(Radiographics. 2002;22:803-816.)
© RSNA, 2002
Sonohysterographic Findings of Endometrial and Subendometrial Conditions1
Patricia C. Davis, MD,
Mary Jane O’Neill, MD,
Isabel C. Yoder, MD,
Susanna I. Lee, MD and
Peter R. Mueller, MD
1 From the Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, White Bldg Rm 270, 55 Fruit St, Boston, MA 02114. Presented as an education exhibit at the 2000 RSNA scientific assembly. Received July 9, 2001; revision requested September 18; final revision received April 9, 2002; accepted April 18. Address correspondence to P.C.D. (e-mail: pcdavis@partners.org).
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Abstract
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Sonohysterography has become the standard test in the evaluation of dysfunctional uterine and postmenopausal bleeding because it allows reliable differentiation between focal and diffuse endometrial and subendometrial lesions, with the most common being polyps and submucosal fibroids. An endometrial polyp usually appears as a well-defined, homogeneous, polypoid lesion that is isoechoic to the endometrium with preservation of the endometrial-myometrial interface. Atypical polyps have cystic components, multiplicity, a broad base, and hypoechogenicity or heterogeneity. Submucosal fibroids are usually broad-based, hypoechoic, well-defined, solid masses with shadowing and an overlying layer of echogenic endometrium that distorts the endometrial-myometrial interface. Atypical fibroids are pedunculated or have a multilobulated surface. The major advantage of sonohysterography is that it can accurately depict the percentage of the fibroid that projects into the endometrial cavity. Endometrial hyperplasia usually appears as diffuse thickening of the echogenic endometrial stripe without focal abnormality, but occasionally focal hyperplasia can be seen. Endometrial cancer is typically a diffuse process, but early cases can appear as a polypoid mass. Adhesions usually appear as mobile, thin, echogenic bands that bridge a normally distensible endometrial cavity, but occasionally thick, broad-based bands or complete obliteration of the endometrial cavity is seen. Although endometrial lesions have characteristic features, a wide range of appearances is possible, with significant overlap between entities. Radiologists should be familiar with the broad spectrum of findings that may be seen at sonohysterography in both benign and malignant processes to raise the appropriate level of concern and to direct the clinician toward the appropriate means of diagnostic biopsy or surgery.
© RSNA, 2002
Index Terms: Uterus, hemorrhage, 854.64 • Uterus, US, 854.12989 • Uterine neoplasms, 854.315, 854.3199, 854.32 • Uterine neoplasms, US, 854.12989
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LEARNING OBJECTIVES FOR TEST 3
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After reading this article and taking the test, the reader will be able to:
- Identify the typical and atypical sonohysterographic appearances of common endometrial and subendometrial lesions.
- Describe the characteristic sonohysterographic appearances of less common endometrial and subendometrial conditions.
- Discuss an algorithmic approach to the work-up of abnormal uterine bleeding.
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Introduction
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Until recently, routine office endometrial biopsy and transvaginal ultrasonography (US) performed to evaluate double-layer thickness of the endometrium were the only tests available for the work-up of patients with postmenopausal bleeding and dysfunctional uterine bleeding. These procedures were often inadequate for evaluation because approximately 50% of cases of abnormal uterine bleeding are caused by focal lesions such as polyps, submucosal fibroids, and focal endometrial hyperplasia. Focal lesions are more likely to be missed at routine endometrial biopsy because of sampling error and underdiagnosed at transvaginal US because of limitations of the double-layer thickness evaluation (1,2).
Sonohysterography, a US technique in which the endometrial cavity is distended with saline, allows evaluation of the single layer of the endometrial lining and enables the radiologist to reliably distinguish focal from diffuse endometrial pathologic conditions. Focal lesions are defined as lesions occupying less than 25% of the endometrial surface area (Fig 1), and diffuse lesions involve a larger percentage of the endometrial surface area (Fig 2).
