For uterine endometrial ultrasound all are true EXCEPT:
A- Normal thickness in postmenopausal age is 2-3 mm. True
B- In postmenopausal women who use hormones, the thickness of endometrium decreases…This (Increases)
C- Fluid within endometrial cavity is seen in both normal and pathological conditions. True
D- Early in the menstrual cycle, the endometrium is a thin echogenic line. True
E- A woman with postmenopausal bleeding shows 3 mm endometrial thickness need endometrial biopsy. True
Endometrial ultrasound:
1 - Ultrasound scanning techniques of the endometrium:
- Endovaginal ultrasound is the first-line examination in endometrial exploration.
- Need a high frequency probe, 5 to 7.5 MHz. For a good visualization of the uterus and the cavity, a wide-area vaginal probe (160 to 200 °) will be favored.
- The endometrium is visible in the form of a central tissue band whose thickness and echogenicity increase during the menstrual cycle.
- Its thickness is measured in sagittal section perpendicular to the cavitary line which separates the two layers. When the cavity is distended with liquid, the thickness of each separately measured sheet is added.
- The thickness and echo structure of the endometrium should be interpreted according to the cycle and the type of hormonal treatment followed.
Hysterosonography is a very interesting complementary examination in the study of the endometrium and its pathology. The injection into the cavity of a saline solution under ultrasound control allows to distend it and provides an artificial contrast to better visualize the endometrium.
- The normal endometrial thickness is 4 to 8 mm in the first part of the cycle and 8 to 14 mm in the second phase of the cycle. In postmenopausal women, it should not exceed 5 mm apart from any hormone replacement therapy. This limit increases to 10 mm under hormone replacement therapy. Beyond this, we will speak of functional or organic endometrial hypertrophy.
During the menstrual phase, the endometrium appears as a duplication of the line of emptiness. During the proliferative phase, its echo-structure is hypoechoic; it becomes hyperechoic in the luteal phase.
- These variations of the endometrial echostructure will be taken into account in the programming of the examination in order to benefit from the best ultrasound contrast:
+ at the end of the proliferative phase (J8-J13) in case of suspicion of polyp (the polyps are hyperechoic),
+ at the end of the cycle (D20-D28) in case of suspicion of endometrial hypertrophy, uterine malformations or in search of intra-cavitary resonance of a uterine myoma.
2 - Endometrium during the menstrual cycle:
The endometrium is very sensitive to hormonal variations. Under the influence of estradiol and progesterone, the endometrium undergoes changes that will allow it to accommodate a possible pregnancy. Two phases are described:
a proliferative phase under estrogenic influence,
a secretory phase under progestative influence. Progesterone has a maturing role that can only be expressed on a mucosa of sufficient thickness previously prepared by estrogen.
It is essential to perfectly locate the hormonal context of the patient before starting any ultrasound. In case of pathology, this will make it possible to issue diagnostic hypotheses compatible with the period of the cycle (suspicion of GEU, functional cyst ...).
Menstrual period:
- Endometrial end,
- Duplication of the cavitary line (hematometry),
- Images of clots and echogenic debris of mucosa (Do not confuse them with polyps).
Proliferative phase:
- Linear cavitary line (endometrial reflection line),
- The endometrium appears as two hypoechoic bands on both sides of the line of reflection,
- May reach 8 to 10 mm at the end of the proliferative phase.
3 - Functional pathology of the endometrium:
It is secondary to an oestro-progestational imbalance (hormone-dependent pathology).
Endometrial atrophy:
Virtually physiological postmenopausal, it shows a state of hypoestrogenemia and can sometimes be the cause of metrorrhagia that can not be attached to this cause after elimination of any other etiology especially tumoral.
During periods of genital activity, it may be secondary to:
+ Iatrogen:
- Agonists or antagonists of LH-RH,
- pure progestins,
- Mini-dose pill,
- Danazol.
+ Pathological:
- hypothalamic-pituitary amenorrhea,
- Ovarian insufficiency.
On the ultrasound plan:
- Cavity line surrounded by a thin hypoechoic band whose thickness is less than 5 mm,
- After a long period of hypoestrogenesis, uterine involution and increased resistance of the uterine arteries.
