(Radiographics. 1999;19:S117-S130.)
© RSNA, 1999
Sonohysterography: The Next Step in the Evaluation of the Abnormal Endometrium1
Johanna R. Jorizzo, MD,
Gioia J. Riccio, MD,
Michael Y. M. Chen, MD and
J. Jeffrey Carr, MD, MS
1 From the Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1088. Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received February 1, 1999; revision requested March 17 and received April 15; accepted April 15. Address reprint requests to J.R.J.
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Abstract
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Sonohysterography is a simple ultrasound (US) procedure that may be used to evaluate the endometrium. The technique involves placement of a 5-F catheter into the endometrial canal with subsequent instillation of sterile saline solution under US guidance. Fifty patients successfully underwent sonohysterography because of apparent abnormal endometrial thickening at transvaginal US, a nonspecific finding. Patients tolerated this procedure well, and no complications were encountered. In the 39 patients who proved to have endometrial pathologic conditions, sonohysterography demonstrated focal processes (polyps, carcinoma, hamartoma) in 15, diffuse processes (hyperplasia, secretory endometrium) in 21, and both focal and diffuse pathologic conditions in three. If a focal process can be delineated, a visually directed biopsy may be necessary. However, if the process is diffuse, a blind aspiration biopsy may be performed on an outpatient basis. In the majority of patients, the diffuse or focal nature of the disease could not be predicted on the basis of initial transvaginal US. Because sonohysterography allows distinction between diffuse and focal abnormalities, it provides physicians with a cost-effective way to plan the next step in case management.
Index Terms: Uterine neoplasms, 854.3199, 854.32 • Uterus, diseases, 854.3199 • Uterus, endometrium, 854.3199, 854.32 • Uterus, hemorrhage • Uterus, US, 854.1298
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INTRODUCTION
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Sonohysterography has been shown to be a safe, simple, and effective outpatient method for evaluating the potentially abnormal endometrium using transvaginal ultrasound (US) in an outpatient setting (1–4). An abnormally thick, irregular, or indistinct endometrium is often seen at pelvic US. The differential diagnosis is broad and includes diffuse processes (eg, endometrial hyperplasia, the secretory phase of the menstrual cycle) and focal diseases (eg, endometrial polyps, carcinoma). These entities are often indistinguishable from each other. Subendometrial pathologic conditions such as submucosal leiomyomas (fibroids) and adenomyosis may also manifest as apparent endometrial thickening. In addition, an atrophic endometrium is occasionally ill defined at initial US. Studies have shown that atrophy is the most common cause of postmenopausal bleeding (60% of cases) and is therefore an important diagnosis to establish (5).
Other studies have shown a high percentage of false-negative results at blind biopsy for focal pathologic conditions (5,6). With instillation of fluid into the endometrial canal, sonohysterography allows differentiation between focal and diffuse endometrial or subendometrial pathologic conditions, which often leads to a specific diagnosis. This differentiation helps the referring physician plan appropriate case management. In this article, we describe and illustrate the technique of sonohysterography and report our results in 50 patients who underwent this procedure for endometrial evaluation.
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MATERIALS AND METHODS
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Sonohysterography was performed in 53 patients with an abnormal or indistinct endometrium at transvaginal US (Fig 1). In three patients, sonohysterography was unsuccessful. Of the 50 patients in whom the procedure was successful, 32 were premenopausal and 18 were postmenopausal. All studies were performed by a radiologist (J.R.J., G.J.R.) and a US technologist in a gynecology office on an outpatient basis. Most patients referred by the gynecologists had a history of excessive premenopausal bleeding (29 of 32 cases) or postmenopausal bleeding (15 of 18). Three premenopausal patients were referred for a history of pelvic pain (n = 1), diabetes mellitus (n = 1), or obesity with anovulation (n = 1). Three postmenopausal patients were referred because of abnormal findings at a Papanicolaou test that suggested endometrial pathologic conditions. All patients were examined with an Acuson 128 XP10 US scanner and a 7.5-MHZ transvaginal probe (Acuson, Atlanta, Ga).
