Sonohysterography: Usual and Unusual Findings - SD

Introduction

I am Dr. Oksana Altaic from the Jefferson Ultrasound Research and Education Institute of Thomas Jefferson University in Philadelphia.

And I'll be speaking on sonohysterography usual and unusual findings.

This lecture was prepared in collaboration with Dr. Anna Loff from the radiology department at the hospital, the University of Pennsylvania, and many of our images are shared.

We're gonna talk about sonohysterography and go through some of the usual and unusual things that we see.

Procedure Review

Let's review the procedure.

The way we do it is we start with a vaginal speculum examination.

We find the uterine cervix, we cleanse it with Betadine, and then we thread a little catheter into the uterus, and blow up a little balloon.

Not necessarily, we don't have to blow that up.

Some people do it just with the straight little kind of catheter.

We prefer to do it actually with the little balloon.

I'll address that a little bit later. Why?

Then we would take out the vaginal speculum and put in the ultrasound probe, and then instill slowly, a little bit of sterile saline into the cavity, expand the cavity, and provide a nice contrast to see the endometrium, and we get such a picture.

This is a beautiful delineation of a smooth, thin endometrium with absolutely no intracavitary masses.

Indications

The indications for this procedure are to provide a detailed, non-invasive evaluation.

The endometrium, we do this in women who have abnormal uterine bleeding, whether they're pre or postmenopausal.

And even in women who have had a normal endometrium on transvaginal sonography, sonohysterography can find some abnormality in about 14% of cases.

This was written up in a JR in 2002, where women had symptoms.

Transvaginal sonography showed a normal endometrial thickness, but the sono histogram did actually contribute in to a diagnosis in 14% of cases.

We do it in patients who have endometrial thickening that's unexplained or needs further evaluation.

It can be done in women with infertility, and recurrent abortions to see the internal structure of the uterine cavity, in uterine disorders, congenital disorders or acquired.

When the endometrium is not visualized on transvaginal sonography, somebody has to be able to evaluate it.

And this is a good non-invasive way, or to further evaluate a finding on transvaginal sonography.

Contraindications

The contraindications are, of course, pregnancy.

We would not want to disturb a pregnancy and active pelvic infection.

We wouldn't want to spread the infection by flushing it backwards through the tubes.

So if the patient is in an active state, she should be treated with antibiotics prior to this procedure.

A lot of the women are perimenopausal postmenopausal, so pregnancy's not an issue.

There are relative contraindications, such as present of an intrauterine device, which nowadays it is possible to do this.

Although 3D sonography is now a very good way to look at these IUDs.

So it's really not necessary to introduce saline into the cavity.

When there are bilateral tubal occlusions, the fluid usually freely floats into the cul-de-sac.

So if the tubes are obstructed, we could introduce more infection that way.

Or if you actually seriously think a patient has endometrial carcinoma, then that's not a good idea to introduce fluid, because we're afraid of trans tubal peritoneal dissemination of these cancer cells.

That's a theoretical risk.

And sometimes we do end up finding endometrial cancers on by this technique.

But if you actually see a large mass and really think it is, we should not be doing this.

Usual Findings

So the usual finding is a thickened endometrium, which has to be explained further.

There are a few little cystic areas here.

The differential diagnosis here is thickening. Is it polyp?

Is it hyperplasia or possibly carcinoma?

Less, much less. It's not suspicious here at all.

That's why we do our sona histogram.

And we delineate a solitary large fibroid.

We can describe how broad-based connection it is to the endometrium and look for additional polyps.

Another patient postmenopausal with bleeding endometrium is too thick, thicker than five millimeters.

And we're looking to see is there a polyp in there, hyperplasia, possibly carcinoma.

And the sono histogram delineates an irregularly thickened endometrium, no polyps, so this most likely hyperplasia.

Another mass that's in the differential is the sub mucus myoma, which is not always clear how much of it is within the or how large the submucosal component is.

So the sonohysterogram delineates that very nicely for us.

Now, myomas tend to shadow, they tend to have some areas of shadowing, whereas the polyps tend to be homogeneous and hyper coic and do not shadow.

