PATHOLOGY OF THE UTERUS

These are the most common cystic lesions of the vagina and usually are found incidentally

during sonographic examination

Gartner Duct Cyst

Most common congenital abnormality of female genital tract is____________resulting in obstruction.

imperforate hymen

Obstruction of the uterus and/or vagina may result in the accumulation of fluid, blood, or pus. What are the MEDICAL TERMINOLOGY for fluid, blood, and pus?

Hydrometra, Hemantometra and Pyometra

________________is seen in hysterectomy patients after surgery.

• The upper size limit of a normal vaginal cuff is 2.1 cm.

• If the cuff is larger than this or contains a well-defined mass or

areas of high echogenicity, it should be regarded with suspicion

for malignancy, especially in the patient who has a previous

history of cancer.

• Nodular areas in the vaginal cuff may be due to post-irradiation

fibrosis.

The Vaginal Cuff

The ____________(posterior cul-de-sac) is the most posterior

and inferior reflection of the peritoneal cavity.

• Because of its location, it is frequently the site of intraperitoneal fluid

collections. As little as 5 mL of fluid has been detected by

transvaginal sonography.

• Fluid in the cul-de-sac is a normal finding in asymptomatic women

and can be seen during all phases of the menstrual cycle.

• Pathologic fluid collections may be associated with ascites, blood

resulting from a ruptured ectopic pregnancy, hemorrhagic cyst, or pus

resulting from an infection. Pelvic abscesses and hematomas can also

occur in the cul-de-sac.

• Sonographic characteristics help to differentiate these findings.

Rectouterine Recess

It is located between the rectum and uterus and is also called the____________?

Pouch of Douglas

• Lies posterior to bladder between lower uterine segment and vaginal canal

• The cervical canal extends from the internal os where it joins the uterine cavity, to

the external os, which projects into the vaginal vault.

• Cylindrical portion of uterus that enters vagina and measures 2 to 4 cm in length

Cervix

• Benign cysts in the cervix which result from chronic cervicitis and are seen frequently in middle-aged women. This cyst results from an obstructed dilated transcervical gland and is also called an epithelial inclusion cyst.

• Chronic inflammatory retention cysts

• Asymptomatic although may cause pain/bleeding with coitus

• On sonographic evaluation include:

• discrete

• round

• fluid-filled

• anechoic

• usually measuring less than 2 cm;

• they may be multiple.

• Occasionally, nabothian cysts may have internal echoes that may be caused by hemorrhage or infection.

Nabothian Cyst

• Present clinically with irregular bleeding.

• Benign condition arises from the hyperplastic protrusion of epithelium of

endocervix or ectocervix.

• Chronic inflammation most likely factor

• Polyps may be pedunculated, projecting out of cervix, or broad-based.

• Ultrasound may or may not see cervical polyps, depending on location.

Cervix Polyps

• Small percentage of leiomyoma (myoma tumors, fibroid

tumors) occur in cervix.

• When myoma is small, patient asymptomatic; as mass enlarges,

bladder or bowel obstruction may result

• Myoma may be pedunculated and prolapse into vaginal canal.

• Sonography may assist in determining the location and

thickness of the stalk.

• Fluid infusion with sonohysterography enhances visualization.

Cervical Leiomyoma

• Cervical stenosis is acquired condition.

• Obstruction of cervical canal at internal or external os resulting

from

• Radiation therapy

• Previous cone biopsy

• Postmenopausal cervical atrophy

• Chronic infection

• Laser or cryosurgery

• Cervical carcinoma

• Menopausal patient may be asymptomatic even though stenosis

can produce a distended, fluid-filled uterus (the result of an

accumulation of uterine secretions, fluid hydrometra, pyometra,

or hematometra).

• Intracavitary fluid collections can be readily seen on ultrasound

and may be indirect indicator of cervical stenosis.

• Premenopausal patients may experience abnormal bleeding,

oligomenorrhea, amenorrhea, cramping, dysmenorrhea, or

infertility.

Cervix Stenosis

• Squamous cell carcinoma is the most common type of cervical

cancer.

• Precursors are cervical dysplasias classified as mild, moderate, or

severe.

• When full thickness of epithelium composed of undifferentiated

neoplastic cells, lesion referred to as carcinoma in situ

• The detection of these abnormalities is attributed to screening with

Papanicolaou (Pap) smears because most of the early lesions are

asymptomatic.

• Advanced cervical cancer is usually evident clinically.

• Sonography may demonstrate a solid retrovesical mass, which may be

indistinguishable from a cervical myoma.

