Unit 2

A thickened endometrium may be a sign of:

• Early intrauterine pregnancy

• Gestational trophoblastic disease

• Endometrial hyperplasia

• Secretory endometrium

• Estrogen replacement therapy

• Polyps

• Tamoxifen/HRT

• Endometrial cancer

What is this image showing?

Thickened Endometrium

What is this image showing?

Thickened Endometrium

Endometrial hyperplasia is caused by:

Unopposed estrogen stimulation

What is unopposed estrogen?

Estrogen dominance, there isn’t enough progesterone produced to keep up with the amount of estrogen.

A premenopausal patient with endometrial hyperplasia, would have an endometrial thickness of _______.

+14mm

An asymptomatic postmenopausal patient with endometrial hyperplasia, could expect to have an endometrial thickness of _______.

8mm {upper normal limit}

A patient with endometrial hyperplasia on sequential estrogen & progesterone, could expect to have an endometrial thickness of _______.

15mm

What is the most common cause of pre & postmenopausal abnormal bleeding?

Endometrial Hyperplasia

Endometrial Hyperplasia is a possible precursor of ___________ _______.

Endometrial Cancer

What is this image showing?

Endometrial Hyperplasia

What is this image showing?

Endometrial Hyperplasia

What are endometrial polyps?

Overgrowth of endometrial tissue

What symptom is common with endometrial polyps?

Vaginal bleeding

What is this image showing?

Endometrial polyps

What are these images showing?

Endometrial polyps

What is endometritis?

Inflammation / infection of the endometrium

Endometritis most commonly occurs in association with…

• PID

• Postpartum

• Following instrumentation of the uterus

What is the ultrasound appearance of Endometritis?

• Thickened endometrium

• Irregular endometrium

• Endometrial fluid

• “Gas”

• Retained tissue

Most endometrial carcinomas are _____________ occurring in _____________ patients.

Adenocarcinoma, Perimenopausal

Endometrial carcinoma has a strong association with…

Estrogen replacement therapy

What is the earliest sign of endometrial carcinoma?

Thickened endometrium

What are the advanced signs of endometrial carcinoma?

• Uterine enlargement with lobular contour

• Mixed echogenicity

• Endometrial fluid collections

• Abdominal pain

• Bleeding (postmenopausal)

If there is uterine enlargement, the carcinoma has invaded the ____________.

Myometrium

What evidence may support the diagnosis of endometrial carcinoma?

• Endometrial thickening

  • TV to measure thickness

• Myometrial invasion

  • Clear evidence for CA

• Synechiae/Asherman Syndrome

  • Bands of endo tissue

What is this image showing?

Endometrial Carcinoma

What is this image showing?

Endometrial Carcinoma

What is synechiae?

Fibrous adhesions across the endometrial cavity

• Walls become adhered to each other

• Various degrees of adhesions

What is another name for synechiae?

Asherman Syndrome

What may be a result from synechiae?

• Infertility

• Amenorrhea

• Oligomenorrhea

Patients with synechiae may have a history of _____ &/or ______.

D&C, abortion

What is the ultrasound appearance of synechiae?

Bright echoes within the endometrial cavity

What is this image showing?

Synechiae / Asherman Syndrome

What is considered Stage l of endometrial cancer?

• Confined to endometrium of body

  • B, C = myometrial extension

What is considered Stage ll of endometrial cancer?

Endometrium into cervix

What is considered Stage lll of endometrial cancer?

• Spread to pelvic area lymph nodes

  • Extended through the serosal layer

What is considered Stage lV of endometrial cancer?

• Mets to other organs

• Extension into bladder/bowel

• Distal lymph nodes

Differential Considerations for the Uterus: 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: endometrial fluid

• Endometritis

• Retained products of conception

• {PID} Pelvic inflammatory disease

• Cervical obstruction

What is this image showing?

A thickened endometrium

What flow has been seen in patients with endometrial carcinoma?

Low resistance {RI <.4}

What flow has been seen in postmenopausal patients with normal or benign endometrium?

High resistance {RI >.5}

Tumor vascularity is a _______ sensitive indicator than RI alone

More

What is the normal measurement for a small endometrial fluid collection?

< 2 ml

It is normal to find small endometrial fluid collections during the….

Normal menstrual cycle

With postmenopausal patients, when is it normal to see endometrial fluid collections?

• Sequential hormones

• Endometrial atrophy

Is the fluid collection included in the endometrial measurement?

No, do not measure the fluid collection

What is this image showing?

Small endometrial fluid collection

Large endometrial fluid collections can be ________, and should be investigated to find a cause.

Suspicious

A large endometrial fluid collection may be a sign of:

• PID

• Pyometra

• Hematometra

• CA’s

• Cervical stenosis

• Congenital anomalies

What is this image showing?

Large endometrial fluid collection

What is this image showing?