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Figure 1. Focal endometrial lesion: endometrial polyp. Sonohysterogram of a patient with postmenopausal bleeding reveals a well-marginated, polypoid mass projecting into the endometrial cavity (white arrow). The remaining endometrium is thin and homogeneous (black arrow), indicating the presence of a focal endometrial lesion. Routine endometrial biopsy would be unlikely to determine the cause of the postmenopausal bleeding in this case. Although the appearance is not completely typical, pathologic analysis revealed an endometrial polyp.
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Figure 2. Diffuse endometrial lesion: endometrial hyperplasia. Sonohysterogram of a patient with postmenopausal bleeding reveals a diffusely thickened endometrium (arrows). Routine endometrial biopsy is appropriate in patients with diffuse endometrial thickening because sampling error is not a concern.
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Sonohysterography enables triage of symptomatic postmenopausal patients to the appropriate means of endometrial sampling and should be performed routinely in this patient population. In addition, in the premenopausal patient population, sonohysterography is a valuable tool for assessing the endometrial cavity in patients with dysfunctional uterine bleeding, recurrent pregnancy loss, and retained products of conception. In patients with focal endometrial abnormalities, the biopsy must be performed with hysteroscopic assistance to obtain representative tissue for diagnosis. The findings at sonohysterography determine whether a blind biopsy, hysteroscopically guided biopsy, or hysteroscopically guided dilation and curettage is the appropriate diagnostic procedure. Unlike focal lesions, diffuse lesions are well diagnosed with routine endometrial biopsy.
In this article, we compare and contrast the typical and atypical sonohysterographic appearances for common endometrial and subendometrial lesions, such as polyps and submucosal fibroids. In addition, we describe the characteristic appearances of less common focal and diffuse conditions, such as endometrial hyperplasia, endometrial cancer, endometrial adhesions, retained products of conception, and tamoxifen effects on the endometrium and subendometrium. An algorithmic approach to the work-up for the patient with abnormal uterine bleeding is also reviewed. This review will provide a useful guide for diagnosis and triage to the general practicing radiologist.
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Sonohysterography in Pre- and Postmenopausal Patients
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Sonohysterography is easily performed, is well tolerated, and is a cost-effective means of directing the work-up for patients with pre- and postmenopausal bleeding (1). In premenopausal patients, sonohysterography is preferably performed during the early proliferative phase (day 4–6) of the patient’s menstrual cycle, when the endometrium is at its thinnest. Although there is no established limit for normal premenopausal endometrial thickness, the endometrium should be uniform in thickness, homogeneous in echotexture, and not displaced by any submucosal, myometrial abnormality (Fig 3) (3).
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Figure 3. Normal premenopausal endometrium. Sonohysterogram reveals a normal premenopausal endometrium (arrows) outlined by saline. It is uniform in thickness, homogeneous in echotexture, and not displaced by any submucosal myometrial abnormalities.
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In postmenopausal patients, the normal atrophic endometrium should measure less than 4 mm in double-layer thickness as seen at transvaginal US and less than 2.5 mm in single-layer thickness at sonohysterography. In addition, the atrophic endometrium should be smooth and uniform in echotexture and not displaced by any submucosal, myometrial abnormalities (Fig 4) (4–6).
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Figure 4. Normal postmenopausal endometrium. Sonohysterogram reveals a thin, smooth, uniform endometrium distended with saline (large arrow). An intramural fibroid in the posterior fundus of this retroverted uterus is incidentally noted (small arrows).
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Common Endometrial Lesions
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Endometrial Polyps
Endometrial polyps are common and a frequent cause of abnormal uterine bleeding. Polyps can be histologically characterized as localized hyperplastic overgrowths of glands and stroma. They account for approximately 30% of cases of postmenopausal bleeding (1). In menstruating women, they may cause intermenstrual bleeding, metrorrhagia, and infertility (7).