• Transvaginal and translabial ultrasound may demonstrate bladder,

ureteral, vaginal, or rectal involvement and may be used in staging

cervical cancer.

• CT and MRI are preferable because they are superior methods for

staging and evaluating lymphatic spread.

• Areas of increased echogenicity or hypoechoic areas with an irregular

outline signify changes compatible with cervical carcinoma.

• Ultrasound is also helpful in guiding biopsies of the cervix and vagina.

• Translabial or transperineal sonography may be used instead of or with

the transvaginal approach to help define the cervical area.

Cervical Carcinoma

Carcinoma in situ (in place), what stage is this?

Stage 0

Confined to the cervix, what stage is this?

Stage I

Extends beyond cx but not to pelvic wall, what stage is this?

Stage II

Extends to pelvic walls, what stage is this?

Stage III

Extends beyond the true pelvis, what stage is this?

Stage IV

What is the Differentail Consideration for the Uterus for ENLARGES UTERUS?

➢ Pregnancy

➢ Postpartum

➢ Leiomyoma

➢ Adenomyosis

➢ Bicornuate or didelphic uterus

Differential Considerations for the Uterus for UTERINE TUMOR?

➢ Leiomyoma

➢ Carcinoma

Differential Considerations for the Uterus for THICKENED ENDOMETRIUM?

➢ Early intrauterine pregnancy

➢ Endometrial hyperplasia

➢ Retained products of conception or incomplete abortion

➢ Trophoblastic disease

➢ Endometritis

➢ Adhesions

➢ Polyps

➢ Inflammatory disease

➢ Endometrial carcinoma

Differential Considerations for the Uterus for ENDOMETRIAL FLUID?

➢ Endometritis

➢ Retained products of conception

➢ Pelvic inflammatory disease

➢ Cervical obstruction

Differential Considerations for the Uterus for ENDOMETRIAL SHADOWING?

➢ Gas (abscess)

➢ Intrauterine device

➢ Calcified myomas or vessels

➢ Retained products of conception

– Incomplete development of one side of the

uterus leads to a unicornuate uterus (i.e., a

uterus with one tube)

– The uterus will appear small and more

lateral in position on sonogram

– A rudimentary horn may be visible

This is?

Unicornuate Uterus

This is?

Unicornuate Uterus

– Double vaginas, cervixes, and uteri function separately

– The two uteri are at approximately a 450 angle to one another

Uterus Didelphus

– Improper fusion leads to two partially or completely separate bicornuate uterine cavities.

– The uterus is heart-shaped

– Most common congenital uterine anomaly.

Bicornuate uterus

This is?

Bicornuate Uterus

– Two partially or completely separate endometrium form.

– The uterus is normally shaped

– Most common congenital uterine anomaly causing infertility.

Septate Uterus

 Also called Myomas, Fibroids, and Fibromyomas

 Most common pelvic tumor

 More common in African American women nulliparous (never borne offspring)

 Smooth muscle cell composition

 Liquefaction, necrosis, hemorrhage, and ultimate calcification may take place.

 Degeneration occurs when myomas outgrow their blood supply; calcification

 May be pedunculated

 Clinical symptoms include

➢ enlarged uterus

➢ profuse and prolonged bleeding

➢ pain

 Myomas are estrogen dependent and may increase in size during pregnancy, although about half of all

myomas show little change during pregnancy.

 Myomas identified in the first trimester are associated with an elevated risk of pregnancy loss, and

this risk is higher in patients with multiple myomas.

 They rarely develop in postmenopausal women, and most stabilize or decrease in size following

menopause because of a lack of estrogen stimulation.

 They may increase in size in postmenopausal patients who are undergoing hormone replacement

therapy.

 Tamoxifen has also been reported to cause growth in leiomyomas. A rapid increase in myoma size,

especially in a postmenopausal patient, should raise the level of concern for a neoplasm.

The signs and symptoms of leiomyomas depend on their size and location.

 Submucosal myomas may erode into the endometrial cavity and cause irregular

or heavy bleeding, which may lead to anemia.

 Fertility may be affected by submucosal or intramural myomas, which may

impede sperm flow, prevent adequate implantation, or cause recurrent miscarriages.

 It is particularly important to diagnose submucosal leiomyomas because they are a

well-established cause of dysfunctional uterine bleeding, infertility, and

spontaneous abortion. Small submucosal leiomyomas may be removed

hysteroscopically (a fibroid removal treatment).

 Uncommonly, a pedunculated subserosal lesion develops a long stalk and is

migratory; it can implant into the blood supply of the broad ligament, omentum, or

the bowel mesentery.