Cervical stenosis

• In a postmenopausal patient

What does IUD stand for?

Intrauterine device

What is an IUD?

Device inserted into the fundal portion of endometrial cavity

An IUD prevents ________ and may act as a _________ _______.

Implantation, spermicidal agent

An IUD placement is verified by the ______ __________.

String identification

If the string goes missing, an investigation for the location is needed?

True

What can be a result of a missing IUD?

• Expulsion

• Uterine perforation

  • Most likely at the time of insertion (1:1000)

What are the different types of IUD’s?

• Safety coil

• Lippe’s loop

• Copper T

• Dalkon shield

Copper T: ParaGard

Coppler/Plastic

Copper T: Progestasert

• Progesterone T

• Yearly replacement

Copper T: Mirena

• Levonorgestrel-releasing

• 5 years (50%)

Copper T: Skyla

• Levonorgestrel-releasing

• 3 years

What IUD is no longer used?

Dalkon shield

What is the ultrasound appearance of an IUD?

• Perpendicular placement of sound beam

• Echogenic linear appearance

• Acoustic shadowing

  • “Double line” of linear shaft

  • Shape identification

When IUD location identification is needed, where should you look?

• Within uterine cavity

• Within myometrium

• External to uterus

When the IUD is found within the uterine cavity, it can be occasionally obscured by a _______ ___________.

Thick endometrium

What is this image showing?

IUDC identification

What is this image showing?

IUDC identification

What is this image showing?

IUDC identification

What is this image showing?

IUDC identification

With a positive pregnancy test, what is extremely important?

Location

___% of pregnancies lost with extraction of IUD.

50

A transvaginal ultrasound is needed to find the exact location of the ________ ____ & _____.

Gestational sac, IUD

When perforation is suspected, what is needed and what may be the differential diagnosis?

• PG test

  • Neg = possible radiograph

• Bowel inflammation

• Peritonitis

With an IUD there is an increased risk of:

• Ectopic pregnancy (30%)

• Pelvic Inflammatory Disease

• Tubo-ovarian abscess

Tubo-ovarian abscess may be found __________ but is most commonly found __________.

Unilateral, bilateral

What is a uterine prolapse?

• Downward displacement of the uterus into the vaginal canal

  • Gradual descent of the uterus in the axis of the vagina taking the vaginal wall with it.

Uterine Prolapse: 1st degree

Cervix at lower uterine

Uterine Prolapse: 2nd degree

Cervix is at vaginal opening

Uterine Prolapse: 3rd degree

Uterus protrudes through the vagina

What is the etiology & precursors for prolapse?

• Stretching of muscle/fibrous tissue

• Increased intra-abdominal/pelvic pressure

• Menopause/Aging

What can cause: stretching of muscle / fibrous tissue.

• Pregnancy

• Childbirth

What can cause: increased intra-abdominal/pelvic pressure.

• Lifting

• Obesity

• Chronic cough

• ‘Chronic’ upright position

Menopause/Aging causes an _________ in ________.

Decrease, estrogen

A type of treatment for uterine prolapse is a _______ ________.

Vaginal pessary

• Soft, flexible device placed into the vagina to reduce the symptoms of prolapse

What are the surgery options for uterine prolapse?

• Repair supporting tissue for organ

• Repair the tissue around vagina

• Close the vaginal opening

• Hysterectomy

What are the preventative measures for uterine prolapse?

• Early detection

• Kegel exercises

What are differential considerations for an enlarged uterus?

• Pregnancy

• Postpartum

• Leiomyoma

• Adenomyosis

• Bicornuate or didelphic uterus

What are the differential considerations for a uterine tumor?

• Leiomyoma

• Carcinoma

What are Leiomyomas also known as?

Fibroids or Myomas

What is the most common benign gynecological tumor?

Leiomyomas

What is the US appearance of a Leiomyoma?

• Whorled, spherical shaped mass of myometrial tissue

• Degeneration may occur or can enlarge

• Multiple

• Pseudocapsule

What are the clinical symptoms of a leiomyoma?

• Enlarged uterus

• Pelvic Pressure

• Pain

• Irregular Bleeding

• Menorrhagia

A leiomyoma can cause infertility issues due to what location?

• Obstruction of tubes

• Obstruction of birth canal

During what process can an increased growth of a leiomyomas occur and what happens?

Pregnancy and bleeding withing fibroid may cause pain

What is a leiomyoma stimulated by?

Estrogen- receptive to hormones

What is the submucosal classification of a leiomyoma?

• Into the endometrial canal

• Deforms the endometrial canal

  • May cause irregular or heavy bleeding

What is the intramural classification of a leiomyoma?

• Within the myometrium

• Most common

What is the subserosal classification of a leiomyoma?

• Protrudes outward

• Pedunculated = extrauterine mass

  • Exophytic or Interligamentous

• May effect adjacent organs