So here the sono histogram delineates, there's only one.

It shows us the connection, which wall helps the gynecologist plan their surgical removal.

Here's another patient, postmenopausal lady has some bleeding, and we see a myoma.

And we're not sure how much of it is submucosal, how much is intramural.

So we introduce a little bit of saline, and we see that the endometrial cavity is clean.

There are no areas of thickening, no polyps.

And this is a transmural myoma that does not really protrude into the cavity.

So there are no endometrial pathology.

Another patient with abnormal uterine bleeding.

And graphically, we're not even sure where the endometrium ends.

Is all of this a thickened endometrium when we measure it?

Is this adenomyosis?

So what's going on, sonohysterography beautifully shows us that the endometrial cavity is here.

All of this is adenomyosis involvement of this posterior wall.

So why would we do sonohysterography and not just go to biopsy?

Well, this does not replace the need for tissue sampling.

So this by no means replaces histologic evaluation.

So histology is what makes the definitive diagnosis.

But this is not replacing that.

What we're doing is we're providing a roadmap for the surgeon.

We're guiding them where to go for a focal resection in the hopes of decreasing the false negative rate of hysteroscopy, which does exist.

And we're picking up other findings.

There could be multiple polyps.

What about the patient who has a polyp removed hysteroscopically, but continues to bleed and eventually is found to have additional polyps in the cavity?

And sometimes there are mixed pathologies, not just a polyp polyp with submucosal myoma, polyp with some type of hyperplasia that's more serious.

So information is always helpful for the managing the physician.

Here's an example of what I mean by hysteroscopic false negative.

This lady had a she a h an office hysteroscopy.

But continued to bleed.

The hysteroscopy was negative.

Subsequently, a sonohysterogram was done, and this showed that there was a myoma in here.

There probably was some difficulty.

This uterus is kind of retroflexed difficulty getting to see the entire fundus.

And in here was a polyp, so we can find multiple abnormalities.

This patient had an obvious polyp, but there was a little one off on the side.

So now the doctor know, the gynecologist knows that there has to get two polyps out.

Here's a patient with a dominant polyp, and then a little adjacent one.

Here's one with three, a patient with multiple findings.

This patient had a diagnosis of complex hyperplasia with atypia and an endometrial polyp.

This patient had complex hyperplasia with atypia and associated polyps.

All of that has to be thorough tissue sampling has to be performed when we see something complicated, complex manifestation like this.

This patient had a polyp and a sub mucus myoma.

There's a shadowing from this myoma, and off to the side was a polyp.

And here's her cavity further away, actually, multiple polyps.

The typical endometrial polyp is a homogeneous hyper coic, smoothly marginated well-defined mass.

And this is obviously seen here on this empty display and on these rendered images we can even see it better.

Some places are now doing only 3D evaluation of the uterus and the endometrial cavity without the sono histogram.

Some places are still doing quite a bit of sonohysterography.

So the typical endometrial polyp is homogeneous smoothly marginated, hyper coic, intracavitary soft tissue mass with preferably visualization of a feeding stalk.

As we can see in this patient.

All three of these.

Unusual Findings

Unusual Polyps

Now, here are some unusual polyps that we've seen.

Here's a polyp that has a little extra bump on it.

Here's a little collection of polyps that look like little chicks lined up in a row.

Here's an elongated polyp.

Here's kind of very broad-based looking polyps.

Here's a polyp with some cystic changes in it, polyps that look a little more rectangular or tubular.

Here's polyps that have different oddly shaped ones kind of tubular.

Here's triangular rounded elongated with sort of flattened borders.

Here's a broad based one.

Here's an odd shaped one, another one that's shaped like a little hammer, so a variety of shapes.

Here's some more unusual ones. Cystic center.

Here's the one with the cystic center.

Here's kind of a bi lobe.

Here are several different, one patient with several different types and shapes, and kind of a bi lobe shape here.

More unusual polyps.

When we did the sonohysterogram, multiple polyps showed up.

Sometimes they look like teeth, like pumpkin teeth, a variety of shapes.