 Transvaginal sonography is often helpful in showing the uterine origin of the

mass and identifying the stalk. Occasionally, a pedunculated myoma becomes

adherent to surrounding structures and develops an auxiliary blood supply.

Sonographic Findings of Leiomyomas

• Uterine enlargement or irregular uterine wall contour with a heterogeneous myometrial texture pattern.

• Look for contour distortion along the interface between the uterus and bladder.

• The myomas alters the normal homogeneous myometrium

• Myomas can be associated with endometrial infection and cancer.

• Blood debris and polyps can artifactually widen the endometrium; therefore definitive diagnosis of the

cause of abnormal bleeding require an endometrial biopsy.

• Cystic degeneration can occur during pregnancy and cause pain. Doppler should be used to assess

the vascularity of myomas.

 The sonographic study should include measurement of the uterus in three dimensions: (1) cervix to

fundus, (2) widest anteroposterior diameter, and (3) widest transverse diameter at fundus diameter.

 The texture of the myoma (calcific, complex, or anechoic), size, and location are described.

Individual myomas are measured if they are discrete.

 The shape of the endometrial complex and its thickness are also described; alterations in the

endometrial border will be evident if a myoma is present. This is especially important in women with a

history of abnormal bleeding.

 Myomas can be associated with endometrial infection or cancer. Blood debris and polyps can

artifactually widen the endometrium; therefore, definitive diagnosis of the cause of abnormal bleeding

might require an endometrial biopsy or sonohysterography.

 Although ultrasound is used to identify myomas in women with abnormal bleeding, uterine

enlargement, or infertility, MRI—with its tissue differentiation characteristics—can be more

sensitive for evaluating the exact location, size, and number of myomas.

Tamoxifen is a ___________drug.

Breast Cancer

Leiomyomas can be_______________________?

Submucosal, Intramural, Subserosal

(displacing or distorting endometrial cavity with subsequent irregular or heavy menstrual bleeding, Infertility)

What kind of Leioyomas can this be?

Submocosal

(confined to myometrium; most common type): may enlarge to cause pressure on adjacent organs; Infertility or recurrent pregnancy loss.

What kind of Leioyomas can this be?

Intramural

(projecting from the peritoneal surface of uterus): Can become pedunculated and appear as extrauterine masses, may enlarge to cause pressure on adjacent organs

What kind of Leioyomas can this be?

Subserosal

1?

Intramural

2?

Pedunculated

3?

Intracavitary

4?

Suberous

5?

Submuscosal

What is the Treatment of Myomas?

 In case of infertility and submucosal myoma, surgery by myomectomy often treatment of

choice

 In cases of menorrhagia, women now have several choices:

➢ Least invasive treatment is hormonal suppression to stop bleeding.

➢ Endometrial ablation uses radiofrequency, microwaves, freezing, or heating ablative technology to ablate or

remove the endometrium and any small surrounding myomas.

➢ Uterine artery embolization (UAE) Small plastic particles are injected into the blood supply to the myoma to

terminate flow.

➢ High intensity focused ultrasound (HIFU) High-intensity focused ultrasound (HIFU) involves the

application of “therapeutic” sonic waves to the uterus and myoma. The myoma is ablated by heating the

tissue and causing tissue death.

➢ Hysterectomy

 Rare, solid tumor arising from myometrium or endometrium

 Commonly in fundus of uterus

 Most common in women 40 to 60 years of age

 Rapid growth

 Sarcoma botryoides: very rare condition in children characterized by

grapelike clusters of tumor mass

Sonographic findings

 Leiomyosarcoma may resemble myomas or endometrial carcinoma with

features of solid or mixed-solid and cystic texture.

 Clinically, rapid enlargement of solid uterine mass in perimenopausal or

postmenopausal patient raises concern about development of

malignancy.

Uterine Leiomyosarcoma

 Myomas are the most common cause of uterine calcifications.

 A less common cause is arcuate artery calcification in the periphery of the uterus.

 These calcifications are thought to occur as a consequence of calcific sclerosis within these vessels

and can indicate underlying diseases, such as diabetes mellitus, hypertension, and chronic renal

failure. Such calcifications have been termed Monckeberg arteriosclerosis and appear in arteries

throughout the body.

 Sonographic Findings:

➢ Focal areas of increased echogenicity

➢ Shadowing

➢ Peripheral echogenic rim.