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Figure 1. Chart demonstrates how sonohysterography may be used to delineate the pathogenesis of an abnormal endometrium identified at transvaginal US. This information is helpful to the clinician in determining appropriate case management.
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In premenopausal patients, the diagnosis of an abnormally thickened endometrium is dependent on the phase of the menstrual cycle (Figs 2–5) (7). In general, a thickness greater than 8 mm during the proliferative phase or greater than 16 mm during the secretory phase is considered abnormal (7). The examination is best performed on day 4, 5, or 6 of the menstrual cycle, when the diameter of the endometrium should be thinnest (2).
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Figures 2-5. Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (arrowheads) (normal thickness, 1-4 mm). (3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6 mm). (4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometrium with a thickness of approximately 11 mm (arrows). (5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm).
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Figures 2-5. Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (arrowheads) (normal thickness, 1-4 mm). (3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6 mm). (4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometrium with a thickness of approximately 11 mm (arrows). (5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm).
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Figures 2-5. Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (arrowheads) (normal thickness, 1-4 mm). (3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6 mm). (4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometrium with a thickness of approximately 11 mm (arrows). (5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm).
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Figures 2-5. Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (arrowheads) (normal thickness, 1-4 mm). (3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6 mm). (4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometrium with a thickness of approximately 11 mm (arrows). (5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm).
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Postmenopausal patients who are undergoing sequential hormone therapy should also undergo evaluation when the endometrium is thinnest because cyclic changes are evident in these patients. Ideally, pelvic US and sonohysterography should be performed either early or late in the hormone cycle (ie, just after withdrawal bleeding or the progesterone phase [day 4, 5, 6, or 25]) (8,9). Postmenopausal patients who are not undergoing hormone replacement therapy or are undergoing either estrogen replacement therapy or combined estrogen and progesterone replacement therapy do not have substantial changes in endometrial thickness and may undergo evaluation at any time. Previous studies suggest a threshold of 8 mm in women with no postmenopausal bleeding as appropriate for exclusion of pathologic thickening. This threshold is lowered to 4 mm in patients with postmenopausal bleeding (Fig 6) (8,9).
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Figure 6. Fluid in the endometrial canal in a 70-year-old woman with postmenopausal bleeding. Sagittal transvaginal US scan shows a small amount of fluid in the endometrial canal, which must be subtracted from the endometrial measurement (A - b).
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When the endometrium is measured at US, care must be taken to exclude the adjacent hypoechoic myometrium and any fluid within the canal. Both walls are measured in the sagittal plane, at right angles to the long axis of the endometrial cavity, and at the fundus unless focal thickening is seen elsewhere (8).
With the use of these criteria for abnormal thickening, patients were selected for sonohysterography. Patients with indistinct endometria or focal thickening at initial transvaginal US also underwent evaluation. Active pelvic inflammatory disease was considered a contraindication for the procedure, and no patient with this clinical diagnosis was included in the study (2).
After a discussion of the procedure with the patient, the only preparation necessary was for the patient to empty the bladder. A speculum, preferably one with a sidearm screw to facilitate later removal without catheter displacement, was used to expose the cervix, which was then cleansed with an iodine swab (Fig 7). A sterile 5-F catheter, with or without an occlusive balloon, was flushed with sterile saline solution before being inserted through the cervical os to prevent the introduction of echogenic air bubbles, which could obscure the endometrium. Various catheter types may be used, including pediatric feeding tubes, intrauterine insemination catheters, and (most frequently in our study) the Goldstein sonohysterography catheter (Cook Ob/Gyn, Spencer, Ind). A 5-F catheter with a 2-mL balloon (ZSI Gynecology Products, Chatsworth, Calif) may be helpful in patients with a patulous cervix. However, this device may be uncomfortable for the patient and may obscure visualization of the lower uterine segment if it is not filled with saline solution and carefully placed in the endocervical canal. It is also more expensive and is not our initial choice.
