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Sonohysterography: The Next Step in the Evaluation of the Abnormal Endometrium¹

¹ From the Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1088. Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received February 1, 1999; revision requested March 17 and received April 15; accepted April 15. Address reprint requests to J.R.J.

View larger version (18K): [in a new window]   Figure 1.   Chart demonstrates how sonohysterography may be used to delineate the pathogenesis of an abnormal endometrium identified at transvaginal US. This information is helpful to the clinician in determining appropriate case management.

View larger version (147K): [in a new window]   Figures 2-5.   Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (arrowheads) (normal thickness, 1-4 mm). (3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6 mm). (4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometrium with a thickness of approximately 11 mm (arrows). (5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm).

View larger version (151K): [in a new window]   Figures 2-5.   Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (arrowheads) (normal thickness, 1-4 mm). (3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6 mm). (4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometrium with a thickness of approximately 11 mm (arrows). (5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm).

View larger version (132K): [in a new window]   Figures 2-5.   Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (arrowheads) (normal thickness, 1-4 mm). (3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6 mm). (4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometrium with a thickness of approximately 11 mm (arrows). (5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm).

View larger version (161K): [in a new window]   Figures 2-5.   Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (arrowheads) (normal thickness, 1-4 mm). (3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6 mm). (4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometrium with a thickness of approximately 11 mm (arrows). (5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm).

View larger version (120K): [in a new window]   Figure 6.   Fluid in the endometrial canal in a 70-year-old woman with postmenopausal bleeding. Sagittal transvaginal US scan shows a small amount of fluid in the endometrial canal, which must be subtracted from the endometrial measurement (A - b).

View larger version (133K): [in a new window]   Figure 7.   Photograph shows equipment used for sonohysterography, including several 5-F catheters (G = Goldstein sonohysterography catheter, P = 5-F pediatric feeding tube, Z = 5-F catheter with 2-mm-diameter balloon), sterile saline solution, ring forceps, speculum, and iodine swabs.

View larger version (157K): [in a new window]   Figures 8, 9.   (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 15 mm. (b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is normal. (9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 12 mm. (b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.

View larger version (144K): [in a new window]   Figures 8, 9.   (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 15 mm. (b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is normal. (9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 12 mm. (b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.

View larger version (133K): [in a new window]   Figures 8, 9.   (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 15 mm. (b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is normal. (9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 12 mm. (b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.

View larger version (128K): [in a new window]   Figures 8, 9.   (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 15 mm. (b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is normal. (9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 12 mm. (b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.

View larger version (164K): [in a new window]   Figures 10, 11.   (10) Polyps in a 30-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Transverse sonohysterogram reveals three polyps (arrows). (11) Polyp in a 47-year-old premenopausal woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 24 mm. (b) Sagittal sonohysterogram shows a focal 30-mm-diameter endometrial polyp (arrows).

View larger version (155K): [in a new window]   Figures 10, 11.   (10) Polyps in a 30-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Transverse sonohysterogram reveals three polyps (arrows). (11) Polyp in a 47-year-old premenopausal woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 24 mm. (b) Sagittal sonohysterogram shows a focal 30-mm-diameter endometrial polyp (arrows).

View larger version (150K): [in a new window]   Figures 10, 11.   (10) Polyps in a 30-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Transverse sonohysterogram reveals three polyps (arrows). (11) Polyp in a 47-year-old premenopausal woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 24 mm. (b) Sagittal sonohysterogram shows a focal 30-mm-diameter endometrial polyp (arrows).

View larger version (156K): [in a new window]   Figures 10, 11.   (10) Polyps in a 30-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Transverse sonohysterogram reveals three polyps (arrows). (11) Polyp in a 47-year-old premenopausal woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 24 mm. (b) Sagittal sonohysterogram shows a focal 30-mm-diameter endometrial polyp (arrows).

View larger version (163K): [in a new window]   Figure 12a.   Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 44 mm and a large area of mixed echogenicity suggestive of a mass. (b) Transverse sonohysterogram shows a 50-mm-diameter polypoid mass protruding into the endometrial cavity (calipers indicate the stalk of the mass). Histopathologic findings indicated poorly differentiated endometrial carcinoma.

View larger version (139K): [in a new window]   Figure 12b.   Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 44 mm and a large area of mixed echogenicity suggestive of a mass. (b) Transverse sonohysterogram shows a 50-mm-diameter polypoid mass protruding into the endometrial cavity (calipers indicate the stalk of the mass). Histopathologic findings indicated poorly differentiated endometrial carcinoma.