Here, again, very cap, a very ulous kind of a cavity outlining a whole host of variable types of polyps.

More unusual polyps.

This was a 26-year-old with dysfunctional uterine bleeding.

And pathology showed that she had multiple polyps and secretory endometrium at biopsy cystic changes we have to make note of cystic changes.

Tamoxifen polyps often have cystic changes.

And these are due to this mucinous metaplasia and a tipia that occur.

So we would like to have a history from the patient.

Usually breast cancer history that she was on a tamoxifen or some type of a serum, a cystic polyp may mimic fluid.

This looked like perhaps some fluid in the cavity until we put more fluid in and realized that that was a cystic polyp with atrophic changes.

And sometimes odd things happen, like in this case, the we blew up the balloon and we did see a polyp, but when we pulled the balloon back, we realized that there was a very large polyp, and the balloon was actually blown up inside of this polyp or pushing it aside.

And only after we pulled it back did we realize the extent of it.

Now, sometimes these polyps come on a long stalk, as we can see here.

They can move around, flip around in the endometrial cavity.

And also one little reminder here, when we do see endometrial polyps that on the way out as we exit, we should look for a cervical polyp as well.

Here, for example, is a little balloon still blown up.

We're after we deflate the balloon, we watch for exit.

And here we see some extra soft tissue within the cervix here.

And that was a cervical polyps.

So there is an association of cervical polyps with endometrial polyps.

Overall in about 27% of patients, we have a c.

There is a cervical polyp along with endometrial polyps in 40% of postmenopausal women, and in 40% of, and in all postmenopausal women on tamoxifen, they found that they had additional cervical.

So we polyps, so we should look for them.

One little technical point would be that watch the pressure on the cervix.

Sometimes we press too hard and we can't see the polyp.

It's only after we release some of that pressure that we allow a little bit of the fluid to come around the polyp, and then we can delineate it.

Here we're seeing power doppler.

Sometimes we see unusual things such as a polyp attached to a sub mucus myoma.

So here's the hypoechoic sound attenuating myoma, and a polyp stuck on top of the myoma.

Hyperplasia

There are usual and unusual manifestations of hyperplasia.

Typically, hyperplasia is a diffuse, smooth end endometrial thickening.

Pathologically, they're classified as simple hyperplasia, complex or atypical hyperplasia.

The atypical ones, 23% of them progress to endometrial cancer.

So it turns out that we really can't differentiate them from endometrial cancer.

So they need to be sampled thoroughly.

Unusual appearances of hyperplasia would be when they are more focal or asymmetrical or irregular in their outlines.

And they have in 26% of cases, they have concomitant polyps.

There is polyp or individual formation, and they can have cysts, and again, would be difficult to differentiate from endometrial cancer.

Here's a case of focal thickening in of the endometrium.

This was hyperplasia, and it had small little polypoid projections.

So this had to be biopsied.

It was focal hyperplasia as we see here.

Myomas

Now, a sub mucus myoma is typically a hypo coex solid mass with acoustical shadowing.

And it has a broad-based connection to the uterine endometrium wall and has a covering of endometrium on top of it.

And here's another one, hypoechoic shadowing kind of a mass.

The atypical myomas are the ones that may not be so obvious where exactly it is connected to the wall of the endometrium.

Sometimes they develop cystic changes within.

This was an unusual one that had a very thick stalk and projected inferiorly, and it had an area of cystic degeneration.

It was kind of difficult to figure out how exactly it was positioned.

Typically, they are fairly smooth, but in some cases, in unusual cases, they have more of a world kind of a pattern.

Another atypical kind of case would be when you have the myoma and sitting on top of it is a blood clot, another one here with a blood clot on top, causing it to have this kind of a mixed pattern.

The doppler can show us the feeding vessel to the myoma, and then we can the area of the clot sitting on top of the fibroid would have no blood flow.

Blood Clots and Debris

Now, other unusual things that we see, we can see various manifest various formations of blood clots, which of course have no blood flow within them.