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Figure 7. Photograph shows equipment used for sonohysterography, including several 5-F catheters (G = Goldstein sonohysterography catheter, P = 5-F pediatric feeding tube, Z = 5-F catheter with 2-mm-diameter balloon), sterile saline solution, ring forceps, speculum, and iodine swabs.
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Advancement of the catheter was aided by grasping the tip with a ring forceps and carefully threading it approximately 5–10 cm into the endometrial canal to position the tip beyond the endocervical canal. The speculum was then carefully removed while the catheter was left in place. Next, the covered transvaginal probe was inserted into the vagina, and continuous scanning in the sagittal and coronal or transverse planes was performed during instillation of sterile saline solution. Various amounts (5–20 mL or more) of saline solution were used depending on how much was retained within the canal; only 2–5 mL are actually needed to distend the cavity adequately. Cervical leakage is common, and it is helpful to have two 20-mL syringes of saline solution available for the procedure. The probe and catheter were then removed. Insertion of the speculum was the most uncomfortable portion of the examination, and most patients did not feel the catheter or fluid if it was instilled slowly.
We record our study on film—although a videotape recording system may be used—which allows for review of the study after its completion. The entire procedure usually takes 10–15 minutes, after which the patient may be sent home. None of our patients reported any immediate or delayed complications (1–4). Follow-up information was obtained from the patients' medical records.
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RESULTS
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As mentioned earlier, sonohysterography was unsuccessful in three of the 53 patients in whom the procedure was attempted. In one patient, cervical stenosis prevented advancement of the catheter through the cervical os. A second patient had a patulous cervix with nonretention of fluid. In this patient, who was seen early in the study, a balloon catheter was not utilized but may have been helpful. In the third patient, nonadvancement of the catheter may have been due to severe uterine anteversion. One can speculate that lower uterine leiomyomas or endometrial masses might also block catheter advancement.
Histopathologic correlation was obtained in 46 of the 50 patients who underwent successful sonohysterography, either by means of subsequent endometrial biopsy (n = 14) hysteroscopic resection (n = 10), hysterectomy (n = 12), or dilation and curettage (n = 10). In four patients, subendometrial leiomyomas (fibroids) were diagnosed on the basis of a characteristic US appearance with multiple additional fibroids but no histopathologic proof.
Endometrial pathologic conditions were present in 39 of 50 patients (78%). Focal pathologic conditions were demonstrated in 15 patients (30%): Seven premenopausal women had polyps, and eight postmenopausal women had polyps (n = 6), carcinoma (n = 1), or hamartoma (n = 1). Diffuse pathologic conditions in 21 patients (42%) included hyperplasia in 13 premenopausal patients, secretory endometria in four premenopausal patients, and hyperplasia in four postmenopausal women. The three patients (6%) with both focal and diffuse pathologic conditions were postmenopausal.
Referral was for abnormal bleeding in 33 of the 39 patients in this category. An additional three postmenopausal patients presented with abnormal findings at the Papanicolaou test (polyps in two patients and endometrial hyperplasia in one). One patient with hyperplasia was referred for pain symptoms; Two premenopausal patients with a thickened endometrium due to the secretory phase of the menstrual cycle were referred for diabetes (n = 1) and obesity with anovulation (n = 1). In the majority of cases, the diffuse or focal nature of the disease could not be predicted on the basis of initial transvaginal US (Table).
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DISCUSSION
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The endometrial polyps seen in our study were often multiple and echogenic and sometimes had cystic components (Figs 8–11) (10). Previous reports have shown uniform echogenicity similar to that of endometrium in benign endometrial polyps. A more heterogeneous texture with cystic spaces was suggestive of histologically complex polyps with areas of hemorrhage, infarction, or inflammation (10). However, endometrial polyps are hyperechoic compared with normal myometrium and contrast with the relatively hypoechoic submucosal fibroids (3). A very small percentage of endometrial polyps may contain malignant foci.
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Figures 8, 9. (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 15 mm. (b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is normal. (9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 12 mm. (b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.