Usual Sonohysterographic Appearance.—
The typical appearance of an endometrial polyp at sonohysterography is a well-defined, homogeneous, polypoid lesion that is isoechoic to the endometrium with preservation of the endometrial-myometrial interface (Fig 5). There usually is a well-defined vascular pedicle within the stalk (Fig 6). In contrast to the transvaginal US demonstration of polyps, which may distort measurements of endometrial thickness if made before saline infusion, at sonohysterography the uninvolved single-layer endometrium appears normal in thickness and should be measured separately from the polyp (8,9).
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Figure 5. Typical endometrial polyp. Sonohysterogram of a patient with postmenopausal bleeding demonstrates a solitary, smooth, well-defined, uniformly echogenic intracavitary lesion (P). This is the typical appearance of an endometrial polyp. Note the narrow base of attachment to the posterior endometrial surface (arrows).
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Figure 6. Typical endometrial polyp. Color Doppler image shows a single feeding artery at the base of attachment of an endometrial polyp to the remaining endometrium (arrow). This is a frequent finding in endometrial polyps.
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Unusual Sonohysterographic Appearances.—
Some of the atypical features of polyps include cystic components (Fig 7), multiplicity (Fig 8), a broad base (Fig 9), and hypoechogenicity or heterogeneity (Fig 10). Occasionally, polyps can have a heterogeneous echotexture with multiple cysts. This complex appearance may indicate hemorrhage, infarction, or inflammation within the polyp (10). A small percentage of endometrial polyps may contain malignant foci or foci of endometrial hyperplasia.
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Figure 7. Cystic endometrial polyp. Sonohysterogram of a premenopausal patient reveals a small cystic space within an otherwise normal-appearing polyp (arrow). The remainder of the endometrium is normal thickness for this patient group (arrowheads).
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Figure 8. Multiple endometrial polyps. Sonohysterogram of a patient with postmenopausal bleeding demonstrates three separate polyps (arrows). This case illustrates the importance of performing sonohysterography even when transvaginal US findings strongly suggest a focal lesion. Accurate localization of the endometrial lesion to guide hysteroscopic resection is an important role for sonohysterography.
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Figure 9. Flat endometrial polyp. Sonohysterogram of a patient with postmenopausal bleeding reveals a broad-based endometrial polyp (arrow). A = measurement of the polyp between the calipers. Note the preservation of the endometrial-myometrial junction (arrowheads), which favors a benign diagnosis such as endometrial polyp. However, because the appearance of focal endometrial hyperplasia and carcinoma can simulate that of benign lesions, tissue sampling must be performed in all cases to exclude malignancy.
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Figure 10. Hypoechoic endometrial polyp. Sonohysterogram of a patient with postmenopausal bleeding demonstrates a large, broad-based polypoid lesion. The hypoechoic nature of this mass (**) with echogenicity similar to that of the underlying myometrium (*) and the indistinct endometrial-myometrial interface (arrowheads) raised the concern for endometrial carcinoma. The uninvolved endometrium is atrophic and echogenic (arrows). Hysteroscopic resection revealed an endometrial polyp with foci of atypical hyperplasia.
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Submucosal Leiomyomas
Submucosal leiomyomas or fibroids are a common source of abnormal uterine bleeding and are associated with reproductive dysfunction, including recurrent miscarriage, infertility, premature labor, fetal malpresentations, and complications of labor (11). They also are associated with postmenopausal bleeding, accounting for approximately 10% of these cases (1). Sonohysterography allows fibroids to be classified easily and accurately by location, size, and degree of intramural extension. The major advantage of sonohysterography over other imaging modalities is that it can accurately depict the percentage of the fibroid that projects into the endometrial cavity. This feature is important because only those fibroids in which at least 50% of the mass projects into the endometrial cavity may be removed hysteroscopically.
Usual Sonohysterographic Appearance.—
At sonohysterography, submucosal fibroids are typically broad-based, hypoechoic, well-defined, solid masses with shadowing. Submucosal fibroids typically have an overlying layer of echogenic endometrium, which helps confirm their subendometrial location and helps distinguish them from endometrial polyps, which arise from the endometrium (Figs 11–13). In addition, as opposed to polyps, submucosal fibroids often distort the interface between the endometrium and myometrium and show acoustic attenuation (12).
