Ultrasound of the Endometrium

Introduction

My name is Tom Winter and I'm from the University of Utah
and I'll be speaking about ultrasound of the endometrium.

For the next 45 minutes we're gonna be talking about
ultrasound of the endometrium.
It's a nice topic because it can be covered pretty much
completely in one session right here.

And we'll talk about why we worry a little bit on
terminology and technique.
We'll discuss what's abnormal in a variety
of clinical scenarios.
We'll talk about abnormalities seen on transvaginal
ultrasound, other competing diagnostic modalities like
endometrial biopsy or DNC.
And then we'll finish up with a lecture within a lecture
of saline infusion sonohysterography.

Importance of Endometrial Cancer

Why do we worry about 10%
of postmenopausal women will have bleeding
and of that 10%, 10% of those will have endometrial cancer.
And even though endometrial cancer is predominantly a
disease of postmenopausal women, five to 10%
of cases will occur in pre premenopausal women.
It's the most common GYN malignancy about 40,000 cases per
year in the United States.
And it's the fourth most common cancer in women
following breast, lung, and colon.
But fortunately because it's detected early due
to the abnormal bleeding and
because we have reasonable treatments for it, it accounts
for only one and a half percent of cancer deaths.

So which of the following statements describes
endometrial cancer?
All of these are true except it's the fourth most common
cause of cancer in women.
Five to 10% of cancer occurs in women under
the age of 40 or 50.
It's the number one cause of bleeding.
There are 40,000 new cases per year in the US
and there are a variety of risk factors.
So all of these are true except it is not the number one
cause of postmenopausal bleeding.
It's the cause we worry about.
But atrophy is actually the number one cause.

Terminology for Abnormal Bleeding

So there's a variety of specific terms with unique meanings
regarding abnormal bleeding.
But if you're a lumper like I am, you can skip to the bottom
and call all of the above abnormal uterine bleeding.

Technique for Measuring the Endometrium

How do we measure the endometrium?
It's very important that we spend time on technique
and try to do things right.
Here's a quote from John Wooden,
the most famous basketball coach of all times
talking about the importance
of attention to the little details.

So we wanna measure the endometrium
transvaginally with an empty bladder.
We wanna measure it in the sagittal plane.
We want wanna measure the thickest portion.
We exclude any fluid in the endometrial
cavity from our measurement.
We visualize the entire endometrium.
And remember that five to 10%
of the time you're not gonna be able to see the endometrium.
You're gonna have fibroids or positioning
or something that gets in your way and that's okay.

So we measure transvaginally,
and this is just an example from a beautiful paper
by Ruth showing how you can see the polyp transabdominally.
But as we all know, it's much better seen transvaginally.
We exclude the hypo coic, inner myometrium.
So as you see on this slide, we measure between the arrows
and we don't include the hypo coic halo.
That's just convention.
If you have fluid, you measure each wall
and add them together and you don't include the central
thickness of the fluid, which makes intuitive sense.
So in this case, the reported thickness would be 4.3
millimeters, 0.21, 0.23.

It's a really important
that we sweep the entire endometrium.
You don't want to just take pictures like in the top left
and say, oh, everything's normal
because then when you move your probe off to the side there,
all of a sudden we have a stage one adenocarcinoma
that's not seen on the initial image.
And again, just to make this point, five, 10% of the time,
whatever, you're not gonna be able
to see the entire endometrium you.
That's okay because the message we want
to give our patients is that if we call the ultrasound
normal, you do not have endometrial cancer.
If we can't see everything, that's okay,
but we just need to go to another case.
Another assessment modality.

So in this case we have a large fibroid up there
and it turned out that there was a stage two B
endometrial cancer here.
Don't accept indistinct endometrial margins.
Endometrial cancer can be infiltrative.
So you can see on our right towards the cervix we have a
sharp line, but towards the left it just kind
of gray and blending in.
And this was a grade two adenocarcinoma.