Uterine Calcifications

 Benign disease

 Diffuse or focal

 Global infiltration of endometrium

 Sonographically presents as bulky enlarged uterus without focal mass

 Adenomyosis is ectopic occurrence of endometrial tissue within myometrium; more common in

posterior aspect

 The tissue penetration usually reaches a depth of at least 2.5 mm from the basal layer of the

endometrium.

 Adenomyosis may arise from multiple pregnancies and deliveries with subsequent uterine shrinking.

Elevated estrogen levels may also promote the growth of myometrial islands of endometrial tissue.

 Adenomyosis is often classified into diffuse and focal forms. The more common form is diffuse

adenomyosis.

 It represents a reactive hypertrophy of the myometrial muscle, which produces uterine enlargement

but usually not to the extent seen with leiomyomas.

 Focal adenomyosis is sometimes called adenomyoma, referring to isolated implants that typically

cause reactive hypertrophy of the surrounding myometrium and produce diffuse uterine enlargement.

 Less common than the diffuse form, focal adenomyosis (adenomyoma) lacks a hypoechoic border that

is seen with fibroids, not endometriosis. Adenomyosis can be appropriately managed with hormone

therapy.

 Patients with adenomyosis are often multiparous and older than patients with endometriosis.

 The patient presents with heavy, painful abnormal menses, and on physical examination, the uterus is

found to range from normal to three times normal size and is globular in contour, boggy, and

somewhat tender.

 Hypermenorrhea

➢ Abnormal uterine bleeding

 Menorrhagia

➢ Prolonged/profuse uterine bleeding

 Metrorrhea

➢ Irregular, acyclic bleeding

 Dysmenorrhea

➢ Pelvic pain during menstruation

 Sonographically, diagnosis may be difficult.

 Most common presentation of extensive adenomyosis is:

➢ Diffuse uterine enlargement

➢ Thickening of posterior myometrium

➢ Indistinct border between endometrium and myometrium (involved area being slightly more

anechoic than normal myometrium)

 Has been described as Swiss cheese or honeycomb pattern

 Calcifications resulting from prior instrumentation are seen along inner myometrium and cervix.

 Doppler studies have also proven helpful in differentiating uterine pathology, as color flow studies of

uterine masses show that myomas and sarcomas typically demonstrate a feeding artery, but

adenomyosis rarely demonstrates feeding arteries.

 Adenomyosis is not always reliably diagnosed by ultrasonography, and

caution is advised because these findings are similar in appearance to

uterine myomas, muscular hypertrophy, myometrial contractions,

endometritis, endometrial carcinoma, and the presence of increased

endometrial secretions.

 The presence of myomas has been shown to limit the ability to diagnose

the severity of adenomyosis.

 Although not reliably diagnosed by ultrasonography, adenomyosis is well

characterized by MRI, which currently is thought by many to be the

best technique for the presurgical diagnosis of adenomyosis.

Adenomyosis

-consist of vascular plexus of arteries and veins

without intervening capillary network.

 Rare; usually involving myometrium and rarely endometrium

 Congenital or teratogenic (acquired) due to pelvic trauma, surgery, or gestational

trophoblastic neoplasia

 Clinically, women of childbearing years have metrorrhagia with blood loss and anemia.

 Diagnosis critical because dilation and curettage may lead to catastrophic hemorrhaging

Sonographic findings

 Sonographically, serpiginous, anechoic structures seen within the pelvis

 Uterine AVMs may appear as subtle myometrial inhomogeneity, tubular spaces within myometrium,

intramural uterine mass, endometrial or cervical mass

 Color Doppler diagnostic to show blood flow within anechoic structures

 May be florid-colored mosaic pattern with apparent flow reversals and

areas of color aliasing

 Spectral Doppler shows high-velocity, low-resistance arterial flow

coupled with high-velocity venous flow with arterial component.

Arteriovenous Malformations

What is the landmark for identification of long axis of uterus?

Endometrial canal

Echogenicity of endometrial tissue is?

compared with homogeneous, medium-level echogenicity of middle

layer of myometrium.

The endometrium should be measured?

perpendicular to the long axis of the uterus.

What is the measurement of the endometrium?

The calipers should be placed at the maximum anterior to posterior diameter of the outer borders, from echogenic border to echogenic border.

 The hypoechoic halo surrounding the endometrium should not be included in the measurement because this represents the inner compact layer of myometrium.

 Fluid, if present, should not be included in endometrial measurements.

What is the Endometrial thickness (mm) for MENSTRUAL CYCLE?

2-3

What is the Endometrial thickness (mm) for EARLY PROLIFERATIVE PHASE?

4-6

What is the Endometrial thickness (mm) for PERIOVULATORY PHASE?

