Ultrasonographic features of endometrium in pre- and postmenopausal women

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

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

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

4. Normal endometrium • Menstrual phase • Days 1-5 • <4 mm • Proliferative phase • Days 6-14 • 4-8 mm • Secretory phase • Days 14+ • Up to 16 mm

5. Normal endometrium • In the follicular phase, the endometrium becomes relatively hypodense • As the cycle progresses the endometrium becomes more hyperechoic

6. Normal endometrium • Ovulatory period = trilaminar endometrium • Echogenic basal layer • Hypoechogenic functional layer • Echogenic line • Usually disappears 48 hours after ovulation

7. 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

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

9. Postmenopausal • Important distinction: symptoms • Exogenous hormones

10. Postmenopausal—differential diagnosis • Polyps • Hyperplasia or cancer • Fibroids

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

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

13. 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

14. 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

15. 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

16. 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

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

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

19. 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

20. 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

21. Results: Postmenopausal group • Descriptive terms • No difference between groups

22. Results: Postmenopausal group

23. 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

24. 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

25. 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)

26. Results: Premenopausal women

27. 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

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

29. Conclusions • In premenopausal women, the average endometrial thickness in women with pathology was still in the normal range for secretoryendometrium

30. 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

31. 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.

32. Conclusions • One weakness of the study is the low rate of pathology

33. Conclusions • DO THE EMB in symptomatic women • High risk women – even very young • Postmenopausal women

34. 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.