So regarding proper measurement of endometrial thickness,
all of the following are true except you need
to do it transvaginally, you need
to do it in the sagittal plane.
It should be made at the thickest portion of the stripe.
Fluid within the cavity should be included in the thickness
and indistinct margins should make you worry about cancer.
And all of these are true except
as we talked about we do not include
fluid within the cavity.

Abnormal Endometrial Thickness in Clinical Scenarios

So what's abnormal?
And that depends on the clinical scenario.
So we'll go through a couple
different clinical scenarios here.

Premenopausal

Number one is premenopausal
and obviously,
endometrial thickness changes depending where you are in your cycle.
But a rough rule of thumbs 15.

So here are just a series
of different patients illustrating the endometrial cavity at
different portions of the cycle.
Here we have a 20-year-old on
or contraceptives on day four, it's just thin and atrophic.
Here on day seven you see the peri ovulatory
or beginning peri ovulatory appearance.
It's kind of trilaminar or three layers.
On day 14, you get the classic peri ovulatory
trilaminar appearance.
On day 17, it starts to thicken up
and you get this genic material.
And then as we get into the late luteal phase,
the entire endometrium, these are two different patients,
is just very thickened right there.

So that's the normal spectrum from menses to right
before the next menses.
And remember that this 15 millimeters is not
a perfect threshold there.
This is a two and a half centimeter endometrium in a
29-year-old asymptomatic patient, one day
before she's supposed to get her period.
And she's asymptomatic, she's young.
This is gonna be normal here.

So what you want to do to try
to obviate these problems is schedule people for
their ultrasounds on the early part of their cycle.
And then you won't run into the conundrum posed
by the secretory phase.

Postmenopausal Bleeding

Scenario number two is postmenopausal bleeding
and basically under five millimeters as normal.
Some people used four,
but the majority of everybody uses five millimeters there.
Remember that there are some nuances to this.
Five millimeters, if you have a focal endometrial
abnormality, that's abnormal even if it's under five.
So if it goes 1, 1 1 4 0.9111, that's abnormal.
There. We talked about an indistinct appearance.
Most of the time it's normal, but it could be cancer
and five to 10% of the time it's gonna be non-diagnostic
because you can't see generally due to fibroids.
Remember not to scare your patient.
Just because the ultrasound isn't under five millimeters
doesn't mean she has cancer.
It just means that we need to go to a more definitive test.
The whole goal of ultrasound is to have something
that when it's normal there is not any cancer.

Postmenopausal on Hormone Replacement Therapy

Third scenario is the post-menopausal patient on
hormone replacement therapy.
And there have been a lot
of oscillations in whether women are being offered peri
or postmenopausal hormone replacement therapy over time.
But bottom line, we keep the five millimeter threshold.
We're not using the eight millimeter threshold that a lot
of people talk about, but
that's not evidence-based medicine right there.
We keep five millimeters
because if it's under five, it's not cancer.
We know we're gonna have more false positives
because the hormone replacement is going
to increase the stripe thickness.
But there are enough cancers between five
and eight that we keep the five millimeter threshold
and accept more false positives.

And here's a 55-year-old on unopposed estrogen
for five years after menopause
and you can see the thickened stripe with blood flow.

Asymptomatic Postmenopausal

What about postmenopausal patient but not bleeding?
You know, should we offer additional investigations
to asmp asymptomatic women with an increased stripe?
This is very controversial.
I think the best paper out there is from UCSF.
It's a meta-analysis
and basically they said that over 11 millimeters is your,
when you pull the trigger to offer endometrial biopsy,
whereas under 11 millimeters,
the risk benefit ratio isn't appropriate there.
You can argue this, it was a meta-analysis,
but it's probably the best data that we have.
All the GYNs that I've talked to think this is reasonable.
Remember, we are not offering a screening exam here.
This is just when grandma comes in, she's not bleeding
and we're looking for an nexel mass or appendicitis
or whatever and we happen
to see something over 11 millimeters.