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Figures 8, 9. (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 15 mm. (b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is normal. (9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 12 mm. (b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.
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Figures 8, 9. (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 15 mm. (b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is normal. (9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 12 mm. (b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.
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Figures 8, 9. (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 15 mm. (b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is normal. (9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 12 mm. (b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.
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Figures 10, 11. (10) Polyps in a 30-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Transverse sonohysterogram reveals three polyps (arrows). (11) Polyp in a 47-year-old premenopausal woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 24 mm. (b) Sagittal sonohysterogram shows a focal 30-mm-diameter endometrial polyp (arrows).
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Figures 10, 11. (10) Polyps in a 30-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Transverse sonohysterogram reveals three polyps (arrows). (11) Polyp in a 47-year-old premenopausal woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 24 mm. (b) Sagittal sonohysterogram shows a focal 30-mm-diameter endometrial polyp (arrows).
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Figures 10, 11. (10) Polyps in a 30-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Transverse sonohysterogram reveals three polyps (arrows). (11) Polyp in a 47-year-old premenopausal woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 24 mm. (b) Sagittal sonohysterogram shows a focal 30-mm-diameter endometrial polyp (arrows).
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Figures 10, 11. (10) Polyps in a 30-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Transverse sonohysterogram reveals three polyps (arrows). (11) Polyp in a 47-year-old premenopausal woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 24 mm. (b) Sagittal sonohysterogram shows a focal 30-mm-diameter endometrial polyp (arrows).
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The one case of endometrial carcinoma appeared inhomogeneous without cystic components and was not clearly distinguishable from the other polypoid masses (Fig 12). Endometrial carcinoma is the most common gynecologic malignancy in the United States. Risk factors include exposure to unopposed estrogen associated with therapy, obesity, and nulliparity as well as hypertension and diabetes (11). Sonohysterography may show focal areas of endometrial thickening, and subsequent biopsy may be guided to these sites (1). An intact subendometrium is suggestive of localized disease, whereas extension of heterogenicity and increased echogenicity in the myometrium is seen with advanced invasive endometrial carcinoma (11).
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Figure 12a. Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 44 mm and a large area of mixed echogenicity suggestive of a mass. (b) Transverse sonohysterogram shows a 50-mm-diameter polypoid mass protruding into the endometrial cavity (calipers indicate the stalk of the mass). Histopathologic findings indicated poorly differentiated endometrial carcinoma.
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Figure 12b. Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 44 mm and a large area of mixed echogenicity suggestive of a mass. (b) Transverse sonohysterogram shows a 50-mm-diameter polypoid mass protruding into the endometrial cavity (calipers indicate the stalk of the mass). Histopathologic findings indicated poorly differentiated endometrial carcinoma.
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Diffuse endometrial hyperplasia was demonstrated in 17 patients. The presence of cystic components may make distinction from polyps difficult at routine US (Figs 13–15). Endometrial hyperplasia is due to endometrial stimulation by unopposed estrogen. Risk factors are similar to those in carcinoma. Simple or cystic hyperplasia is the most common form and consists of cystically dilated endometrial glands. The condition is not associated with future development of malignancy. However, atypical endometrial hyperplasia with atypical cellularity is believed to be premalignant (9) and may have irregular hypoechoic components (11).
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Figure 13a. Endometrial carcinoma in a 51-year-old woman with a 4-week history of bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 23 mm. (b) Sagittal sonohysterogram shows diffuse thickening secondary to hyperplasia.
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Figure 13b. Endometrial carcinoma in a 51-year-old woman with a 4-week history of bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 23 mm. (b) Sagittal sonohysterogram shows diffuse thickening secondary to hyperplasia.
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Figures 14, 15. (14) Endometrial carcinoma in a 45-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 20 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia. The catheter tip is seen in the canal (arrow). (15) Endometrial hyperplasia in a 53-year-old woman with no bleeding who was undergoing estrogen replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 17 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia.