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Figure 11. Typical fibroids with submucosal extent. Sonohysterograms from three separate patients with dysfunctional uterine bleeding demonstrate the typical appearance of submucosal fibroids. These lesions are all hypoechoic, broad based, and well circumscribed, and they displace the endometrium to varying degrees. Arrowheads indicate the normal endometrium flowing over the submucosal masses; arrows indicate the endoluminal component. The percentage of protrusion of the fibroid into the endometrial cavity should be classified as equal to or greater than 50% (11) or less than 50% (12). Mural fibroids can have a submucosal component that deviates the endometrial cavity, but they are not considered submucosal fibroids unless the epicenter of the fibroid is within the cavity (13).
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Figure 12. Typical fibroids with submucosal extent. Sonohysterograms from three separate patients with dysfunctional uterine bleeding demonstrate the typical appearance of submucosal fibroids. These lesions are all hypoechoic, broad based, and well circumscribed, and they displace the endometrium to varying degrees. Arrowheads indicate the normal endometrium flowing over the submucosal masses; arrows indicate the endoluminal component. The percentage of protrusion of the fibroid into the endometrial cavity should be classified as equal to or greater than 50% (11) or less than 50% (12). Mural fibroids can have a submucosal component that deviates the endometrial cavity, but they are not considered submucosal fibroids unless the epicenter of the fibroid is within the cavity (13).
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Figure 13. Typical fibroids with submucosal extent. Sonohysterograms from three separate patients with dysfunctional uterine bleeding demonstrate the typical appearance of submucosal fibroids. These lesions are all hypoechoic, broad based, and well circumscribed, and they displace the endometrium to varying degrees. Arrowheads indicate the normal endometrium flowing over the submucosal masses; arrows indicate the endoluminal component. The percentage of protrusion of the fibroid into the endometrial cavity should be classified as equal to or greater than 50% (11) or less than 50% (12). Mural fibroids can have a submucosal component that deviates the endometrial cavity, but they are not considered submucosal fibroids unless the epicenter of the fibroid is within the cavity (13).
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Unusual Sonohysterographic Appearances.—
Atypical appearances of leiomyomas seen at sonohysterography include pedunculated submucosal fibroids (Fig 14), fibroids that have prolapsed into the endocervical canal often preventing sonohysterography (Fig 15), and fibroids with a multilobulated surface (Fig 16) (3,10,13).
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Figure 14. Pedunculated submucosal fibroid. Sonohysterogram of a patient with severe menorrhagia requiring transfusion demonstrates a hypoechoic mass that is completely endoluminal with a narrow base of attachment (arrows). The endometrium covering the fibroid is thickened and irregular (arrowheads), a finding that suggests chronic edema or inflammation related to irritation from the submucosal mass. The presence of overlying echogenic endometrium helps distinguish between submucosal and mucosal abnormalities.
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Figure 15a. Fibroid prolapse. (a) Transvaginal US scan of a patient with postmenopausal bleeding obtained before planned sonohysterography shows a large mass (M) protruding from the cervical os (arrows). C = cervical stroma. (b) Magnetic resonance image reveals a large prolapsed submucosal fibroid (F) expanding the cervical canal (arrows).
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Figure 15b. Fibroid prolapse. (a) Transvaginal US scan of a patient with postmenopausal bleeding obtained before planned sonohysterography shows a large mass (M) protruding from the cervical os (arrows). C = cervical stroma. (b) Magnetic resonance image reveals a large prolapsed submucosal fibroid (F) expanding the cervical canal (arrows).
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Figure 16. Lobulated fibroid. Sonohysterogram of a patient with dysfunctional uterine bleeding reveals a large, multilobulated, submucosal fibroid (arrows) arising from the left lateral wall. The endometrial stripe is of normal thickness (arrowheads) and can be seen passing over the submucosal lesion.