View larger version (160K): [in a new window]   Figure 13a.   Endometrial carcinoma in a 51-year-old woman with a 4-week history of bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 23 mm. (b) Sagittal sonohysterogram shows diffuse thickening secondary to hyperplasia.

View larger version (149K): [in a new window]   Figure 13b.   Endometrial carcinoma in a 51-year-old woman with a 4-week history of bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 23 mm. (b) Sagittal sonohysterogram shows diffuse thickening secondary to hyperplasia.

View larger version (150K): [in a new window]   Figures 14, 15.   (14) Endometrial carcinoma in a 45-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 20 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia. The catheter tip is seen in the canal (arrow). (15) Endometrial hyperplasia in a 53-year-old woman with no bleeding who was undergoing estrogen replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 17 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia.

View larger version (129K): [in a new window]   Figures 14, 15.   (14) Endometrial carcinoma in a 45-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 20 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia. The catheter tip is seen in the canal (arrow). (15) Endometrial hyperplasia in a 53-year-old woman with no bleeding who was undergoing estrogen replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 17 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia.

View larger version (128K): [in a new window]   Figures 14, 15.   (14) Endometrial carcinoma in a 45-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 20 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia. The catheter tip is seen in the canal (arrow). (15) Endometrial hyperplasia in a 53-year-old woman with no bleeding who was undergoing estrogen replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 17 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia.

View larger version (122K): [in a new window]   Figures 14, 15.   (14) Endometrial carcinoma in a 45-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 20 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia. The catheter tip is seen in the canal (arrow). (15) Endometrial hyperplasia in a 53-year-old woman with no bleeding who was undergoing estrogen replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 17 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia.

View larger version (153K): [in a new window]   Figures 16, 17.   (16) Secretory endometrium in a 40-year-old woman with diabetes. (a) Sagittal transvaginal US scan obtained on day 33 of the menstrual cycle suggests a focal endometrial bulge with a thickness of 18 mm. (b) Sagittal sonohysterogram shows a diffuse endometrial prominence with a thickness of 12 mm (cursors indicate diameter of a single wall). Secretory endometrium was confirmed at histopathologic examination. (17) Secretory endometrium in an obese, anovulatory 32-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Sagittal sonohysterogram shows diffuse thickening of 12 mm. Histopathologic findings were consistent with secretory endometrium.

View larger version (146K): [in a new window]   Figures 16, 17.   (16) Secretory endometrium in a 40-year-old woman with diabetes. (a) Sagittal transvaginal US scan obtained on day 33 of the menstrual cycle suggests a focal endometrial bulge with a thickness of 18 mm. (b) Sagittal sonohysterogram shows a diffuse endometrial prominence with a thickness of 12 mm (cursors indicate diameter of a single wall). Secretory endometrium was confirmed at histopathologic examination. (17) Secretory endometrium in an obese, anovulatory 32-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Sagittal sonohysterogram shows diffuse thickening of 12 mm. Histopathologic findings were consistent with secretory endometrium.

View larger version (146K): [in a new window]   Figures 16, 17.   (16) Secretory endometrium in a 40-year-old woman with diabetes. (a) Sagittal transvaginal US scan obtained on day 33 of the menstrual cycle suggests a focal endometrial bulge with a thickness of 18 mm. (b) Sagittal sonohysterogram shows a diffuse endometrial prominence with a thickness of 12 mm (cursors indicate diameter of a single wall). Secretory endometrium was confirmed at histopathologic examination. (17) Secretory endometrium in an obese, anovulatory 32-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Sagittal sonohysterogram shows diffuse thickening of 12 mm. Histopathologic findings were consistent with secretory endometrium.

View larger version (159K): [in a new window]   Figures 16, 17.   (16) Secretory endometrium in a 40-year-old woman with diabetes. (a) Sagittal transvaginal US scan obtained on day 33 of the menstrual cycle suggests a focal endometrial bulge with a thickness of 18 mm. (b) Sagittal sonohysterogram shows a diffuse endometrial prominence with a thickness of 12 mm (cursors indicate diameter of a single wall). Secretory endometrium was confirmed at histopathologic examination. (17) Secretory endometrium in an obese, anovulatory 32-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Sagittal sonohysterogram shows diffuse thickening of 12 mm. Histopathologic findings were consistent with secretory endometrium.