Tamoxifen

The last scenario is tamoxifen.
As we all know, Tamoxifen is
great at treating breast cancer.
It has the risk of breast cancer recurrence,
but it does increase the risk of endometrial issues.
This problem may be going away
as we're getting some more selective estrogen receptor
modulators, but they're still not in wide use right now.
And so just as in patients on hormone therapy,
the endometrium in patients on
tamoxifen is gonna be abnormal.
It stays abnormal for a long time
after you quit taking it,
it decreases about a mil per year right there.
So if you've been on tamoxifen for five years,
it may take a while for it to come back down to normal.
Bottom line, there's a little bit of controversy out there,
but all the GY I talked
to say we really shouldn't be imaging women on tamoxifen
because it's gonna look abnormal.
We're gonna get worried. So they
more or less treat symptoms.
If the patient's bleeding,
then they go ahead and deal with it.

So you can see in this case here we have a 34
millimeter thick endometrium.
Couple months later it's five centimeters thick,
looks very abnormal.
And these turned out to be benign polyps.

Summary of Thresholds

So to sum up all of this complex stuff here, postmenopausal
with bleeding, this is the most important category
over five millimeters.
It doesn't mean you have cancer,
but we need to evaluate if you're
postmenopausal bleeding on hormones.
If you're postmenopausal bleeding on tamoxifen,
we still use five millimeters.
If you're postmenopausal
and you're not bleeding, we use 11 millimeters.
And if you're premenopausal, we use 15 millimeters.
This is very complex.
Ruth did a superb job writing up the consensus statements.
So take a look at that if you have other questions.

Abnormalities Seen on Transvaginal Ultrasound

So now let's move on
to abnormalities seen on transvaginal ultrasound.
As we said
before at the beginning of the lecture, most women,
fortunately who are bleeding,
who are postmenopausal, don't have cancer.
Two thirds of the time it's atrophy.

So here's a great appearance of an atrophic endometrium
that just needs medical management.
Doesn't need anything else.

We can see polyps transvaginally.
Here's a classic appearance of a polyp.
This is not an SIS this is a regular vaginal scan.
This is kind of an interesting one
because again, this is not an SIS
but you can see the polyp kind of peristalsing back
and forth with myometrial contractions.
There. It has the classic appearance of a polyp
with a single blood vessel going into the stock right there.
And this was a benign polyp.

We've all seen a million fibroids.
The key thing here is submucosal location since we're
worried about abnormal bleeding.

And then the thing that we worry about
is endometrial cancer.
And even though this appearance here is great for a polyp,
it's homogeneous, it's hyper coic.
99% of this was benign polyp at surgery,
but 1% in the top left corner, there was a focus
of grade one adenocarcinoma there.

So focal masses are surgical masses.
They generally come out.

Other Diagnostic Modalities

Let's talk about some of the other
diagnostic modalities out there.
And again, it's not
that something is good and something is bad.
Each has strengths and weaknesses.

Now the classic imaging modality was the his ofs ping agram.
And we did that in the old days
before we had something better.
But it has completely fallen out of favor
for evaluation of the endometrium.
It has way too many false positives,
way too many false negatives.
Here are two different REI patients who had focal masses.
One of these turned out to be a polyp.
One turned out to be a cancer.
So the only thing we're doing these
for now is tubal patency, dilation and cure.
As my mother-in-law calls it dust and clean.

This is the classic diagnostic test.
Because of the morbidity discomfort cost involved,
it is no longer a diagnostic test.
It's just a therapeutic option.
The key thing about DNC is remember that you only sample 10
to 20% of the endometrial cavity.
So it's good for endometrial cancers
because cancers tend to be large
and they tend to shed cells.
But for focal lesions it's not nearly as good.