When we see these kind of scraggly looking soft tissue densities, we can try to break them up with the catheter.

We push the catheter back and forth. We suck out the clots.

We might inject a little bit of the saline to make them help them break up.

We use a gentle catheter manipulation, and this flushing with saline for moving around blood clots, some kind of mucus or debris or adhesions.

We can aspirate the contents and then reinfuse and help break it up as this happened.

In this case, this was the balloon, and there was this fluffy soft tissue material on top.

And we flushed, reinfused aspirated.

And when we pulled back the balloon, the cavity was then clean.

So we flushed it out.

This debris may clump up, maybe a little blood clot, and can mimic a polyp.

We call these pseudo polyps.

And one way to get information about this is try this gentle catheter flushing technique.

And in this case, this was completely flushed out, and the cavity underneath it was normal.

So good thing to keep in mind.

More examples here from Dr. Les was a case that looked like it might be a mass of some sort, but catheter flushing was able to remove these blood clots.

And there was a normal cavity underneath all of this.

Another example of blood clots, in this case, a bit of a retracting clot, flushing technique dislodged the blood clot.

Another patient here who had a catheter manipulation.

There was this small little abnormality here, but when we did the flushing technique, it ended up being like a long loose adhesion that would whip around inside the endometrial cavity changing its position here and there.

And this woman was complaining of inability to become pregnant.

And it was thought that possibly this was serving as irritation to the endometrial lining, possibly functioning sort of like an IUD.

And there was a thought about if she doesn't is not able to get pregnant, possibly removing such a an adhesion and seeing if she does get pregnant.

Adhesions and Scarring

We can delineate adhesions and SUNY eye in the uterus.

Now, these then may mo vibrate a little bit during the flushing technique, but they don't disappear.

They stay in place.

They literally are unchanged in position with the catheter manipulation.

This can happen after there's been some type of uterine trauma, prior procedures et cetera.

And these patients, some may have menstrual abnormalities.

They may complain of fertility problems and pregnancy losses.

Here are couple examples of linear bands and adhesions delineated by fluid.

Here's a thick band or a signia in the uterus that was not changed with the flushing technique.

Sonohysterography has a sensitivity of 75%, and a specificity of 93% with a positive predictive value of 43% for adhesions and signia in the uterus.

The cavity does not distend very well because the adhesion is not allowing the uterine cavity to open up.

Sometimes we see thick bands of tissue.

Sometimes they're thin, they can be mobile, they can be adherent, they can be actually constricting.

Here's an example of sneaky eye that slightly moved, but did not change at all during the catheter flushing technique.

Here's a patient with an area of irregular thickening and band like adhesions scarring, a focal area of scarring.

She had had a prior abortion.

A patient with a post myomectomy adhesion, a scar that bridges the anterior and posterior wall and does not allow the walls to separate.

We can see this after abdominal myomectomy, or well, abdominal myomectomy in the sense when the endometrial cavity was inadvertently entered, or through hysteroscopic techniques where there has been some injury to the endometrial surface.

So in this case, the thickening was kind of nonspecific, but this did not change.

During cavity distention after DNC, we can see these kind of bands.

Here, again, a scar to the point where it actually can cause a uterine stenosis.

Here's some fluid within the cavity.

Here's the upper cavity, here's the lower cavity.

And this scar here.

This formed an actual area of stenosis.

Now let me prove that to you. Here.

We're gonna do a transverse section through the upper part of the cavity.

So we see a fairly normal cavity transversely.

Then we do a section through this scar area, and we see that the cavity becomes stenotic.

And then we do our third section below it, where once again, the cavity opens up.

So in the middle of the cavity, we have a stenosis from adhesions, giving it so-called hourglass appearance.

The cesarean section scars can be a problem for us.

Sometimes they may not allow the catheter to be placed completely into the a cavity.

But in those cases, the balloon can be blown up in the cervix.

And still we can get the information.

This was a sort of a stenotic segment in the lower uterine area, secondary to cesarean section scar.

We can fill these little niches, c-section niche scars with fluid.

