Ultrasonographic features of endometrium in pre- and postmenopausal women C. Tracy Suit, MD Cornelia de Riese, MD Samuel Prien, PhD Kelsey Kelso, BS

Background The endometrium is a dynamic tissue Menstrual cycle Postmenopausal Exogenous hormones

Transvaginal US Non-invasive Relatively inexpensive Good safety profile Readily available

Normal endometrium Menstrual phase Proliferative phase Secretory phase Days 1-5 <4 mm Proliferative phase Days 6-14 4-8 mm Secretory phase Days 14+ Up to 16 mm Thickest about day 21 of the cycle

Normal endometrium In the follicular phase, the endometrium becomes relatively hypodense As the cycle progresses the endometrium becomes more hyperechoic Hyperechogenicity is due to an enlargement of the spiral arteries and and increase in glycogen in the glands

Normal endometrium Ovulatory period = trilaminar endometrium Echogenic basal layer Hypoechogenic functional layer Echogenic line Usually disappears 48 hours after ovulation During the ovulatory period, the endometrium takes on a trilaminar appearance. The echogenic line represents the endometrial cavity

Normal endometrium Postmenopausal women Averages < 5 mm If on exogenous hormones, < 8 mm is considered normal A small amount of fluid may be considered normal Fluid is never considered normal if there are echoes suggestive of blood or debris: associated with CA

Premenopausal—Differential Diagnosis Often due to normal proliferation under hormonal influences Can include: Polyps Polypoid growths Hyperplasia or cancer Submucosal fibroids D

Important distinction: symptoms Exogenous hormones Postmenopausal Important distinction: symptoms Exogenous hormones If patients are symptomatic (ie, PMB) they are MUCH more likely to have hyperplasia or cancer

Postmenopausal—differential diagnosis Polyps Hyperplasia or cancer Fibroids Fibroids are less likely in the postmenopausal period, as they atrophy after menopause If fibroids or polyps are suspected, sonohysterography can be used to further elucidate these lesions

Associated sonographic findings Polyps: cystic spaces Hyperplasia: regular/homogeneous echotexture Cancer: irregular margins, indistinct borders between the endometrium and myometrium, heterogeneous echotexture, complex fluid

Study objective To evaluate the predictive value of endometrial thickness and descriptive sonographic appearance on pathology in pre- and postmenopausal women

Methods 1903 gynecologic ultrasounds of the endometrium were performed between January, 2004 and January 2009 Stratification: Of these, 367 had pathology performed within 3 months of the ultrasound The patients were then divided into either pre- or post menopausal after review of the chart

Methods Each US was critically evaluated for: Endometrial thickness Descriptors of the endometrium Hyper- or hypoechoic Heterogeneous Regular or irregular Ill-defined Secretory Presence of polyps, fluid or fibroids

Exclusion criteria No corresponding pathology (EMB, curettage, or hysterectomy) within 3 months of the US No measurement of the endometrial thickness or distortion by fibroids so that the endometrium could not be meaningfully evaluated Patient less than 18 years old

Methods Pathology was classified into groups: Benign: proliferative or secretory, atrophic, or chronic endometritis Precancerous or cancerous: simple hyperplasia with or without atypia, complex hyperplasia with or without atypia, endometrial cancer

Statistics Endometrial descriptors were compared with pathology using a Chi-Square analysis Endometrial thickness and age were compared using a Student’s t-test

Results Overall: N=367 Postmenopausal group: N=76 Benign: 69 PreCA/CA: 7 Premenopausal group: N=291 Benign: 267 PreCA/CA: 24

Result: Postmenopausal group Of the 7 women with pathologic findings: 1 with complex hyperplasia without atypia 6 women with cancer Average endometrial thickness 20.3 mm Range 13.63 mm to 37 mm

Results: Postmenopausal group Age Benign: 54 PreCA/CA: 62 There was a trend toward older age with precancer or cancer Endometrial thickness Benign: 9.7 mm PreCA/CA : 17.9 mm p<0.05

Results: Postmenopausal group Descriptive terms No difference between groups

Results: Postmenopausal group

Results: Premenopausal group Of the women with preCA/CA: 18 with simple hyperplasia Ranged from 1 mm to 29 mm Average endometrial thickness 11.6 mm 6 with endometrial cancer Average endometrial thickness 24 mm

Results: Premenopausal group Age: Benign: 39 preCA/CA: 43 Trend toward older age with diagnosis of hyperplasia or cancer Endometrial thickness: Benign: 8.9 mm preCA/CA: 15.0 p<0.01

Results: Premenopausal group Descriptive terms If the endometrial stripe was described as heterogeneous or irregular, the patients were significantly more likely to have hyperplasia or cancer (p<0.01)

Results: Premenopausal women

Conclusions Confirmed that endometrial thickness is increased in pathological conditions such as hyperplasia and cancer But hyperplasia was diagnosed often within the “normal” ranges, especially in the premenopausal women The average endometrial thicknesses were significantly elevated in each group, however,

Conclusions In the postmenopausal group, complex hyperplasia and cancer were diagnosed with an endometrial thickness of 3 and 5 mm, respectively

Conclusions In premenopausal women, the average endometrial thickness in women with pathology was still in the normal range for secretory endometrium

Conclusions In addition, no simple hyperplasia was diagnosed in the postmenopausal group—when pathology was found, it was much more likely to have become frank cancer

Conclusions Heterogeneity and irregularity in echo pattern were significantly more likely to be associated with hyperplasia or cancer in the premenopausal group. It may have not reached significance in the postmenopausal women due to the smaller sample size.

Conclusions One weakness of the study is the low rate of pathology

Conclusions DO THE EMB in symptomatic women High risk women – even very young Postmenopausal women High risk women include those with menorrhagia or intramenstrual bleeding, anovulatory pattern

OUTLOOK What can the sonohysterogram add? We need to correlate findings to ethnicity, metabolic and exogenous as well as endogenous hormonal influences to further define high risk scenarios.