What's replaced,
DNC from a diagnostic standpoint is the endometrial biopsy
right there or EMB.
And there's a bazillion different catheters out there,
but basically you put them up
and you sample some of the cells.
This only samples 15% of the endometrial service.
So again, it's very good. It's not perfect.
And there are some papers that say
that endometrial biopsy is far from perfect,
but in general, most people say
that endometrial biopsy is good for cancer,
but it's horrendous for polyps.
In the Sloan Kettering study,
it picked up only 4% of polyps.
And as we try to distinguish between using
endometrial biopsy versus SIS,
endometrial biopsy hurts a lot more than SIS

hysteroscopy is kind of the gold standard.
Remember there are two different types.
There's in the office with a little midaz and fentanyl
and there's in the operating room we fill the cavity
with fluid put in our scope right there.
Obviously the operating room version,
you can use bigger scopes and see a lot more and do more,
but it's a lot more costly and has more morbidity there.
And there's a lot of papers that says that SIS is as good
or better than hysteroscopy in finding lesions.
Obviously we can't do something about the lesions once we
find them though with SIS let's now talk about,
saline infusion sonohysterography,
which I think is really underutilized,
in evaluation of the endometrium.

And we'll divide this lecture within a lecture
to an overview technique and then a bunch of examples.
And even if you do not do,
SIS,
although I hope you consider it,
I think looking at all these examples will make you
much better sonographer.

Saline Infusion Sonohysterography (SIS)

Overview

So there's a whole bunch of different synonyms out there
for SIS there and it's a mixture of the etymology of Greek
and Latin, but it literally means writing on the
uterus with sound there.

Primacy is always tough to distinguish,
but the first paper I found was by Nini in 1981.
It's still an active research area.
You know, over a five or six year period I found about
70 citations.
And that was just searching for one word.
If you search for all the other synonyms,
you'd find a lot more, we average about two a week.
You know, it's not high volume, but it's solid.
It's not a difficult study to perform.

One of the key things to remember about SIS
or any screening test is
that some expert in their ivory tower may have a wonderful
test, but if you and I can't use it
and we have 300 million people in America,
it's not gonna be a good test there.

So one of the beautiful things about SIS is
that the average person it works great for,
and there was one trial where they compared nurses
to second year resis to fourth year resis to fellows
and found equal accuracy.
They, another person basically
said the same thing there.

Now remember when we talk about SIS,
we always perform a full transvaginal ultrasound
as part and parcel of it.
We look at the uterus, we measure the fibroids
that are sticking off the side,
but we're not gonna talk about that here.
We're gonna focus about the SIS And in this era
of rising costs, you start to wonder, is this overkill?
We like technology in America,
but does it really change outcomes?

And so there's a very small minority of the papers that say
that if you're really good, you don't need SIS.
And that may be true if you're really, really good.

So here's an example of a small polyp right here
and I think we would all agree that it's there
and you see it much better on the SIS.
But conversely, take a look at this case,
here's the midline, and then to show you
that I'm not cheating, I'm sweeping from side to side,
showing you the entire endometrium
and even retrospectively, this looks normal to me.
We do the SIS and there's an obvious bump plain as day.

So the overwhelming bulk
of the literature says the transvaginal ultrasound is
not good enough there.
And just picking one paper out of there, a quarter
to a third of the women with a normal trans VG had
an abnormal SIS.

Indications

So what are the indications for SIS?
Pretty much anything to do with the endometrium, any kind
of anything that you can think of.
One of the classic indications is discordance.
Here's a 48-year-old who had irregular bleeding.
Her stripe was 17 millimeters there,
her path showed normal endometrium.
Well we've got discordance, we've got normal path at EMB,
but we have an abnormal stripe
and she's symptomatic, she's bleeding.
And as we said before, endometrial biopsy is pretty good
for cancer but it's awful for focal lesions.
So we went and did this SIS
and here you can see an obvious in three planes right here,
large four centimeter polyp and that explains her bleeding.

So our main goal is distinguishing focal disease
from diffuse disease.
There we're actually pretty good at distinguishing polyps
from cancer from fibroids, but we're not good enough.
So a bottom line, focal masses go in the bucket.
Focal masses are surgical masses.