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Uncommon Endometrial Lesions
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Endometrial Hyperplasia
Endometrial hyperplasia is caused by endometrial stimulation by unopposed estrogen. Endometrial hyperplasia is histologically defined as a proliferation of endometrial glands of irregular size and shape, with an increase in the gland-stroma ratio compared with the normal proliferative endometrium (7). Risk factors for developing endometrial hyperplasia are similar to those in carcinoma, including exposure to unopposed estrogen (either endogenous or exogenous), tamoxifen usage, nulliparity, obesity, hypertension, and diabetes. There is a range of histologic patterns of endometrial hyperplasia, ranging from hyperplasia without atypia, which has little or no malignant potential, to severe atypia in which 20% of cases progress to endometrial cancer (13). Endometrial hyperplasia accounts for approximately 4%–8% of cases of postmenopausal bleeding (1,2).
At sonohysterography, endometrial hyperplasia typically appears as a diffuse thickening of the echogenic endometrial stripe without focal abnormality (Fig 17); however, focal endometrial hyperplasia can occasionally be seen (Fig 18). The latter form of hyperplasia is more difficult to differentiate from endometrial polyps at sonohysterography because the characteristics of the focal endometrial thickening occurring in both conditions overlap.
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Figure 18. Atypical endometrial hyperplasia. Sonohysterogram of a patient with postmenopausal bleeding shows a focal hyperechoic polypoid mass resembling a broad-based endometrial polyp (arrows). The endometrial-myometrial interface (arrowheads) is preserved. Hysteroscopic biopsy revealed endometrial hyperplasia with mild atypia. This case illustrates the considerable overlap between the various types of focal endometrial lesions. Pathologic characteristics cannot be distinguished based on sonohysterographic findings alone.
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Endometrial Cancer
Endometrial carcinoma is the most common gynecologic malignancy in the United States and is predominantly a disease of postmenopausal women, with the average age at presentation being 59 years. Despite its prevalence, it accounts for less than 1.5% of cancer deaths because the majority of cases are detected when the carcinoma is still confined to the uterus. The early detection is the result of the hallmark early symptom of endometrial cancer, uterine bleeding, which leads the physician to perform endometrial biopsy, often at a favorable stage (7). Although postmenopausal bleeding is a common sign of endometrial cancer, recent studies have shown that only 4%–5% of women with postmenopausal bleeding have endometrial cancer (1,2).
The most common appearance of endometrial cancer at transvaginal US is nonspecific thickening of the endometrium. Even at sonohysterography, endometrial cancer can be difficult to distinguish from endometrial hyperplasia and polyps. This diagnosis should be suspected when the single layer of the endometrium is thicker than 8 mm, irregular, broad based, or poorly marginated or when the endometrial-myometrial interface is disrupted. Endometrial thickness measurements often overlap in benign and malignant conditions (5). However, it has been shown that a single-layer endometrial thickness less than 2.5 mm is rarely associated with malignancy (14).
At sonohysterography, endometrial cancer is typically a more diffuse process (Fig 19); however, early cases can appear as a polypoid mass (Fig 20). An intact subendometrium is suggestive of localized disease, whereas extension of heterogeneity and increased echogenicity in the myometrium is seen with advanced invasive endometrial carcinoma (15).
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Figure 19. Typical endometrial cancer. Sonohysterogram of a patient with postmenopausal bleeding demonstrates diffuse, irregular, inhomogeneous thickening of the anterior endometrium, involving greater than 25% of the endometrial surface area (between arrowheads). The endometrial cavity is distended with fluid (between arrows), and the posterior layer of endometrium is atrophic and imperceptible. Although the endometrial-myometrial interface adjacent to the abnormal endometrium appears fairly well defined (broken white line) (M = inner layer of myometrium), pathologic analysis revealed invasive endometrial carcinoma.
