Postmenopausal Vaginal Bleeding and Endometrial Thickening

A common indication for postmenopausal sonography is —

postmenopausal vaginal bleeding (PMB)

— are among the differential abnormalities that can be linked to vaginal bleeding in the postmenopausal population

Endometrial atrophy, uncontrolled HRT, endometrial hyperplasia, endometrial polyps, submucosal or intracavitary leiomyoma, endometrial carcinoma, and some ovarian tumors

HRT will influence the sonographic appearance of the —

endometrium

Transvaginal sonography has been reported to be highly effective, with a sensitivity of up to 95% for detecting endometrial carcinoma when an endometrial thickness threshold of — is used for the patient with PMB

4 to 5 mm

If the endometrium measures less than —, the bleeding is typically caused by endometrial atrophy

5 mm

if the endometrium exceeds —, endometrial biopsy is warranted

5 mm

The asymptomatic patient, or those with no vaginal bleeding, can have an endometrial thickness of up to —

8 mm

Negative postmenopausal vaginal bleeding: normal endometrial thickness (mm)

< 8

Positive postmenopausal vaginal bleeding: normal endometrial thickness (mm)

< 5

Normal postmenopausal endometrium. This endometrium (between calipers) appears thin and echogenic.

In the postmenopausal patient, the endometrium often bleeds spontaneously secondary to

atrophy

the most common cause of PMB is

endometrial atrophy

with endometrial atrophy the endometrium will appear thin and should not exceed —, although with atrophy the endometrium typically measures 4 mm or thinner

5 mm

A — in the postmenopausal patient usually does not warrant endometrial biopsy

thin endometrial stripe

— is a common cause of abnormal vaginal bleeding, not only in the postmenopausal female but also in the reproductive years.

Endometrial hyperplasia

Endometrial hyperplasia results from the —

unopposed stimulation of estrogen on the endometrium

Endometrial hyperplasia may also be caused by —

polycystic ovary syndrome, obesity, tamoxifen therapy for breast cancer, or estrogen-producing ovarian tumors, such as the ovarian thecoma or granulosa cell tumor

There seems to be an increased risk for one form of endometrial hyperplasia (—) progressing into endometrial carcinoma more often in the postmenopausal woman.

atypical adenomatous hyperplasia

an endometrial biopsy is typically warranted to rule out —

endometrial carcinoma

Endometrial atrophy. Longitudinal transvaginal sonogram revealing a thin endometrium (arrowhead) measuring only 2 mm in a postmenopausal woman with vaginal bleeding, which is indicative for endometrial atrophy.

A thickened endometrium (between arrows) is demonstrated in this patient with endometrial hyperplasia.

clinical findings of endometrial hyperplasia

1. abnormal uterine bleeding (any age)

2. PCOS

3. obesity

4. tamoxifen therapy

sonographic findings of endometrial hyperplasia

1. Thickened echogenic endometrium

2. Small cystic spaces within the endometrium

— is the most common female genital tract malignancy, with PMB being the most common clinical presentation.

Endometrial carcinoma

Endometrial carcinoma is most often in the form of —

adenocarcinoma

endometrial carcinoma has been linked with

unopposed estrogen therapy, nulliparity, obesity, chronic anovulation, Stein–Leventhal syndrome, estrogen-producing ovarian tumors, and the use of tamoxifen

peak incidence at the time of diagnosis for endometrial carcinoma is

50 and 65 yeras of age

Tumors with penetration into the surrounding myometrium have a — than those confined to the endometrium

poorer prognosis

clinical findings of endometrial carcinoma

1. postmenopausal bleeding

2. intermenstrual bleeding

3. enlarged uterus

4. elevation of CA-125

ultrasound of Endometrial carcinoma

sonographic findings of endometrial carcinoma

1. Thickened endometrium

2. Heterogeneous uterus

3. Enlarged uterus with lobular contour

4. Endometrial fluid

5. Polypoid mass within the endometrium

Pulsed Doppler of the uterine cavity may indicate — in the presence of endometrial carcinoma

low-impedance flow

— are small nodules of hyperplastic endometrial tissue that may cause abnormal vaginal bleeding in both postmenopausal or perimenopausal woman

Endometrial polyps

Endometrial polyps have been linked with

infertility during the reproductive period

Endometrial polyps can have many different shapes, including a —

broad base, or can be pedunculated and, if large, may prolapse through the cervix.

Polyps are better visualized with the use of —

saline infusion sonohysterography

Treatment for endometrial polyps is typically a —

polypectomy with the use of hysteroscopy

A key clinical feature of patient with an endometrial polyp is —

intermenstrual bleeding.

clinical findings of endometrial polyps

1. asymptomatic

2. menometrorrhagia

3. intermenstrual bleeding

4. has been linked with infertility in reproductive-aged groups

A polyp is suspected in a patient with focal thickening of the endometrium

Saline (S) infusion sonohysterography better depicts the evidence of an endometrial polyp (arrow).

Three-dimensional endometrial polyp. A. Longitudinal image of a rounded mass (between arrows) within the endometrial cavity suggesting a polyp. B. Coronal reconstruction of the uterus (arrowheads) revealing the presence of a polyp (between calipers) within the endometrial cavity (arrows).

estrogen-producing tumors such as the thecoma, which is mostly benign, have been shown to cause —

abnormal thickening of the endometrium with subsequent vaginal bleeding

the malignant serous and mucinous cystadenocarcinomas have been associated with —

vaginal bleeding

— are often elevated in women who have some forms of cancer

Serum levels of CA-125

elevation of CA 125 has been linked with cancers of the —

ovary, endometrium, breast, gastrointestinal tract, and lung

CA125 may also be elevated in some benign conditions such as —

endometriosis, pelvic inflammatory disease, fibroids, and even pregnancy

— is a breast cancer drug that inhibits the effects of estrogen on the breast, thus slowing the growth of malignant breast cells.

Tamoxifen

Tamoxifen can also be used in the treatment of —

female infertility as well

tamoxifen use has been linked with the development of —

endometrial hyperplasia, endometrial polyps, and endometrial carcinoma.

Sonographically, tamoxifen will cause cystic changes to occur within the endometrium, and it produces a more —

heterogeneous and thickened endometrial appearance