Ultrasonographic features of endometrium in pre- and postmenopausal women

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
• lt4 mm
• Proliferative phase
• Days 6-14
• 4-8 mm
• Secretory phase
• Days 14
• Up to 16 mm

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Normal endometrium

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

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Normal endometrium

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

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Normal endometrium

• Postmenopausal women
• Averages lt 5 mm
• If on exogenous hormones, lt 8 mm is considered
  normal
• A small amount of fluid may be considered normal

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PremenopausalDifferential Diagnosis

• Often due to normal proliferation under hormonal
  influences
• Can include
• Polyps
• Polypoid growths
• Hyperplasia or cancer
• Submucosal fibroids

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Postmenopausal

• Important distinction symptoms
• Exogenous hormones

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Postmenopausaldifferential diagnosis

• Polyps
• Hyperplasia or cancer
• Fibroids

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Associated sonographic findings

• Polyps cystic spaces
• Hyperplasia regular/homogeneous echotexture
• Cancer irregular margins, indistinct borders
  between the endometrium and myometrium,
  heterogeneous echotexture, complex fluid

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Study objective

• To evaluate the predictive value of endometrial
  thickness and descriptive sonographic appearance
  on pathology in pre- and postmenopausal women

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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

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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

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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

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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

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Statistics

• Endometrial descriptors were compared with
  pathology using a Chi-Square analysis
• Endometrial thickness and age were compared using
  a Students t-test

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Results

• Overall N367
• Postmenopausal group N76
• Benign 69
• PreCA/CA 7
• Premenopausal group N291
• Benign 267
• PreCA/CA 24

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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

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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
• plt0.05

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Results Postmenopausal group

• Descriptive terms
• No difference between groups

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Results Postmenopausal group
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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

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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
• plt0.01

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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 (plt0.01)

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Results Premenopausal women
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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

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Conclusions

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

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Conclusions

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

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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

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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.

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Conclusions

• One weakness of the study is the low rate of
  pathology

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Conclusions

• DO THE EMB in symptomatic women
• High risk women even very young
• Postmenopausal women

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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.