Preparation and Technique

Preparation is key.
We already had the quote from John Wooten,
if you like military metaphors for semi surgical procedures,
a pin of sweat will save a gallon of blood.

So we schedule a patient early in her menes,
we give some Motrin couple hours ahead of time.
You wanna be a nice person and she'll be less anxious.
There are a couple other exceptions,
but those are so unusual.
Just take a look at the paper we wrote on this.

So why scan during days four to seven?
Well, there's a couple reasons.
Number one, you don't wanna scan a pregnant patient.
You don't wanna put a catheter or fluid in there.
So that's probably the main reason.
Number two, you're not gonna have
as many false positives both in the adnexa
and in the endometrium
because you're not gonna have as many ovarian cysts
that you have to follow and you're not gonna have the really
funky appearance to the endometrium.

So here's a example from a really nice paper by MJ O'Neill
and she shows on day 23 this very lumpy, bumpy,
secretory endometrium.
Could any of these be a polyp? Sure.
Could any of these be a cancer? Sure.
And then she brings her back.
And on day five it's completely normal.

So if we scan patients in the second half of their cycle,
we're gonna create a lot of havoc.
So we just wanna make a habit
of scanning everybody early in the cycle.
Then we get beautiful images like this.

Now obviously some women
with abnormal bleeding aren't gonna know when their period
is, so you just take them when you do them.
But many times you can make these studies diagnostic here
are two different patients who had blood in their cavity.
But you use the probe to kind of OTT it, break up the blood,
suck the fluid in and out,
and you can generally get a diagnostic study.
It just takes more work. So in terms of timing,
what's the optimal time to schedule either transvaginal
or SIS?
You have a bunch of options.
And again, the optimal time is day four to 10.
Now you could say day five to nine.
Day four to nine, but somewhere in
there, what are the risks?

Patients usually experience a little cramping
because you're descending the endometrial cavity.
So they think they're having their period, they may
or may not have a little bit of spotting.
You want to consent them for infection endometritis or UTI.
But I knock on wood, I've never had one.
These are really, really unusual
vasovagal reactions do occur.
I've had two and they've been very severe.
So you wanna be very gentle when you're
inflating the fluid there.

One of the things we worry about, one of the theories
for endometriosis is retrograde menstruation.
And you think we're putting fluid in
and washing the endometrial lining into the
peritoneal cavity.
So that is a theoretical concern,
but without going into the details,
it's not a practical concern.
It doesn't happen. In the same vein,
you have up staging, you're scanning postmenopausal patients
who are bleeding who may have endometrial cancer
and do we worry about blowing the cancer cells out into the
peritoneal cavity And up upstaging them there.
We had a nice paper where we put, baggies over the end
of the fallopian tubes
and then did SISs in the operating room collected
the fluid and looked at it.

So bottom line, it's theoretical concern, but it's not real.
And there's lots of data saying
that prognosis does not change when you do an SIS
or an HSG in patients with endometrial cancer.

And finally, perforation should essentially never happen.

Here's our typical tray set up for an SIS.
You can, you know, modify this however you want.
The catheter like so many things in life,
it's the operator, not the equipment.
This was a nice study where they used six different
catheters and 600 women
and there's not a big difference there.
We tend to use these specialized endometrial
or SIS catheters that you see on the left, which are more
or less modified Foley catheters.
I like these. But if you're doing mission work in Africa,
you can use a small diameter Foley.
You can use a five French soles catheter.
Catheter in the middle is an example
of a Goldstein catheter.

So all these things work, choose the correct speculum.
There are basically two types of speca.
There is the Peterson and there is the graves right there.
It doesn't matter that much,
but a medium Peterson's kind of small.
It's nice to start with if you have a mal tip who's,
obese, you may want to go with a large graves there.
Try to get the lighted speculums if you're
lucky enough to have them.
Many places aren't. So we just use the standard metal.