Endometrial hypertrophy:
- Demonstrates hormonal imbalance, endogenous absolute or relative hyperoestrogeny (obesity, PCO, anovulation) or iatrogenic (estrogenic treatment, Tamoxifen),
- Ultrasound does not allow to determine the benign or malignant character of the hypertrophy. Histological verification is most often essential,
- The ultrasound measurement of the thickness of the endometrium must be done in the first part of the cycle. Hypertrophy is evident from 10 mm thick,
- In case of diffuse thickening, the endometrium exceeds 15 mm, sometimes globular appearance but respecting a clear junction with the myometrium,
- The cavitary line is often less visible but remains central which eliminates a large mucous polyp.
We distinguish:
- simple hypertrophy: mucosa globally homogeneous and hyperechoic. In hysterosonography, the banks are regular,
- mucosal folds: can be quite large, hyperechoic and localized,
polypoid hypertrophy: associated mucous polyps,
- glandulo-cystic hypertrophy: hypertrophy associated with cystic images (cystic dilation of the glandular channels). These images often have a benign character.
Differential diagnosis of these cysts:
+ uterine adenomyosis lesions,
+ cystic atrophy of the endometrium,
+ vitelline vesicle of a beginning pregnancy,
+ Molar pregnancy.
- Interest of hysterosonography in case of diagnostic doubt: Thick mucosa with corrugated edge surrounding an empty cavity.
Discordant endometrium:
The thickness of the endometrium does not correspond with the period of the cycle or the gynecological context.
Hyperechoic aspect of secretory type in follicular period:
- early ovulation,
- dysplastic endometrium,
- endometritis,
- mucous polyp,
- LUF syndrome,
secretory transformation linked to an inductive treatment of ovulation.
Hypoechoic aspect in secretory period:
- late ovulation,
- date error.
4 - Organic pathology of the endometrium:
Mucous polyps:
- Focal and benign hyperplasia of the endometrium.
Initially limited to a small dystrophic zone of the endometrium, it grows and is pediculised to internalize in the cavity. In the long run, it can undergo a fibrous transformation.
- Hyperechoic and poorly absorbent, they may contain one or more cystic zones (glandular-cystic polyp).
- Rounded or oval, their visualization will be optimal around J11-J13, the endometrium hypoechogene ensuring a good contrast. In the secretory phase, embedded in the endometrium of the same tonality, their visualization will be more difficult (interest of hysterosonography).
A- Normal thickness in postmenopausal age is 2-3 mm. True
B- In postmenopausal women who use hormones, the thickness of endometrium decreases…This (Increases)
C- Fluid within endometrial cavity is seen in both normal and pathological conditions. True
D- Early in the menstrual cycle, the endometrium is a thin echogenic line. True
E- A woman with postmenopausal bleeding shows 3 mm endometrial thickness need endometrial biopsy. True
Endometrial ultrasound:
- Endovaginal ultrasound is the first-line examination in endometrial exploration.
- Need a high frequency probe, 5 to 7.5 MHz. For a good visualization of the uterus and the cavity, a wide-area vaginal probe (160 to 200 °) will be favored.
- The endometrium is visible in the form of a central tissue band whose thickness and echogenicity increase during the menstrual cycle.
- Its thickness is measured in sagittal section perpendicular to the cavitary line which separates the two layers. When the cavity is distended with liquid, the thickness of each separately measured sheet is added.
- The thickness and echo structure of the endometrium should be interpreted according to the cycle and the type of hormonal treatment followed.
Hysterosonography is a very interesting complementary examination in the study of the endometrium and its pathology. The injection into the cavity of a saline solution under ultrasound control allows to distend it and provides an artificial contrast to better visualize the endometrium.
- The normal endometrial thickness is 4 to 8 mm in the first part of the cycle and 8 to 14 mm in the second phase of the cycle. In postmenopausal women, it should not exceed 5 mm apart from any hormone replacement therapy. This limit increases to 10 mm under hormone replacement therapy. Beyond this, we will speak of functional or organic endometrial hypertrophy.
During the menstrual phase, the endometrium appears as a duplication of the line of emptiness. During the proliferative phase, its echo-structure is hypoechoic; it becomes hyperechoic in the luteal phase.
- These variations of the endometrial echostructure will be taken into account in the programming of the examination in order to benefit from the best ultrasound contrast:
+ at the end of the proliferative phase (J8-J13) in case of suspicion of polyp (the polyps are hyperechoic),
+ at the end of the cycle (D20-D28) in case of suspicion of endometrial hypertrophy, uterine malformations or in search of intra-cavitary resonance of a uterine myoma.