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Figure 20. Atypical endometrial cancer. Sonohysterogram of a patient with heavy postmenopausal bleeding demonstrates an irregular, polypoid lesion (white arrows) arising from the posterior endometrial surface. There are irregular, frondlike projections extending from its surface into the endometrial cavity, which is distended with echogenic fluid due to mixing of saline with blood. The polypoid nature of the mass, with a narrow base of attachment (black arrows) involving less than 25% of the endometrial surface area, is atypical for endometrial cancer. Despite the indistinct endometrial-myometrial interface, pathologic analysis revealed noninvasive endometrial cancer.
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Intrauterine Adhesions
Patients with endometrial adhesions may present with infertility or recurrent pregnancy loss. At initial transvaginal US evaluation, the diagnosis of adhesions is difficult because the endometrium often appears normal. However, occasionally adhesions may be seen at transvaginal US as irregularities or hypoechoic bands within the endometrium (16).
At sonohysterography, adhesions typically appear as mobile, thin, echogenic bands that bridge a normally distensible endometrial cavity (Fig 21) (17). Less typical appearances include thick, broad-based bridging bands (Fig 22) and complete obliteration of the endometrial cavity (Fig 23). As the severity of adhesions progresses, the endometrial cavity may become difficult to distend during saline infusion (8). Adhesions can also be associated with endometrial scars, which have a variable appearance, ranging from small echogenic areas of focal endometrial thickening (Fig 24) to areas of denuded endometrium (Fig 25).
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Figure 21. Thin endometrial adhesions. Sonohysterogram of a patient with primary infertility demonstrates a thin echogenic band (arrow) crossing a normally distensible endometrial cavity. The ability to distend the cavity suggests that the adhesions are not severe.
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Figure 22. Thick endometrial adhesions. Sonohysterogram of a patient with a history of multiple miscarriages reveals a thick, irregular, echogenic band (arrow) traversing a less distensible cavity. This adhesion may interfere with implantation and was treated hysteroscopically.
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Figure 23a. Endometrial cavity obliterated by adhesions. (a) On a preliminary transvaginal US scan in a patient with secondary infertility after therapeutic abortion, the endometrial lining at the fundus appears normal (white arrow); however, it is not well seen in the lower uterine segment (black arrow). (b) Subsequent sonohysterogram shows a small amount of saline (arrowheads) in the lower uterine segment with obliteration of the remainder of the cavity by dense fibrous adhesions (arrows).
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Figure 23b. Endometrial cavity obliterated by adhesions. (a) On a preliminary transvaginal US scan in a patient with secondary infertility after therapeutic abortion, the endometrial lining at the fundus appears normal (white arrow); however, it is not well seen in the lower uterine segment (black arrow). (b) Subsequent sonohysterogram shows a small amount of saline (arrowheads) in the lower uterine segment with obliteration of the remainder of the cavity by dense fibrous adhesions (arrows).
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Figure 24. Endometrial scar. Sonohysterogram of a patient obtained immediately after dilation and curettage reveals an echogenic focus (arrow) within an otherwise normal-appearing endometrium. A = measurement of the lesion between the calipers. The echogenic focus most likely represents fibrosis within an endometrial scar. Although this finding is commonly associated with adhesions, no adhesions were present.
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Figures 25. Endometrial scar. Sonohysterogram of a patient obtained after hysteroscopic resection of a submucosal fibroid shows a small echogenic focus. The deep myometrial postsurgical defect is associated with the small echogenic focus, as well as denuded endometrium within the defect, findings consistent with a scar.
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Retained Products of Conception
Retained products of conception can be usually managed without the need for sonohysterography. However, patients occasionally remain symptomatic after dilation and curettage because of a small focus of retained placental tissue. Sonohysterography is an ideal method for identifying and localizing the residual tissue in these problematic cases. Retained products of conception are typically more irregular in contour than endometrial polyps and can be variable in size and appearance (Fig 26) (18).
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Figure 26a. Retained products of conception. (a) Transvaginal US scan of a patient with persistent pain and menometrorrhagia 2 years after delivery demonstrates nonspecific thickening of the endometrial stripe (arrows). The patient had undergone several prior dilation and curettage procedures without hysteroscopic guidance and remained symptomatic. The ß-chorionic gonadotropin level was normal. (b) Subsequent sonohysterogram reveals a large 2.7-cm focal mass in the endometrial cavity that has a narrow attachment to the anterior uterine fundus (arrows). Hysteroscopic resection of the mass revealed necrotic, retained placental tissue.