Another patient here where we're filling out quite a deep surgical defect, we would like to alert the gynecologist that the covering is extremely thin, and actually can measure it and tell them how much myometrium covers that area.

Another patient with a cesarean section that ended up having a very thin, anterior lower uterine segment wall, only a four millimeter thickness that we reported to the gynecologist.

This patient had infertility.

She had had a prior myomectomy and was not able to get pregnant afterwards.

And when we dis tried to distend her cavity, it was impossible.

There were areas of shadowing and adhesions, so we were only able to fill a very small part of the lower uterine segment.

A little bit of air escaped into the interstices of the upper cavity, but the whole thing was scarred.

And this was an asherman's syndrome, where actually a little bit of that air was helpful to show that little parts could get in, but the cavity itself could not be distended.

After myomectomy, sometimes there's a defect in the endometrium, and that can fill out with fluid.

During Sonohysterography, giving this appearance of a myomectomy defect.

Adenomyosis

Occasionally you will witness during a sono histogram, suddenly the appearance of numerous bright reflectors throughout the myometrium.

They suddenly come out of nowhere.

So as soon as you instill a little bit of saline into the uterus without any kind of a force, suddenly you have these little micro bubbles of air, essentially, that have a lot of reverberations.

With our study where we have actually shown myometrial cracks in the uterus occurring with adenomyosis, we think that this is a manifestation of adenomyosis.

Let me show you a few more examples.

Here was a patient who had absolutely no bright reflectors in her wall.

As soon as we put the balloon in and instilled started instilling a little bit of fluid, these little bright reflectors appeared.

They were shadowing here, there were, and they increased in number as we instilled a little more of this fluid.

Here's another uterus, looks like we're expecting to see some adenomyosis here.

The minute we inject a tiny amount of fluids.

Suddenly a collection of little micro foci of bright reflectors appears what we think is air that might've been in the catheter.

And this was absolutely not present prior to the installation of fluid.

We have found that these that we can actually fill these some of these cystic spaces during the sonohysterogram as happened in this patient, there was no fluid here.

And then we were, here's the myometrial crack, and then filling of this space.

So in those other cases, we think that the micro air bubbles escape in through these little tiny cracks into the myometrium.

This is another patient that had absolutely no cystic changes.

But after filling the cavity, there was a fluid filling, a little outpouching with a connection with this crack in the myometrium.

The another example here of a patient with a focal adeno myoma here, a heterogeneous rounded area, no real mass effect blood flow throughout the mass.

And as we started filling, we have bright reflectors that suddenly occur.

And over the course of time, fluid shows up in the wall.

So this, there must be some little small connection that is allowing this fluid to fill.

In some cases, it may be impossible to extend the cavity, especially if it's been scarred.

And sometimes it's the air that actually may help you.

During the sono histogram, this patient had postmenopausal bleeding.

And when we instilled a little bit of fluid, we could not really distend the cavity, but a little bit of air was able to find its way.

And we were trying to delineate the endometrium, but realized that suddenly this was actually filling a larger area of myometrium, showing little tracks of how this air escaped.

And infiltrated here into the myometrium, proving to us, we think that there were connections with the endometrium, and infiltration with adenomyosis.

Now, there was no force applied here, absolutely at all.

This patient certainly wouldn't have even allowed that.

And we have this distribution of air then throughout the myometrium as a sign of adenomyosis, which by the way, was proven in this case with MRI.

Congenital Anomalies

Congenital anomalies.

We see we can introduce fluid into the cavity.

Here. We can see this is in conjunction with 3D, from Dr. Anna Loff loaned me these cases, where we have fluid filling one horn and not the other horn.

In this patient with a long septum that separated the two cavities.

Another patient where fluid did fill two horns because the septum was incomplete.

And therefore a sub septate kind of a uterus, which in some cases may have additional pathology, such as a polyp on this one.

Couple polyps on this other patient sub septate uterus.

And here's a Sona histogram with an unusual T-shaped uterus.

Patient who had been on DES, mother was on DES, and patient developed a t-shaped uterus.

And subsequent infertility.

