Endometrial abnormalities

Endometrial abnormalities by Dr. Fathmath Shudhfa

1. ENDOMETRIAL ABNORMALITIES Dr. Fathmath Shudhfa Ibrahim 1 st year Resident MD Radiodiagnosis

2. CONTENTS Normal Endometrium Endometrial Hyperplasia Endometrial Atrophy Endometrial Polyps Endometrial Carcinoma Endometritis Endometrial Adhesions Intrauterine Contraceptive devices

3. NORMAL ENDOMETRIUM Endometrium undergoes cyclic changes which prepare it for implantation of a fertilized ovum. The normal endometrial cavity is seen as a thin echogenic line. The sonographic appearance of the endometrium varies during the menstrual cycle. The endometrium is composed of a superficial functional layer and a deep basal layer .

4. Functional Layer (stratum functionalis ) -Changes in response to ovarian hormone cycles -Sheds during menstruation Deep basal layer (stratum basalis ) -Remains intact during the cycle -Contains spiral arteries which supplies the functional layer as it thickens -Unresponsive to ovarian hormones.

5. The endometrium is best measured on a midline sagittal scan of the uterus should include both anterior and posterior portions of the endometrium. It is important not to include the thin hypoechoic inner layer of myometrium in this measurement.

6. The menstrual phase endometrium consists of a thin echogenic line. During the proliferative phase , the endometrium thickens, reaching 4 to 8 mm Periovulatory phase . endometrium measures 6-10mm and gives three layer appearance

7. Normal, thin ,early proliferative endometrium Normal, late-proliferative endometrium with triple-layer appearance. Central echogenic line is caused by opposed endometrial surfaces surrounded by a thicker hypoechoic functional layer, bounded by an outer echogenic basal layer. Normal, early-secretory phase endometrium. The functional layer surrounding the echogenic line has become hyperechoic

8. Normal, thick, hyperechoic late-secretory endometrium S ecretory phase . The endometrium in this phase measures 7 to 14 mm in thickness.

9. Normal, thin, postmenopausal endometrium

10. IMAGING MODALITY T ransvaginal sonography Sonohysterography Reconstructed coronal view, 3-D sonography

11. POSTMENOPAUSAL ENDOMETRIUM  Postmenopausal Endometrium should be thin, homogeneous , and echogenic . Homogeneous , smooth endometria measuring 5 mm or less are considered within the normal range with or without hormonal replacement therapy. The endometrium in a patient undergoing hormonal replacement therapy may vary up to 3 mm if cyclic estrogen and progestin therapy is being used

12. HYDROMETROCOLPOS AND HEMATOMETROCOLPOS Obstruction of the genital tract results in the accumulation of secretions and blood in the uterus( metro ) and/or vagina ( colpos ), with the location depending on the amount of obstruction. Before menstruation, the accumulation of secretions in the vagina and uterus is referred to as hydrometrocolpos . After menstruation, hematometrocolpos results from the presence of retained menstrual blood.

13. Causes Congenital - imperforate hymen. vaginal septum -vaginal atresia - rudimentary uterine horn. acquired -cervical stenosis from endometrial or cervical tumors - postirradiation fibrosis

14. ENDOMETRIAL HYPERPLASIA Definition -Proliferation of glands of irregular size and shape, with an increase in the gland/ stroma ratio compared with the normal proliferative endometrium. -The process is diffuse but may not involve the entire endometrium. Histologically -Hyperplasia without cellular atypia  (<2%progress to carcinoma) -Hyperplasia with cellular atypia  (25%progress to carcinoma)

15. Each of these types may be further subdivided into: simple (cystic) hyperplasia  the glands are cystically dilated and surrounded by abundant cellular stroma - complex (adenomatous) hyperplasia  the glands are crowded together with little intervening stroma .

16. Endometrial hyperplasia is a common cause of abnormal uterine bleeding. D evelops from -unopposed estrogen stimulation in postmenopausal women. - I t is usually caused by unopposed estrogen HRT in perimenopausal women.

17. Causes of endometrial hyperplasia - persistent anovulatory cycles - polycystic ovarian disease - obese women with increased production of endogenous estrogens . estrogen -producing tumors  ovarian granulosa cell tumors , endometroid Ca and thecomas Pregnancy Tamoxifen therapy Endometrial Carcinoma Tamoxifen therapy=> associated with endometrial polyps, adenomysosis , carcinoma

18. Ultrasound Findings -Endometrial hyperplasia is considered when the endometrium exceeds 10 mm in thickness, especially in menopausal patients - In postmenopausal women, 5mm thickness is significant. - M ay also cause asymmetric thickening with surface irregularity, an appearance that is suspicious for carcinoma.