You want to insert the speculum, and backing up in terms of the type
of speculum right there if you have it.
Get the kind that is open on the side so that it's easy
to take the, speculum out without dislodging the catheter.
But again, many times we don't have access to those.
So you just have to feed the catheter down the
speculum while you're removing it.
And that works, to insert the speculum,
make sure it's warm, make sure it's lubricated when you go
in, go in at a 45 degree angle and cheat posteriorly
because the anterior in Troy s near the urethra is a lot
more sensitive.

So come in and push posteriorly once you get it in,
turn it straight up and down.
And here's just a diagram from bates's guide,
just beautiful images in there.

Then you open up the speculum
and here is the os.
Just looking at it straight on right there.
This is where you wanna spend your time.
You really want to get this picture right here.
Have good lighting so that you can get this
because if you try to cut corners here
and the os off to off to the side,
sometimes you can pass the catheter in,
but sometimes it gets very difficult.
So do it this way and it works easier.

The next most difficult part of the exam is
to pass the catheter right here.
And you know, people ask, well
how often are you gonna have problems?
And the answer is, it depends.
If you have an 80-year-old who's never had kids,
you're more likely to have cervical stenosis.
Whereas if it's a 40-year-old who's had eight vaginal
deliveries, it's probably gonna go pretty easily there

if you have a cervix that you just can't get through.
The first thing I generally try as a uterine sound,
always use the smallest one
that our trays come with all of these.
But I always use the skinniest one.
Remember we're not sounding the uterus,
we're just trying to get up the cervix.
We just want a little bit of pressure right there.

You can use a specialized catheter.
A buddy of mine who's an REI doc told me about this
egg retrieval catheter.
This is really nice here.
This is the patent egg retrieval catheter,
but I'm sure there are other bands out there.
You can just use a conventional oh three eight inch
glide wire and put a five French,
dilator over it and that'll work.
You can also use a tenaculum,
but remember that if you use this,
you wanna apply it properly.

So the cervix has, let's get back to our diagram here.
The cervix has its blood vessels coming in at the nine
o'clock position and the three o'clock position.
So you wanna put your tenaculum at noon right there.
And again, we are not doing surgery
so you need just a little traction.
So just put that down one click, go very slowly
and you'll get enough purchase right there

when you put the balloon in, put it in slowly
when you inflate the balloon, inflate the balloon slowly
when you infuse saline, infuse saline slowly
and that will,
rehabilitate against a vasovagal reaction.

Remember that you could have a polyp hiding
behind the balloon in the lower uterine segment.
So when you're done, you want to deflate the balloon
and then just pull out so
that you get a nice look at things You want to try.

As you get more experienced,
put the catheter in the cervical canal.
We had a paper in the Green Journal a couple years ago
where somewhat counterintuitively it actually hurt less if
you inflated the balloon in the cervix than in
the endometrial cavity.

So this is from the literature here, just showing the,
balloon inflated in the cervical cavity on
a hysterosalpingogram.
And here's one of our studies
where we've got the balloon inflated in the
cervix right there.
And the nice thing about this, A, it hurts less
and B, you use less fluid
because you don't have to do pullout imaging
because you can see the entirety of the endometrial cavity.

The flip side to this is that about 10%
of the time the balloon's gonna pop out
and you have to put the speculum back in again.
Failure rate depends totally on your pretest probabilities
right there, but it's around 10%.
As you get better, you'll have many fewer failures.
And remember that gynecologists working in the office
10% of the time they can't get in at office.
Hysteroscopy, what are some of the false positives
and problems you can have?

Air bubbles, the balloon obscuring,
the lower uterine segment crud, mimicking polyps,
mechanical shearing of the endometrium,
doing your study at the wrong time in the cycle.

So here's an example of air bubbles right there
and you can generally figure that out real time.

Again, we have to deflate the balloon
to examine the lower uterine segment properly.
If you have some grunge within the endometrial cavity
like we do here, you can deflate the balloon, kind
of scoop it in, break it up, suck it out, put in more fluid,
and then you get a really pretty study.