View larger version (158K): [in a new window]   Figure 18a.   Endometrial polyp and hyperplasia in a 71-year-old woman with bleeding who was undergoing hormone replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 26 mm accompanied by cysts. (b) Sagittal sonohysterogram shows a large polyp (arrowheads) and diffuse endometrial thickening of approximately 8 mm. Diagnoses of an endometrial polyp and hyperplasia were confirmed at hysterectomy.

View larger version (153K): [in a new window]   Figure 18b.   Endometrial polyp and hyperplasia in a 71-year-old woman with bleeding who was undergoing hormone replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 26 mm accompanied by cysts. (b) Sagittal sonohysterogram shows a large polyp (arrowheads) and diffuse endometrial thickening of approximately 8 mm. Diagnoses of an endometrial polyp and hyperplasia were confirmed at hysterectomy.

View larger version (168K): [in a new window]   Figure 19a.   Endometrial malacoplakia in a 67-year-old woman with postmenopausal bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Transverse sonohysterogram suggests irregular, diffuse thickening with a posterior mass (arrows). Histopathologic analysis revealed endometrial malacoplakia.

View larger version (178K): [in a new window]   Figure 19b.   Endometrial malacoplakia in a 67-year-old woman with postmenopausal bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Transverse sonohysterogram suggests irregular, diffuse thickening with a posterior mass (arrows). Histopathologic analysis revealed endometrial malacoplakia.

View larger version (137K): [in a new window]   Figures 20, 21.   (20) Submucosal fibroid in a 58-year-old woman with postmenopausal bleeding. (a) On a transverse transvaginal US scan, the endometrium appears indistinct (arrowheads). (b) Transverse sonohysterogram shows a submucosal fibroid (F) and a thin (2-mm) overlying endometrium (arrows). The submucosal fibroid was confirmed histopathologically. (21) Submucosal fibroid in a 47-year-old woman with irregular bleeding who was undergoing hormone replacement therapy. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Sagittal sonohysterogram shows a submucosal fibroid (arrowheads). The overlying endometrium is thin.

View larger version (151K): [in a new window]   Figures 20, 21.   (20) Submucosal fibroid in a 58-year-old woman with postmenopausal bleeding. (a) On a transverse transvaginal US scan, the endometrium appears indistinct (arrowheads). (b) Transverse sonohysterogram shows a submucosal fibroid (F) and a thin (2-mm) overlying endometrium (arrows). The submucosal fibroid was confirmed histopathologically. (21) Submucosal fibroid in a 47-year-old woman with irregular bleeding who was undergoing hormone replacement therapy. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Sagittal sonohysterogram shows a submucosal fibroid (arrowheads). The overlying endometrium is thin.

View larger version (167K): [in a new window]   Figures 20, 21.   (20) Submucosal fibroid in a 58-year-old woman with postmenopausal bleeding. (a) On a transverse transvaginal US scan, the endometrium appears indistinct (arrowheads). (b) Transverse sonohysterogram shows a submucosal fibroid (F) and a thin (2-mm) overlying endometrium (arrows). The submucosal fibroid was confirmed histopathologically. (21) Submucosal fibroid in a 47-year-old woman with irregular bleeding who was undergoing hormone replacement therapy. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Sagittal sonohysterogram shows a submucosal fibroid (arrowheads). The overlying endometrium is thin.

View larger version (167K): [in a new window]   Figures 20, 21.   (20) Submucosal fibroid in a 58-year-old woman with postmenopausal bleeding. (a) On a transverse transvaginal US scan, the endometrium appears indistinct (arrowheads). (b) Transverse sonohysterogram shows a submucosal fibroid (F) and a thin (2-mm) overlying endometrium (arrows). The submucosal fibroid was confirmed histopathologically. (21) Submucosal fibroid in a 47-year-old woman with irregular bleeding who was undergoing hormone replacement therapy. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Sagittal sonohysterogram shows a submucosal fibroid (arrowheads). The overlying endometrium is thin.

View larger version (140K): [in a new window]   Figure 22a.   Polypoid adenomyoma in a 43-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium is indistinct. (b) Sagittal sonohysterogram shows a polypoid mass (arrows) arising from the subendometrium. A polypoid adenomyoma was found at hysterectomy.

View larger version (126K): [in a new window]   Figure 22b.   Polypoid adenomyoma in a 43-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium is indistinct. (b) Sagittal sonohysterogram shows a polypoid mass (arrows) arising from the subendometrium. A polypoid adenomyoma was found at hysterectomy.