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Figure 26b. Retained products of conception. (a) Transvaginal US scan of a patient with persistent pain and menometrorrhagia 2 years after delivery demonstrates nonspecific thickening of the endometrial stripe (arrows). The patient had undergone several prior dilation and curettage procedures without hysteroscopic guidance and remained symptomatic. The ß-chorionic gonadotropin level was normal. (b) Subsequent sonohysterogram reveals a large 2.7-cm focal mass in the endometrial cavity that has a narrow attachment to the anterior uterine fundus (arrows). Hysteroscopic resection of the mass revealed necrotic, retained placental tissue.
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Tamoxifen-induced Endometrial and Subendometrial Changes
Tamoxifen is a nonsteroidal antiestrogen compound used extensively as adjuvant therapy for breast cancer in pre- and postmenopausal women. Tamoxifen inhibits estrogen-dependent tumor growth by competing with estrogen at its receptor sites. This competition for receptor sites may result in either antiestrogenic or weakly estrogenic effects, depending on tissue site andreceptor status. An increased risk of endometrial carcinoma as well as an increased risk of endometrial hyperplasia and polyps has been reported in patients undergoing tamoxifen therapy (19,20).
In patients receiving tamoxifen, cystic changes within an apparently thickened endometrium are frequently seen at transvaginal US and can represent cysts within endometrial hyperplasia, endometrial polyps (Fig 27), or endometrial carcinoma (19–21). In addition, tamoxifen can cause reactivation of adenomyosis in the inner layer of the myometrium, adjacent to the endometrium, causing apparent endometrial thickening on transvaginal US scans. This entity is usually associated with overlying endometrial atrophy, which can be distinguished only after sonohysterography demonstrates that the abnormality is localized to the inner myometrium rather than the endometrium (Fig 28). It is not always easy to identify the normal overlying endometrium because this process can occasionally distort the endometrial-myometrial interface. In these cases, the concern for endometrial hypertrophy should be raised and endometrial sampling performed (22).
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Figure 27a. Tamoxifen-associated endometrial lesion. (a) Transvaginal US scan of an asymptomatic patient receiving tamoxifen reveals a markedly thickened, heterogeneous endometrial stripe (arrowheads) with multiple cystic areas (arrows). (b) Subsequent sonohysterogram clearly shows a focal polypoid lesion containing multiple cysts (P). The remainder of the endometrium was normal in thickness (arrowheads). Pathologic analysis revealed an endometrial polyp.
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Figure 27b. Tamoxifen-associated endometrial lesion. (a) Transvaginal US scan of an asymptomatic patient receiving tamoxifen reveals a markedly thickened, heterogeneous endometrial stripe (arrowheads) with multiple cystic areas (arrows). (b) Subsequent sonohysterogram clearly shows a focal polypoid lesion containing multiple cysts (P). The remainder of the endometrium was normal in thickness (arrowheads). Pathologic analysis revealed an endometrial polyp.
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Figure 28a. Tamoxifen-associated subendometrial lesion. (a) Transvaginal US scan of an asymptomatic patient receiving tamoxifen demonstrates an apparently thickened endometrial stripe (arrows). (b) Subsequent sonohysterogram reveals cysts (arrows) that are predominantly subendometrial. The patient also had a focal cystic polyp (P) that contained foci of hyperplasia.
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Figure 28b. Tamoxifen-associated subendometrial lesion. (a) Transvaginal US scan of an asymptomatic patient receiving tamoxifen demonstrates an apparently thickened endometrial stripe (arrows). (b) Subsequent sonohysterogram reveals cysts (arrows) that are predominantly subendometrial. The patient also had a focal cystic polyp (P) that contained foci of hyperplasia.