Intrauterine Devices

Another case loan from Dr. Loff, sonohysterography could help us out with abnormal positions of intrauterine devices.

Here was a case where we did instill a little bit of fluid because it wasn't clear to us what happened with this arm of the IUD.

Was it broken? Was it just bent, turned out that it was just bent and had a little bit of infiltration.

Nowadays, using 3D Sono sonography could be a very good way of just doing this without the SHG part.

Unusual Endometrial Masses

Sometimes you'll see unusual endometrial masses.

In this case, it was a soft tissue mass within the cavity, which had a cystic change.

And pathology revealed that this was a polypoid adenoma, which is really focal adenomyosis tissue bulging into the cavity.

Here's another patient, another one with an unusual mass.

Both of these had a cystic change within them, but not that that's very specific.

And pathology, again, revealed a polypoid, adeno myoma.

Another patient with an unusual mass after surgical removal.

This was an adeno fibroma.

Another case here looks almost kind of like a fibroid.

Here's a cavity that has little tiny irregularities along the margin of the wall.

Biopsy showed that this was a uns sloughed endometrium related to progestational therapy in this patient was put on progestin.

So we have a little nodular irregular endometrial thickening in this patient.

Here's another patient that had some bleeding, and sono histogram showed this little tiny irregularities, which tissue sampling revealed that the biopsy revealed that it was an endometrial polyp with histologic features of progestational therapy, but there was no evidence of malignancy.

Endometrial Cancer

Now, sometimes we do make the diagnosis of endometrial cancer on a sono histogram, even though it's not intentional.

This looked just like a thickened endometrium.

It looked fairly homogeneous.

There was no reason to suspect really that there was a cancer.

But once a fluid was placed into the cavity, it was found that there was a very hypervascular irregular mass.

This is from Dr. Scout showing us here a case of endometrial cancer.

So even though we don't want to do it occasionally, we may end up showing this.

Its histography postmenopausal bleeding is a presenting sign in 80 to 85% of endometrial cancers.

And endometrial cancer accounts for only 10 to 20% of postmenopausal bleeding.

So a lot of things out there are not cancer.

That's why occasionally we will see it on the sonar histogram.

Most of the time, postmenopausal bleeding is due to atrophy, postmenopausal atrophy, which accounts then for 40 to 50% of patients with bleeding and their cavities are normal.

The blood in a cavity that has endometrial cancer can provide sort of a natural sono histogram.

We're not placing any fluid in this cavity.

This is just bleeding within the cavity outlining these soft tissue irregularities.

Here's another patient that we attempted to do a sono histogram, but the cavity was indispensable.

The little bit of fluid that went in outlined a lot of irregularity, so we immediately stopped the procedure, and biopsy showed that this was cancer.

Now, that's one of the benefits of doing a balloon inflation because you can talk about the cavity dis extensibility.

Another benefit of doing the balloon is with the adenomyosis, because we feel that when we distend the cavity with that little extra pressure, that could open up some of these myometrial cracks, and help us show a connection with the endometrium.

But as far as this goes with a non distensible cavity, that could be a sign of malignancy.

Here's a couple more, few more images of patients with a natural sonar histogram, meaning that this fluid is blood outlining these very irregular lobulated usually hyper coic masses.

That is endometrial carcinoma.

Again, natural hgs outlining very irregular thick tissue in postmenopausal Ute, right?

More samples of endometrial cancers.

This was inadvertently sono histogram was done.

It's thought to be the probably a polyp in there turns out to be cancer.

Conclusion

So, atypical sonohysterography findings may be seen with unusual polyps, sub mucus, myomas, hyperplasias, debris, blood clots, mucus strands, adhesion.

SUNY give us atypical findings.

There's a variety of scars, including asherman's syndrome, c-section scars.

There are unusual appearances of congenital anomalies.

We talked about these adenomyosis tracts that we're picking up that can, we either can fill them with fluid, and we believe that we're filling them with some air bubbles.

There are unusual endometrial masses that occasionally we can encounter.

And at the very end, rarely you may encounter inadvertently in endometrial carcinoma.

So I thank you for your attention.