6-8

What is the Endometrial thickness (mm) for SECRETORY PHASE

8-15

Abnormally thick endometrium results from variety of condition: ?

➢ Early intrauterine pregnancy

➢ Gestational trophoblastic disease

➢ Endometrial hyperplasia

➢ Secretory endometrium

➢ Estrogen replacement therapy

➢ Polyps

➢ Endometrial carcinoma

Many endometrial pathologies, such as hyperplasia, polyps and carcinoma, can cause abnormal leeding, especially in postmenopausal patient.

___________is a common condition in which functioning endometrial tissue is present outside the

uterus.

 The ectopic tissue can be found almost anywhere in the pelvis, including the ovary, fallopian tube,

broad ligament, the external surface of the uterus, and scattered over the peritoneum, cul-de-sac, and

even the bladder.

 The endometrial tissue cyclically bleeds and proliferates.

 In the diffuse form, this leads to disorganization of the pelvic anatomy with an appearance similar to

PID or chronic ectopic pregnancy.

 Two forms of endometriosis have been described: diffuse and localized (endometrioma).

 The diffuse form is more common, consists of endometrial plantings within the peritoneum, and is

rarely diagnosed by sonography.

 The localized form consists of a discrete mass called an endometrioma, or chocolate cyst, and can

frequently be found in multiple sites. The patient with an endometrioma is usually asymptomatic.

Sonographic Findings

 Endometriosis may appear as bilateral or unilateral ovarian cysts with patterns

ranging from anechoic to solid, depending on the amount of blood and its

organization (Fig. 44.19).

 The ovaries are typically adherent to the posterior surface of the uterus or stuck in the

cul-de-sac and may be intimately associated with the rectosigmoid colon and difficult

to define.

 Obscured organ borders and multiple irregular cystic masses also suggest either

disseminating cancer or pelvic infection, and the clinical picture and serial

sonographic studies determine when and if exploratory surgery is indicated.

 Clinical findings include severe dysmenorrhea, chronic pelvic pain from peritoneal

adhesions and bleeding, or dyspareunia

 Endometrioma

 Sonographic Appearance

➢ Well-defined unilocular or multilocular

➢ Predominantly cystic mass containing

➢ Diffuse homogeneous, low-level internal echoes (Fig. 44.20).

➢ Occasionally a fluid-fluid level can be seen.

➢ Small linear hyperechoic foci may be present in the wall and are thought to be

cholesterol deposits accumulating in the cyst wall.

 Clinical symptoms help to differentiate endometriosis from a

hemorrhagic ovarian cyst, ovarian neoplasm, or tubo-ovarian abscess.

Endometriosis

 Disorders of endometrium may also occur in menopausal patients with breast cancer

receiving tamoxifen therapy.

 Tamoxifen is a partial estrogen receptor antagonist used in postmenopausal women

with estrogen receptor positive breast cancer.

 The effects on the uterus include epithelial metaplasia, hyperplasia, and even

carcinoma. In these patients, transvaginal scanning may show thickened, irregular

cystic endometrium. These patients frequently have biannual serial ultrasound

examinations of their uterus and endometrium. A biopsy is performed in suspicious

cases.

This is the ___________

PATHOLOGY OF THE ENDOMETRIUM

 Two possible explanations for the cause of endometriosis are presented.

 The first is that the chronic retrograde flow of menstrual fluid through the tubes and into

the pelvis may produce implantation and proliferation of endometrial cells with cyclic

bleeding. This is the “transtubal migration” theory.

 The second theory involves the evaluation of endometrial activity in susceptible cells that

retain the embryonic capacity to differentiate in response to hormonal stimulation. The

resulting tissue bleeds and proliferates with the resultant production of pain, scarring, and

endometrium-lined collections of blood known as endometriomas.

 Endometriosis may occur in any menstruating female.

 Clinical symptoms include painful periods (dysmenorrhea) or painful intercourse

(dyspareunia); lower abdominal, pelvic, and back pain; irregular bleeding; and infertility

secondary to adhesions and fibrosis.

Endometriosis & Endometrioma

This is ?

Endometriosis

This is?

is the most common cause of abnormal uterine bleeding in

both premenopausal and postmenopausal women. Hyperplasia develops from

unopposed estrogen stimulation.

 It appears as a thickening of the endometrium.

 In premenopausal women, if the endometrium measures more than 14 mm (double

thickness), hyperplasia is suggested.

 The optimal time period for this assessment in a woman still having menses is day 6

through day 10, after bleeding and before the endometrium is again stimulated.

