usually disappears 48 hours after ovulation

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

8 PremenopausalDifferential Diagnosis Often due to normal proliferation under hormonal influences Can include: Polyps Polypoid growths Hyperplasia or cancer Submucosal fibroids

9 Postmenopausal Important distinction: symptoms Exogenous hormones

10 Postmenopausaldifferential diagnosis Polyps Hyperplasia or cancer Fibroids

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 Students 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 : 17.9 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

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 groupwhen 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

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.

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