19. Thickened endometrium caused by multiple small polyps confirmed on sonohysterogram Thick, cystic endometrium caused by hyperplasia in patient taking tamoxifen Differential thickness : normal thickening during the secretory phase, sessile endometrial polyps, submucosal fibroids, Endometrial cancer, adherent blood clots Pregnancy and ectopic pregnancy Incomplete abortion

20. Endometrial hyperplasia has a nonspecific appearance so any focal abnormality should lead to biopsy if there is clinical suspicion for malignancy.

21. ENDOMETRIAL ATROPHY The majority of women with postmenopausal uterine bleeding have endometrial atrophy. Histologically - endometrial glands may be dilated -cells are cuboidal or flat -the stroma is fibrotic

22. On transvaginal sonography -an atrophic endometrium is usually thin - measuring less than 5 mm these patients, no further investigation or therapy is necessary. A thin endometrium with cystic changes on transvaginal sonography is consistent with a diagnosis of cystic atrophy , but when the endometrium is thick, the appearance is indistinguishable from that of cystic hyperplasia

23. ENDOMETRIAL POLYPS Endometrial polyps are common benign lesions more frequently seen in perimenopausa l and postmenopausal women . Polyps may cause uterine bleeding, although most are asymptomatic. In the menstruating woman, endometrial polyps may be associated with intermenstrual bleeding or menometrorrhagia and may be a cause of infertility .

24. Histologically - polyps are localized overgrowths of endometrial tissue covered by epithelium and projecting above the adjacent surface epithelium. Types pedunculated broad based may have a thin stalk

25. Ultrasonographic findings -Frequently identified as focal masses within the endometrial canal. -Or as nonspecific echogenic endometrial thickening . - T hey may also appear as a focal, round, echogenic mass within the endometrial cavity. Transvaginal scan shows a thick endometrium (arrowheads) with central round polyp (arrow)

26. Color Doppler US -used to image vessels within the stalk. -A feeding artery in the pedicle can frequently be seen with color Doppler ultrasound ( pedicle artery sign ) Color Doppler ultrasound shows feeding vessel.

27. Well-defined, round echogenic polyp Carpet of small polyps Polyp on a stalk.

28. Sonohysterography - Polyps are best seen at sonohysterography - appear as echogenic, smooth, intracavitary masses outlined by fluid Sonohysterogram confirms polyp (arrow) and thick endometrium (arrowheads) caused by hyperplasia.

29. Polyp with cystic areas Small Polyp Small Polyp

30. Hysterosalpingography -Seen as pedunculated filling defects within the uterine cavity

31. MRI T2-weighted MR imaging -Appears as low-signal-intensity intracavitary masses surrounded by high-signal-intensity fluid and endometrium.

32. ENDOMETRIAL CARCINOMA Most common carcinoma of the female reproductive system. Histologically -Adenocarcinoma (95%) -Sarcoma (5%) Most endometrial carcinomas (75%-80%) occur in postmenopausal women, age 55-62years The most common clinical presentation is uterine bleeding .

33. strong association with - estrogen replacement therapy in postmenopausal women. - anovulatory cycles in premenopausal women. An increased risk of endometrial carcinoma has been reported in patients receiving tamoxifen therapy, as well as an increased risk of endometrial hyperplasia and polyps.

34. Other risk factors include - Obesity - Diabetes Hypertension low parity

35. Carcinoma of the endometrium staging (FIGO)- International federation of Gynecology and Obstetrics, revised 2009

36. Ultrasound Findings - A thickened endometrium must be considered cancer until proven otherwise. -The thickened endometrium may be well defined, uniformly echogenic, and indistinguishable from hyperplasia and polyps. Abdominal Ultrasound

37. Cancer is more likely when the endometrium has a heterogeneous echotexture with irregular or poorly defined margins . Sonography may be used in the preoperative evaluation of a patient with endometrial carcinoma by determining myometrial invasion . transvaginal scan, show a large, heterogeneous endometrial mass (arrowheads) compressing the surrounding myometrium

38. An intact subendometrial halo (inner layer of myometrium) usually indicates superficial invasion, whereas obliteration of the halo indicates deep invasion . Endometrial carcinoma may also obstruct the endometrial canal, resulting in hydrometra or hematometra . Although certain sonographic appearances tend to favor a benign or malignant etiology , there are overlapping features, and endometrial biopsy is usually required for a definitive diagnosis.

39. Transvaginal scans show localized irregular endometrial thickening with echogenic polypoid projections (arrows) into the fluid-filled endometrial canal.

40. color and spectral Doppler ultrasound - controversial . - Blood flow is difficult to detect in the normal endometrium .