 In asymptomatic postmenopausal women, 8 mm (double thickness) is the upper limit of

normal. However, women on sequential estrogen and progesterone replacement

regimens may have endometrial thickness up to 15 mm during the estrogen phase; the

thickness decreases after progesterone is added.

 Ideally a woman using sequential hormones should be studied at the beginning or

end of her hormone cycle, when the endometrium is theoretically at its thinnest.

 Hyperplasia is less common during the reproductive years, but it may occur with

persistent anovulatory cycles, with polycystic ovarian disease, and in obese women

with increased production of endogenous estrogens.

 Hyperplasia may also be seen in women with estrogen-producing tumors, such

as granulose cell tumors and thecomas of the ovary.

 Because hyperplasia has a nonspecific sonographic appearance, an endometrial

biopsy is necessary for diagnosis. Sonohysterography can also be performed to

evaluate the internal structure of the endometrial canal.

 Most women with postmenopausal uterine bleeding are experiencing endometrial

atrophy.

 On transvaginal sonography, an atrophic endometrium is thin, measuring less than

5 mm.

 If the postmenopausal patient has irregular bleeding and a thickened endometrium,

this may warrant a sonohysterography procedure or an endometrial biopsy.

 Ultrasound is used to help the clinician triage which patients are candidates for

biopsy. Clinicians may use the endometrial measurement alone (for example, greater

than 5 to 8 mm without bleeding), or they may use symptoms as their criteria (for

example, less than 5 to 8 mm with bleeding).

Sonographic Findings

 The endometrium is usually diffusely thick and echogenic with well-defined margins.

 Focal or asymmetric thickening can occur. Small cysts representing dilated cystic

glands may be seen within the endometrium.

 Although cystic changes within a thickened endometrium are more frequently

witnessed in benign conditions, they can also be observed in endometrial carcinoma.

Endometrial Hyperplasiaa

Patient with ________can be asymptomatic, or they may present with uterine

bleeding.

 Histologically, polyps are overgrowths of endometrial tissue covered by epithelium.

 They contain a variable number of glands, stroma, and blood vessels. Approximately 20% of

endometrial polyps are multiple.

 They may be pedunculated, be broad-based, or have a thin stalk.

 They typically cause diffuse or focal endometrial thickening and are more frequently seen in

perimenopausal and postmenopausal women.

 In menstruating women, they may be associated with menometrorrhagia or infertility.

 In postmenopausal women, especially those being investigated for bleeding, the major

differential considerations are hyperplasia, submucosal myomas, or, less commonly,

endometrial carcinoma.

Sonographic Findings

 Sonographically, polyps appear toward the end of the luteal phase and are represented by a

hypoechoic or isoechoic region within the hyperechoic endometrium.

 They initially may appear as nonspecific echogenic endometrial thickening.

 The polyp may be diffuse or focal and may also appear as a round echogenic mass within the

endometrial cavity.

 Cystic areas representing histologically dilated glands may be seen within a polyp.

 A feeding artery in the pedicle may be identified with color Doppler.

 Individual polyps are better visualized when outlined by intracavitary fluid.

 Sonohysterography is a valuable technique when transvaginal sonography is unable to differentiate an

endometrial polyp from a submucosal leiomyoma. Color Doppler sonohysterography can be

particularly useful in discriminating polyps from submucosal myomas based on the presentation of

feeding vessels. Polyps present most often with one primary feeding vessel, whereas myomas typically

have multiple microvessels arising from the inner myometrium.

Endometrial Polyps

 Endometrial thickening or fluid may indicate _______________ ?

 ………… is an infection within endometrium of the uterus.

 It occurs most often in association with PID, in postpartum state, or following

instrumentation of uterus.

 In patients with pelvic infection, uterus is conduit for infectious spread to tubes and

adnexa.

 Postpartum patients may develop endometritis after prolonged labor, vaginitis,

premature rupture of the membranes, or retained products of conception.

 Clinically, patient has intense pelvic pain.

 Sonographically, the endometrium appears prominent, irregular, or both, with a

small amount of endometrial fluid.

 Pus may be demonstrated in the cul-de-sac as echogenic particles or debris.

 Enlarged ovaries with multiple cysts and indistinct margins may be seen secondary

to periovarian inflammation.

 Dilation of the fallopian tube shows fluid-filled tubular shapes in a folded

configuration and well-defined echogenic walls.

 A thickened tubal wall (5 mm or more) indicates acute disease. These should be

distinguished from a fluid-filled bowel by gentle compression on the pelvic wall to

look for peristalsis or movement in the bowel lumen.