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Figures 14, 15. (14) Endometrial carcinoma in a 45-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 20 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia. The catheter tip is seen in the canal (arrow). (15) Endometrial hyperplasia in a 53-year-old woman with no bleeding who was undergoing estrogen replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 17 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia.
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Figures 14, 15. (14) Endometrial carcinoma in a 45-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 20 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia. The catheter tip is seen in the canal (arrow). (15) Endometrial hyperplasia in a 53-year-old woman with no bleeding who was undergoing estrogen replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 17 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia.
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Figures 14, 15. (14) Endometrial carcinoma in a 45-year-old woman with excessive bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 20 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia. The catheter tip is seen in the canal (arrow). (15) Endometrial hyperplasia in a 53-year-old woman with no bleeding who was undergoing estrogen replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 17 mm. (b) Sagittal sonohysterogram shows diffuse thickening due to hyperplasia.
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A secretory endometrium is indistinguishable from endometrial hyperplasia at sonohysterography and was the diagnosis in four of our earlier cases. Improved timing of the examination should decrease the number of patients with this diagnosis (Figs 16, 17).
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Figures 16, 17. (16) Secretory endometrium in a 40-year-old woman with diabetes. (a) Sagittal transvaginal US scan obtained on day 33 of the menstrual cycle suggests a focal endometrial bulge with a thickness of 18 mm. (b) Sagittal sonohysterogram shows a diffuse endometrial prominence with a thickness of 12 mm (cursors indicate diameter of a single wall). Secretory endometrium was confirmed at histopathologic examination. (17) Secretory endometrium in an obese, anovulatory 32-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Sagittal sonohysterogram shows diffuse thickening of 12 mm. Histopathologic findings were consistent with secretory endometrium.
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Figures 16, 17. (16) Secretory endometrium in a 40-year-old woman with diabetes. (a) Sagittal transvaginal US scan obtained on day 33 of the menstrual cycle suggests a focal endometrial bulge with a thickness of 18 mm. (b) Sagittal sonohysterogram shows a diffuse endometrial prominence with a thickness of 12 mm (cursors indicate diameter of a single wall). Secretory endometrium was confirmed at histopathologic examination. (17) Secretory endometrium in an obese, anovulatory 32-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Sagittal sonohysterogram shows diffuse thickening of 12 mm. Histopathologic findings were consistent with secretory endometrium.
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Figures 16, 17. (16) Secretory endometrium in a 40-year-old woman with diabetes. (a) Sagittal transvaginal US scan obtained on day 33 of the menstrual cycle suggests a focal endometrial bulge with a thickness of 18 mm. (b) Sagittal sonohysterogram shows a diffuse endometrial prominence with a thickness of 12 mm (cursors indicate diameter of a single wall). Secretory endometrium was confirmed at histopathologic examination. (17) Secretory endometrium in an obese, anovulatory 32-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Sagittal sonohysterogram shows diffuse thickening of 12 mm. Histopathologic findings were consistent with secretory endometrium.
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Figures 16, 17. (16) Secretory endometrium in a 40-year-old woman with diabetes. (a) Sagittal transvaginal US scan obtained on day 33 of the menstrual cycle suggests a focal endometrial bulge with a thickness of 18 mm. (b) Sagittal sonohysterogram shows a diffuse endometrial prominence with a thickness of 12 mm (cursors indicate diameter of a single wall). Secretory endometrium was confirmed at histopathologic examination. (17) Secretory endometrium in an obese, anovulatory 32-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Sagittal sonohysterogram shows diffuse thickening of 12 mm. Histopathologic findings were consistent with secretory endometrium.
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More than one pathologic process may be seen in any given patient, which makes complete evaluation of the entire endometrium essential (Figs 18, 19). Malacoplakia, which was seen in one of our patients with postmenopausal bleeding, is a rare condition that is more often seen in the genitourinary tract but has also been reported in the endometrium (12). This entity is believed to be the result of defective phagocytic function of the histiocyte in response to infection. The bacteria, usually Escherichia coli, persist and calcify, forming the diagnostic intra- and extracellular Michaelis-Gutmann bodies. Dilation and curettage yields soft yellow tissue, which represents inflammatory cells. Patients may respond well to antibiotics, but the condition may recur (12).