You can have blood clots
that mimic focal masses as we see here.
Could any of these be a polyp?
Could any of these be a cancer? Absolutely.
But we spent some time breaking these things up mechanically
sucking the fluid out.
And in the bottom right you can see we get a pretty
study after some effort.

If you're scanning in the secretory phase,
which you really don't want to be,
but you can shove the catheter in and raise a flap
and get a false positive for a polyp.

Color doppler, the rule in the books is
that a polyp contains a single vessel
and fibroids contain multiple vessels.
This is true most of the time,
but there are a lot of exceptions.
So it's not pathognomonic and you can't use it reliably.

If you have 3D by all means use it, you know.
So here's an example of a couple polyps there.
In reality, I think syn mode is just as good.
But if you have the 3D, it's great to use.
And here's just an example of a pre 3D,
getting the C plane there.

Pathology Examples

So which of these four patients has a malignant cause
for postmenopausal bleeding?
And we see bumps in all of them,
but this turns out to be retained.
Products of conception from mjs article.
Here's a bunch of polyps, here is a fibroid
and this is the endometrial cancer right here.

So we're pretty good at making path
diagnosis, but not good enough.

So in terms of pathology, we'll start
with endometrial polyps.
They're typically homogeneous hyper coic with a narrow base.
They account for about 30% of postmenopausal bleeding.
And what you want to do is tell your gynecologist
how many they are, where they are,
what the base of attachment is.

So we have longitudinal and coronal planes
and multiple polyps.
And again, we can't make histo diagnosis.
This looks like a polyp here.
It's great, it's homogeneous, it's hyper coic.
But when it was whacked out in the top right corner,
there was a small focus of grade one adenocarcinoma.

Here's just another example, you know,
and hopefully I'd call that on ev,
but you wonder if you'd pass by it.
But here it is on the SIS. Here's another example.
Here's an obvious polyp here,
but then what's this hiding behind the balloon?
So remember you always have to deflate the balloon
and here you can see the solitary feeding stock
of a second polyp.

Fibroids are really, really, really common.
The bottom line on these is you wanna figure out whether
it's more half in or half out.
If it's more than half in,
you can do a good job removing it hysteroscopically,
but if it's more than half in the myometrium,
you end up needing to go to a myomectomy.
So that's the information we want to give our GYN docs.

So here's just a classic appearance of a fibroid.
You have this cap of endometrium on top, the fibroid here,
and obviously both of these from mjs article are projecting
into the cavity and can be removed.
Hysteroscopically, here's one.
You know, would you call that transvaginally?
Might be tough, but with the SIS it's really easy to call
and you get a sense of how much
of it is sticking in the cavity.
And here you see multiple blood vessels in it.

Here's a another one right here.
And again, it's pretty easy to see that most
of this is sticking in the endometrial cavity
so it can be removed.
Hysteroscopically, here's another one right here.
Classic appearance, multiple blood vessels.
And you can see it nicely outlined by
that thin cap of endometrium.

Hyperplasia makes up about 6% of postmenopausal bleeding.
And there's a spectrum from simple hyperplasia without
atypia all the way up to severe atypia,
basically on the road to cancer right there.
Same risk factors as cancer.

So here you can see this irregular appearance here.
This turned out to be simple hyperplasia.
Here you can see something that looks like a polyp,
but there was complex hyperplasia without atypia within it.
Here you can see this plaque
and this turned out to be mild atypia.

And then the reason we're doing this whole talk
is endometrial cancer.
As we said before, it's the fourth most common cancer.
It's typically broad and large is we see right here.

So which of these is not endometrial cancer?
We're gonna come back to this in a couple minutes,
but I'm giving you four examples
of abnormalities in the endometrium.