Sonographic findings

 Endometrium may appear thick, contain fluid, air or clot or appear

normal.

 Endometrium considered normal up to 20 mm.

 Measurement of >20 mm should raise suspicion of endometritis,

hemorrhage, or retained products of conception.

 Risk for endometritis increases with premature rupture of

membranes, retained clot or POCs and prolonged labor.

 As the infection worsens, periovarian adhesions may form and fuse the inflamed tube and

ovary, called the tubo-ovarian complex.

 Further progression results in a tubo-ovarian abscess that appears as a complex

multiloculated mass with septations, irregular shaggy margins, and scattered internal echoes.

 There can be posterior enhancement and a fluid-debris level. Gas bubbles are present in rare

cases; however, these also are observed in normal postpartum patients.

 In the immediate postpartum period, the presence of retained tissue is difficult to distinguish

from inflammatory debris or blood clots.

 The sonographic appearance can be similar to that of other adnexal masses, so clinical

correlation is important.

 Sonography can also be useful in following the response to antibiotic therapy or in guided

transvaginal aspirations and drainage. If the aspirate is purulent, catheter drainage is used.

Endometritis

 Intrauterine synechiae (endometrial adhesions, Asherman syndrome) are found in women with

posttraumatic or postsurgical histories, including uterine curettage. Synechiae can cause infertility

or recurrent pregnancy loss.

 Sonographic Findings: Ultrasonography may demonstrate bright echoes within the endometrial cavity

in this condition.

 The diagnosis is difficult unless fluid is distending the endometrial cavity. This is best identified

during the secretory phase when the endometrium is more hyperechoic.

 Synechiae are more easily observed in the gravid uterus, where they appear as a hyperechoic band

traversing the uterus from anterior to posterior.

 Sonohysterography is an excellent technique for demonstrating adhesions and should be performed in

cases of suspected adhesions. Adhesions appear as bridging bands of tissue that distort the cavity or as

thin, undulating membranes that connect from one side of the uterus to the other. Thick, broad-based

adhesions may prevent distention of the uterine cavity. Adhesions can be divided under hysteroscopy.

Synechiae

___________is the most common gynecologic malignancy in North America, and its

incidence has been rising.

 Most endometrial malignancies are adenocarcinomas occurring in postmenopausal patients.

 The most common clinical presentation is uterine bleeding, although only 10% of women with

postmenopausal bleeding will have endometrial carcinoma.

 There is a strong association with replacement estrogen therapy.

 In the premenopausal woman, anovulatory cycles and obesity are also considered risk factors.

 The earliest change of endometrial carcinoma is a thickened endometrium. An abnormally thick

endometrium is also associated with endometrial hypertrophy and polyps.

 Although increased endometrial thickness is an early finding in endometrial carcinoma,

enlargement with lobular contour of the uterus and mixed echogenicity are correlated with

more advanced stages of the disease. The risk of malignancy increases with the presence of a

large endometrial fluid collection or clinical symptoms, such as abdominal pain or bleeding.

 Endometrial carcinoma may obstruct the endometrial canal, resulting in hydrometra or hematometra.

 The level of myometrial invasion (superficial versus deep) also can be detected by transvaginal ultrasonography, although

contrast-enhanced MRI is more sensitive. MRI is also valuable in evaluating extrauterine extension and involvement of

lymph nodes.

 Tamoxifen, a nonsteroidal antiestrogen compound, is widely used for adjuvant therapy in premenopausal and

postmenopausal women with breast cancer and has secondary effects on the endometrium.

 An increased risk of endometrial carcinoma, hyperplasia, and polyps has been reported in patients on tamoxifen therapy. On

sonography, tamoxifen-related endometrial changes are nonspecific and similar to those described in hyperplasia, polyps, and

carcinoma. Because it may be difficult to distinguish the endometrial-myometrial border in many of these patients,

sonohysterography is valuable.

 Sonography may be helpful in staging carcinoma and in distinguishing between tumors limited to the uterus (stages I and II)

and those with extrauterine extension (stages III and IV). Both MRI and CT are useful in staging by demonstrating

lymphadenopathy and distant disease (stages III or IV). Endometrial biopsy is usually required for a definite diagnosis.

Sonographic Findings

 Transvaginal examination is helpful in screening for early changes of endometrial hyperplasia or carcinoma

by accurately measuring endometrial thickness.

 Sonographically, a thickened endometrium (greater than 4 to 5 mm, and this value varies institution to

institution) should be considered cancer until proven otherwise.

 Demonstration of myometrial invasion is clear evidence for endometrial carcinoma.