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Figure 18a. Endometrial polyp and hyperplasia in a 71-year-old woman with bleeding who was undergoing hormone replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 26 mm accompanied by cysts. (b) Sagittal sonohysterogram shows a large polyp (arrowheads) and diffuse endometrial thickening of approximately 8 mm. Diagnoses of an endometrial polyp and hyperplasia were confirmed at hysterectomy.
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Figure 18b. Endometrial polyp and hyperplasia in a 71-year-old woman with bleeding who was undergoing hormone replacement therapy. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 26 mm accompanied by cysts. (b) Sagittal sonohysterogram shows a large polyp (arrowheads) and diffuse endometrial thickening of approximately 8 mm. Diagnoses of an endometrial polyp and hyperplasia were confirmed at hysterectomy.
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Figure 19a. Endometrial malacoplakia in a 67-year-old woman with postmenopausal bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Transverse sonohysterogram suggests irregular, diffuse thickening with a posterior mass (arrows). Histopathologic analysis revealed endometrial malacoplakia.
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Figure 19b. Endometrial malacoplakia in a 67-year-old woman with postmenopausal bleeding. (a) Sagittal transvaginal US scan shows the endometrium with a thickness of 18 mm. (b) Transverse sonohysterogram suggests irregular, diffuse thickening with a posterior mass (arrows). Histopathologic analysis revealed endometrial malacoplakia.
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Subendometrial pathologic conditions, which were not appreciated as such at initial transvaginal US, were seen in 11 of 50 patients (22%), all of whom presented with abnormal bleeding. Ten patients including seven pre- and three postmenopausal women had submucosal fibroids. Focal adenomyoma was seen in a premenopausal woman. Sonohysterography showed a hypoechoic mass with an overlying echogenic endometrium in most cases, which established the subendometrial location. Submucosal fibroids may show acoustic attenuation (3). Some may prolapse almost entirely into the endometrial cavity. Those in which at least 50% of the mass projects into the endometrial cavity may be removed at hysteroscopy (4).
Adenomyosis is caused by the extension of endometrial glands and stroma into the myometrium. The focal form is an adenomyoma that is seen as a focal uterine mass (11). The single case of adenomyoma seen in our study was sonographically indistinguishable from a submucosal fibroid. However, distinction from a diffuse process is valuable for subsequent management decisions (Figs 20 –22).
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Figures 20, 21. (20) Submucosal fibroid in a 58-year-old woman with postmenopausal bleeding. (a) On a transverse transvaginal US scan, the endometrium appears indistinct (arrowheads). (b) Transverse sonohysterogram shows a submucosal fibroid (F) and a thin (2-mm) overlying endometrium (arrows). The submucosal fibroid was confirmed histopathologically. (21) Submucosal fibroid in a 47-year-old woman with irregular bleeding who was undergoing hormone replacement therapy. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Sagittal sonohysterogram shows a submucosal fibroid (arrowheads). The overlying endometrium is thin.
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Figures 20, 21. (20) Submucosal fibroid in a 58-year-old woman with postmenopausal bleeding. (a) On a transverse transvaginal US scan, the endometrium appears indistinct (arrowheads). (b) Transverse sonohysterogram shows a submucosal fibroid (F) and a thin (2-mm) overlying endometrium (arrows). The submucosal fibroid was confirmed histopathologically. (21) Submucosal fibroid in a 47-year-old woman with irregular bleeding who was undergoing hormone replacement therapy. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Sagittal sonohysterogram shows a submucosal fibroid (arrowheads). The overlying endometrium is thin.