So here's just a classic example.
Big lobulated, mass exophytic projecting into the cavity.
Here's another cancer from PC here we had a cervical
stenosis or occlusion with a malignant hetro.
You can see that there. Here's another
one from mjs article.
Very irregular lobulated maybe invading into the myometrium.
You can see these look the same.

And the key thing to remember here is
that endometrial cancer can be very scarce
and very infiltrative.
So if you're not getting good distention of the cavity,
worry that you have an infiltrative endometrial cancer there
and your odds ratio is around seven
or eight with poor distention.

And here's a experiment we did
where obviously this patient was not complaining
of pain when we were infusing fluid in clamp.
Both fallopian tubes got a great seal at the cervix
and pushing really, really hard.
I could barely distend the endometrial cavity right there.
And this was an infiltrating endometrial cancer.

Here's one looks great for a polyp.
Has a single blood vessel like a polyp,
but at surgery, the bottom right corner
of this had a tiny focus of papillary serous carcinoma.

So, again, focal masses are surgical masses.
Then you look at this one, lobulated, hyper coic irregular.
This is a classic appearance for endometrial cancer.
Turned out to be breast cancer
metastatic to the endometrium.

So we can't make path diagnoses.

So which one of these is not endometrial cancer?
And you can see multiple varieties right there.
But these top two turned out to be cancer.
This was cancer with in a polyp
and this was breast cancer metastatic to the uterus.

Can you use SIS and tamoxifen?
Some people say yes,
but the bulk of the majority says,
the endometrium is always gonna look abnormal
in patients on tamoxifen.
So talking to my gyno friends,
basically they don't recommend imaging, whether transvaginal
or SIS anybody on tamoxifen
because it's always gonna look abnormal.
You just wait till they bleed
and then you treat them at that point in time.

Other Uses

You can uses IS to evaluate infertility.
Here's a malaria infusion abnormality seen on SIS
Here's an example of asherman's syndrome.
Following DNC, we had multiple adhesions,
bringing the uterus down.

We can look at tubal anatomy.
We said that the only reason we're doing HSGs now is really
to look for tubal fill and spill.
Well, you can use ultrasound contrast agents
as you see in this video clip right here
and determine whether the tube is open or not.

And the we're obviously not gonna get nearly
as pretty pictures as we do
with the conventional history of cell picogram.
But if all we care about is the tube open
and spilling, this is good enough
and we get a much better look at the endometrium with SIS

you can use fancy ultrasound contrast agents
or you can just grab some room air,
put it in a 20 cc syringe
and slammed that in in terms
of intervention right here.

Bottom line, a couple people are working on this.
This is from a friend of mine and he's very talented
and he's got these Rube Goldberg type contraptions,
but it's not ready for prime time.

So basically if you see a polyp, then you need
to go to hysteroscopy.

Comparison to Other Modalities

How does SIS compare to other standards?
It's as good as diagnostic hysteroscopy under general
anesthesia at detecting focal lesions
and it's better tolerated than an office hysteroscopy.
There another quote you can avoid two outta
three hysteroscopies.
It's a lot safer, cheaper, quicker for the patient.
SIS is better tolerated, requires less intervention,
provides significant cost savings when compared
to office hysteroscopy.

Conclusion

So to sum up, we talked about why we worry terminology
and technique, what's abnormal in a variety of scenarios.
Abnormalities seen on transvaginal ultrasound,
other diagnostic modalities like,
DNC,
endometrial biopsy hysteroscopy.
Then we had a talk within a talk on saline infusion.
Sonohysterography divided into overview how to do it,
and then examples of multiple different pathology.

Remember, technique matters despite Tom Cruise buying his
own ultrasound machine there, it really helps
to know what you're doing there.

So know how to measure it.
Remember that under five millimeters reliably excludes
endometrial cancer over 11 millimeters in asymptomatic
post-menopausal women.
Not hard data, but most people would say
biopsy at that point.

And remember that SIS is easy to perform, works for all
of us who are average, has a short learning curve
and is a really, really good test.

And I want to thank all of these people
for slides and pictures.
Thank you.