 Transvaginal ultrasonography demonstrates myometrial invasion as thickening and irregularity of the central

endometrial interface with echogenic or hypoechoic patterns combined with infiltration of hyperdense structures

in the myometrium.

 Cystic changes within the endometrium are more commonly seen in endometrial atrophy, hyperplasia, and polyps

but can also be seen with carcinoma.

 Endometrial masses containing numerous vascular branches with color imaging should also raise the level of

suspicion for carcinoma.

Endometrial Carcinoma

What may help distinguish between benign and malignant endometrial thickening?

Doppler Ultrasonography of the uterine artery

_____________is used to evaluate the resistive index (RI = peak systolic

− end diastolic/peak systolic) or pulsatility index (PI = peak systolic −

end diastolic/mean).

Pulsed Doppler

_____________(RI less than 0.4) has been found in patients with

endometrial carcinoma

Low Resistance flow

______________-(RI greater than 0.5) in normal or benign endometria.

High resistance flow

What are the common Regimens in Menopausal Women?

1. No hormones

2. 3. 4. Unopposed estrogen (usually Premarin); if uterus is present, unopposed estrogen is associated with increased

risk for endometrial hyperplasia or carcinoma.

Continuous/combined estrogen and progesterone (Premarin and Provera):

➢ Combination produces endometrial atrophy after 3 to 6 months.

➢ Usually no risk of endometrial cancer

➢ Women may have “breakthrough” bleeding during month and/or annoying progesterone side effects (i.e., irritability, depression, bloating,

breast tenderness)

Sequential estrogen and progesterone (Premarin first half, then Provera second half of month)

➢ Women have predictable withdrawal bleeding at end of each month.

What are the beneficial effects of ESTROGEN?

 Alleviates menopausal symptoms (hot flashes, night sweats, painful intercourse)

 Reduces risk of osteoporosis, vertebral and hip fractures

 Reduces risk of heart attacks, strokes

What are the beneficial effects of PROGESTERONE?

 Produces endometrial atrophy

 Reduces risk of endometrial hyperplasia/cancer

What are the Negative effects of the ESTROGEN?

 Increases risk of endometrial hyperplasia/cancer

What are the Negative effects of the PROGESTERONE?

 Increases risk of breast cancer

 Causes irritability, depression, breast tenderness in some women

____________________also occur with ectopic pregnancy,

endometritis, degenerating myomas, and recent abortion.

 Sonographic Findings: Transvaginal sonography, with its improved resolution,

sometimes shows tiny endometrial fluid collections not seen on transabdominal

scans.

 ………………………. (less than 2 mL) are common in women

during the menstrual phase of the cycle. They are seen in postmenopausal

women, especially during the menstrual phase in women taking sequential

hormones.

 In a uterus with a fluid collection, the anteroposterior diameter of the fluid should be

subtracted from the endometrial measurement for a true assessment of endometrial

thickness.

Small Endometrial Fluid Collections

should be regarded with suspicion.

 Obstruction of the cervical os results in the accumulation of secretions, blood, or both in the

uterus.

 Before menstruation, the accumulation of secretions is referred to as hydrometrocolpos.

 Following menstruation, hematometrocolpos results from the presence of retained menstrual

blood.

 The obstruction may be congenital, imperforate hymen (most common), vaginal septum,

vaginal atresia, or a rudimentary uterine horn. Hydrometra and hematometra may also be

acquired as a result of cervical stenosis from endometrial or cervical tumors or from post-

irradiation fibrosis.

 They may also be caused by uterine, cervical, tubal, or ovarian carcinoma. Hyperplasia and

polyps also cause endometrial fluid collections, so these collections also indicate increased risk of endometrial carcinoma.

 However, large amounts of endometrial fluid also are associated with benign conditions,

such as congenital anomalies or cervical stenosis from prior instrumentation or childbirth.

 The patient typically complains of abdominal pain and has an enlarged abdominal mass. She

may or may not have vaginal bleeding. The presence of fever suggests infection of the blood

collection.

 Laboratory results show an elevated white blood cell count. In simple hematometra, the

uterine cavity returns to normal promptly after dilation and curettage. Pyometra is more

likely to occur with uterine cancer. Abnormal development of the vagina or uterus may

result in a cystic uterine or vaginal collection of mucus in children. When menstruation

begins, the collection consists of blood.

 Sonographic Findings: The sonographic picture of large endometrial cavity fluid collections

is that of a centrally cystic, round, moderately enlarged uterus. This may contain echogenic

material if pus or blood is present.

Large Endometrial Fluid Collection