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Algorithmic Approach to Abnormal Uterine Bleeding
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To appropriately care for patients and obtain a prompt diagnosis, it is helpful to use an algorithmic approach in the work-up of patients with abnormal uterine bleeding. These patients may be divided into three specific groups, each with a different clinical work-up: patients with postmenopausal bleeding, patients receiving estrogen replacement therapy, and patients undergoing tamoxifen therapy.
In patients with postmenopausal bleeding, transvaginal US should be the initial examination performed. If the endometrium measures less than 4 mm on transvaginal US scans, endometrial atrophy is assumed to be the cause of the postmenopausal bleeding. However, if the patient continues to have abnormal bleeding, continued follow-up with transvaginal US or routine endometrial biopsy should be performed. If the endometrium measures greater than 4 mm or is not visualized at transvaginal US, sonohysterography is recommended for further evaluation. A single-layer thickness of the endometrium of less than 2.5 mm is considered diagnostic of endometrial atrophy. Diffuse thickening of the endometrium of more than 2.5 mm at sonohysterography suggests a diffuse endometrial lesion, and routine endometrial biopsy should provide an adequate specimen for diagnosis. When focal endometrial abnormalities are identified, hysteroscopically guided resection of the abnormality is required to prevent sampling error related to the nonspecific routine endometrial biopsy (Fig 29) (1–3,14).
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Figure 29. Algorithm for a patient presenting with postmenopausal bleeding (PMB). TVUS = transvaginal US, ENDO = endometrium, SONO HSG = sonohysterography, F/U = follow-up. (Adapted from reference 14.)
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Asymptomatic postmenopausal patients undergoing transvaginal US for the purpose of surveillance because of hormone replacement therapy or tamoxifen therapy are managed slightly differently compared with patients with postmenopausal bleeding. In patients receiving hormone replacement therapy, many observers allow the double-layer thickness of the endometrium to be up to 6 mm on transvaginal US scans before performing a more specific evaluation with biopsy and/or sonohysterography, provided the endometrial stripe remains smooth and homogeneous. In patients receiving sequential hormone replacement therapy, if the endometrial stripe is thicker than 6 mm at transvaginal US but otherwise normal, reimaging earlier in the hormonal cycle may eliminate the need for additional evaluation (Fig 30) (23). Some observers even suggest performing histologic sampling in asymptomatic patients undergoing hormone replacement therapy when the endometrial thickness is greater than 4 mm (4,24). Patients receiving tamoxifen therapy who are found to have abnormally thick or irregular endometrial stripes are often cared for more aggressively because of the higher prevalence of neoplasia in this subgroup of patients (Fig 31) (25). Dilation and curettage provides a more complete method of endometrial sampling than routine endometrial biopsy alone in cases of focal endometrial lesions or abnormalities of the endometrial-myometrial interface.
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Figure 30. Algorithm for a patient receiving estrogen replacement therapy (ERT) with an abnormal endometrial appearance at transvaginal US (TVUS). ENDO = endometrium, SONO HSG = sonohysterography, F/U = follow-up. (Adapted from references 14 and 26.)
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Figure 31. Algorithm for a patient receiving tamoxifen. There is little role for routine biopsy in this higher risk population. TVUS = transvaginal US, ENDO = endometrium, SONO HSG = sonohysterography, ABNL ENDO/MYO INT = abnormal endometrial-myometrial interface, F/U = follow-up. (Adapted from reference 22.)
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Conclusions
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Sonohysterography has become the standard test in the imaging evaluation of dysfunctional uterine bleeding and postmenopausal bleeding because it allows reliable differentiation between focal and diffuse endometrial lesions. The most common findings are polyps and submucosal fibroids. Although these focal lesions have characteristic features that are well defined, a wide range of appearances is possible, with significant overlap between the various entities. It is essential for the radiologist to be familiar with the broad spectrum of findings that may be seen at sonohysterography in both benign and malignant processes to raise the appropriate level of concern and to direct the clinician toward the appropriate means of diagnostic biopsy or surgery.
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References
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Abstract
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