2 - Endometrium during the menstrual cycle:
The endometrium is very sensitive to hormonal variations. Under the influence of estradiol and progesterone, the endometrium undergoes changes that will allow it to accommodate a possible pregnancy. Two phases are described:
a proliferative phase under estrogenic influence,
a secretory phase under progestative influence. Progesterone has a maturing role that can only be expressed on a mucosa of sufficient thickness previously prepared by estrogen.
It is essential to perfectly locate the hormonal context of the patient before starting any ultrasound. In case of pathology, this will make it possible to issue diagnostic hypotheses compatible with the period of the cycle (suspicion of GEU, functional cyst ...).
Menstrual period:
- Endometrial end,
- Duplication of the cavitary line (hematometry),
- Images of clots and echogenic debris of mucosa (Do not confuse them with polyps).
Proliferative phase:
- Linear cavitary line (endometrial reflection line),
- The endometrium appears as two hypoechoic bands on both sides of the line of reflection,
- May reach 8 to 10 mm at the end of the proliferative phase.
3 - Functional pathology of the endometrium:
It is secondary to an oestro-progestational imbalance (hormone-dependent pathology).
Endometrial atrophy:
Virtually physiological postmenopausal, it shows a state of hypoestrogenemia and can sometimes be the cause of metrorrhagia that can not be attached to this cause after elimination of any other etiology especially tumoral.
During periods of genital activity, it may be secondary to:
+ Iatrogen:
- Agonists or antagonists of LH-RH,
- pure progestins,
- Mini-dose pill,
- Danazol.
+ Pathological:
- hypothalamic-pituitary amenorrhea,
- Ovarian insufficiency.
On the ultrasound plan:
- Cavity line surrounded by a thin hypoechoic band whose thickness is less than 5 mm,
- After a long period of hypoestrogenesis, uterine involution and increased resistance of the uterine arteries.
Endometrial hypertrophy:
- Demonstrates hormonal imbalance, endogenous absolute or relative hyperoestrogeny (obesity, PCO, anovulation) or iatrogenic (estrogenic treatment, Tamoxifen),
- Ultrasound does not allow to determine the benign or malignant character of the hypertrophy. Histological verification is most often essential,
- The ultrasound measurement of the thickness of the endometrium must be done in the first part of the cycle. Hypertrophy is evident from 10 mm thick,
- In case of diffuse thickening, the endometrium exceeds 15 mm, sometimes globular appearance but respecting a clear junction with the myometrium,
- The cavitary line is often less visible but remains central which eliminates a large mucous polyp.
We distinguish:
- simple hypertrophy: mucosa globally homogeneous and hyperechoic. In hysterosonography, the banks are regular,
- mucosal folds: can be quite large, hyperechoic and localized,
polypoid hypertrophy: associated mucous polyps,
- glandulo-cystic hypertrophy: hypertrophy associated with cystic images (cystic dilation of the glandular channels). These images often have a benign character.
Differential diagnosis of these cysts:
+ uterine adenomyosis lesions,
+ cystic atrophy of the endometrium,
+ vitelline vesicle of a beginning pregnancy,
+ Molar pregnancy.
- Interest of hysterosonography in case of diagnostic doubt: Thick mucosa with corrugated edge surrounding an empty cavity.
Discordant endometrium:
The thickness of the endometrium does not correspond with the period of the cycle or the gynecological context.
Hyperechoic aspect of secretory type in follicular period:
- early ovulation,
- dysplastic endometrium,
- endometritis,
- mucous polyp,
- LUF syndrome,
secretory transformation linked to an inductive treatment of ovulation.
Hypoechoic aspect in secretory period:
- late ovulation,
- date error.
4 - Organic pathology of the endometrium:
- Focal and benign hyperplasia of the endometrium.
Initially limited to a small dystrophic zone of the endometrium, it grows and is pediculised to internalize in the cavity. In the long run, it can undergo a fibrous transformation.
- Hyperechoic and poorly absorbent, they may contain one or more cystic zones (glandular-cystic polyp).
- Rounded or oval, their visualization will be optimal around J11-J13, the endometrium hypoechogene ensuring a good contrast. In the secretory phase, embedded in the endometrium of the same tonality, their visualization will be more difficult (interest of hysterosonography).
Labels
Radiology MCQ