41. Endometrial thickness -A better method for discriminating between normal and pathologic or benign and malignant endometrium than Doppler ultrasound of the uterine, subendometrial , or intraendometrial arteries

42. MRI Ideal imaging modality for staging of endometrial Ca. A n important predictor of lymph node metastases. A lso allow accurate assessment of more advanced disease such as cervical stromal invasion or adnexal involvement . C ontrast-enhanced MRI has been shown to be superior to both in demonstrating myometrial invasion. MRI can also assess cervical extension (stage II) and extrauterine extension (stages III and IV).

43. On unenhanced T1-weighted images - Endometrial cancer is isointense relative to hypointense normal endometrium. On T2-weighted images - shows heterogeneous intermediate signal intensity relative to hyperintense normal endometrium. Relative to normal myometrium, the tumor is mildly hyperintense on T2-weighted images. At conventional MR imaging, the depth of myometrial invasion is optimally depicted with T2- weighted sequences.

44. Tamoxifen -A nonsteroidal antiestrogen compound which is widely used for adjuvant therapy in premenopausal and postmenopausal women with breast cancer. - Tamoxifen acts by competing with estrogen for estrogen receptors.

45. In premenopausal women - T amoxifen has an antiestrogenic effect I n postmenopausal women I t may have estrogenic effects . An increased risk of endometrial carcinoma, endometrial hyperplasia and polyps has been reported in patients receiving tamoxifen therapy.

46. On sonography - T amoxifen -related endometrial changes are nonspecific and similar to those described in hyperplasia, polyps, and carcinoma. -Cystic changes within the thickened endometrium are frequently seen -Polyps are frequently seen. - A correlation exists between increased endometrial thickness and duration of tamoxifen therapy longer than 5 years .

47. In some patients taking tamoxifen , the cystic changes actually have been shown to be subendometrial in location and represent abnormal adenomyosis -like changes in the inner layer of myometrium . Because it may be difficult to distinguish the endometrial- myometrial border in many of these patients, sonohysterography is valuable in determining whether an abnormality is endometrial or subendometrial .

48. Thick, cystic endometrium caused by large polyp in patient receiving tamoxifen .

49. ENDOMETRITIS May occur Postpartum after D&C association with PID . Sonographically the endometrium may appear thick and/or irregular, and the cavity may or may not contain fluid. Gas with distal acoustic shadowing may be seen within the endometrial canal .

50. ENDOMETRIAL ADHESIONS Endometrial adhesions ( synechiae , Asherman’s syndrome) are posttraumatic or postsurgical in nature and may be a cause of infertility or recurrent pregnancy loss . The sonographic diagnosis is difficult unless fluid is distending the endometrial cavity.

51. Transvaginally Irregularities or a hypoechoic bridgelike band within the endometrium . This is best seen during the secretory phase, when the endometrium is more hyperechoic . Endometrial Adhesions

52. SHG is an excellent technique for demonstrating adhesions and should be performed in all cases of suspected adhesions . Adhesions appear as bridging bands of tissue that distort the cavity or as thin, undulating membranes best seen on real-time sonography . Thick , broad-based adhesions may prevent distention of the uterine cavity. The adhesions can be divided under hysteroscopy.

53. INTRAUTERINE CONTRACEPTIVE DEVICES Sonography has an important role in evaluating the location of intrauterine contraceptive devices (IUCDs). IUCDs are readily demonstrated on both transabdominal and transvaginal sonography . They appear as highly echogenic linear structures in the endometrial cavity in the body of the uterus. Acoustic shadowing from the IUCD is usually demonstrated, and two parallel echoes (entrance-exit reflections), representing the anterior and posterior surfaces of the IUCD, may also be observed.

54. Sonography can demonstrate -Malposition - P erforation -Incomplete removal - Eccentric position of an IUCD suggests myometrial penetration. If the IUCD is not seen on sonography , a radiograph should be taken to assess whether it is lying free in the peritoneal cavity or is not present, having been previously expelled.

55. Adenomyosis Radiopedia and Haaga 6/e Focal – adenomyoma Diffuse USG: Enlarged globular uterus (AP asymmetry) Myometrial heterogeneity due to endometrial implants and smooth muscle hypertrophy Diffuse echogenic nodules 2-6 mm Subendometrial cysts (HHG in cysts) Endometrial pseudowidening - due to poor endomyometrial junction Rain shower appearance: multiple fine areas of attenuation throughout the lesion

56. MRI: T2 ill defined thickening of low T2 signal band JZ: <8 mm excludes the diagnosis 8-12 mm Possible cases Supporting features: High T2 si linear striations (finger like projections) extending out from endometrium to myometrium T1WI high si foci: endometrial rests +- punctate HHG >12 mm highly specific for adenomyosis

57. REFERENCES Diagnostic Ultrasound Carol M.Rumack Fundamentals of Diagnostic Radiology-Bryant&Helms Other sources from internet

58. Thank you