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Figures 20, 21. (20) Submucosal fibroid in a 58-year-old woman with postmenopausal bleeding. (a) On a transverse transvaginal US scan, the endometrium appears indistinct (arrowheads). (b) Transverse sonohysterogram shows a submucosal fibroid (F) and a thin (2-mm) overlying endometrium (arrows). The submucosal fibroid was confirmed histopathologically. (21) Submucosal fibroid in a 47-year-old woman with irregular bleeding who was undergoing hormone replacement therapy. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Sagittal sonohysterogram shows a submucosal fibroid (arrowheads). The overlying endometrium is thin.
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Figures 20, 21. (20) Submucosal fibroid in a 58-year-old woman with postmenopausal bleeding. (a) On a transverse transvaginal US scan, the endometrium appears indistinct (arrowheads). (b) Transverse sonohysterogram shows a submucosal fibroid (F) and a thin (2-mm) overlying endometrium (arrows). The submucosal fibroid was confirmed histopathologically. (21) Submucosal fibroid in a 47-year-old woman with irregular bleeding who was undergoing hormone replacement therapy. (a) On a sagittal transvaginal US scan, the endometrium appears indistinct. (b) Sagittal sonohysterogram shows a submucosal fibroid (arrowheads). The overlying endometrium is thin.
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Figure 22a. Polypoid adenomyoma in a 43-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium is indistinct. (b) Sagittal sonohysterogram shows a polypoid mass (arrows) arising from the subendometrium. A polypoid adenomyoma was found at hysterectomy.
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Figure 22b. Polypoid adenomyoma in a 43-year-old woman with excessive bleeding. (a) On a sagittal transvaginal US scan, the endometrium is indistinct. (b) Sagittal sonohysterogram shows a polypoid mass (arrows) arising from the subendometrium. A polypoid adenomyoma was found at hysterectomy.
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The use of tamoxifen as an adjunctive treatment for breast cancer has resulted in an increased prevalence of endometrial polyps, hyperplasia, and carcinoma. This drug is an estrogen antagonist in the breast but has a weak estrogenic effect in the uterus (1). In addition, subendometrial cystic lesions are associated with tamoxifen and may represent reactivation of adenomyosis (4). Transvaginal US is recommended for monitoring of tamoxifen therapy. An atrophic endometrium is of no concern and requires no further imaging and no biopsy. On the other hand, if the endometrium appears too thick or irregular, sonohysterography should be performed. With endometrial pathologic conditions, blind or visually directed biopsy may be recommended depending on whether the process is diffuse or focal. Endometrial cysts with a thin overlying endometrium may be safely monitored because this condition is benign. Sonohysterography reliably shows the subendometrial location, thus saving these patients from unnecessary biopsy (4).
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CONCLUSIONS
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An atrophic endometrium is the most common cause of postmenopausal bleeding (60%) and is an important finding that may be established by means of routine US or subsequent sonohysterography in a postmenopausal woman with an anteroposterior diameter of the endometrium of 4 mm or less.
When a diffuse endometrial process is present, a cost-effective aspiration endometrial biopsy (without visual guidance) should be adequate for diagnosis. However, a focal lesion seen at sonohysterography should be further evaluated with visually directed biopsy, polypectomy, or myomectomy (if hysterectomy is not performed) because of the high percentage of false-negative results at blind biopsy.
Sonohysterography may also show subendometrial pathologic conditions as the cause of an apparently abnormal endometrium at routine sonography. Blind endometrial biopsy is not indicated in these patients, whereas hysteroscopic myomectomy may be performed in certain cases.
Sonohysterography is a simple, well-tolerated outpatient procedure that improves evaluation of the potentially abnormal endometrium. This technique has few contraindications (eg, active pelvic inflammatory disease) and leads to virtually no complications. It may be performed rapidly without significant patient discomfort and provides the referring physician with valuable information that will help determine the next step in case management in a cost-effective manner.
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References
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Goldstein SR. Assessing uterine changes in women taking tamoxifen; sonohysterography as an office procedure. Contemp Obstet Gynecol 1995; 1:1-11.
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Abstract
INTRODUCTION
