Ultrasound of the Uterus and Endometrium

Endometrial Polyps

Endometrial polyps are typically echogenic, focal thickening, sometimes with an associated vascular stalk demonstrated on color Doppler interrogation.

They're typically benign tumors of the surface end endometrium with centrally positioned blood vessels.

Occasionally sessile, more often, pedunculated usually solid occasionally with cystic components.

Rarely these lesions have a pre-malignant potential, particularly when large and seen in older patients, they're associated with intra menstrual spotting and are treated with hysteroscopic resection went symptomatic.

Fibroids (Myomas)

Another patient presented with abnormal bleeding. In this instance, the patient had known myomas a few words about fibroids or omas.

They're the most common benign solid tumor in women and the main indication for hysterectomy in the us Approximately 20 to 40% of women have symptomatic fibroids.

Those symptomatic, those symptoms typically being bleeding, pelvic pressure or pain, and about half of fibroids are asymptomatic.

For reasons not well understood. There have increased incidents in African American women.

Fibroids are known to respond to hormonal stimulation, so may increase rapidly in early pregnancy and tend to decrease in size after menopause.

Transabdominal views of this enlarged uterus by convention, the u myomas are included when reporting the overall uterine dimensions.

So long axis, AP and transverse dimensions of this uterus shown here, and endo vaginal views, we see an anterior, left fundal subserosal myoma and a submucosal myoma.

The terminology would, a suggested terminology would be several myomas, including a centrally positioned likely submucosal myoma distorting the endometrium.

Such a myoma can be associated with abnormal bleeding.

Here is a netter diagram and a pathologic correlate demonstrating the different locations and terminology for myomas involving the uterus.

These terms can be helpful when describing what is seen on ultrasound as these locations may be associated with differences on physical exam or, regarding, clinical history and bleeding patterns.

The bleeding associated with fibroids is usually menorrhagia, heavy menstrual bleeding, occasionally bleeding between periods.

Menometrorrhagia particularly if those fibroids are submucosal or intracavitary.

Some women present with pressure symptoms, dysmenorrhea or pelvic pain.

Adenomyosis

Another patient who presented with abnormal bleeding and an enlarged uterus on exam demonstrated. This on ultrasound, the uterus is enlarged, but unlike the last case, it has a globular and smooth configuration rather than discrete focal myomas, which could be measured.

The entire myometrium is heterogeneous and altered in echogenicity.

This enlarged g globular uterus with heterogeneous echo texture and tiny myometrial cysts is a manifestation of adenomyosis.

It's worth remembering. This is different from mys involvement and is managed different. Clinically it's worth thinking of this condition as endometriosis of the myometrium with ectopic endometrial tissue involving the muscle.

If it is unclear on ultrasound, this diagnosis can be pursued by means of pelvic MR scan.

This condition is treated medically, not surgically, yet.

Large Exophytic Myoma

Another case presented with abnormal bleeding, also with an enlarged uterus. On exam, these views demonstrate the uterus with the caliber placed demonstrating uterine size long axis, AP and transverse.

And it's worth, realizing that this patient who had a very large myoma shown here, on images which no longer demonstrate the uterus, posterior to the bladder, would be described as such.

The uterine dimensions given initially do not include this large dominant exophytic subserosal myoma arising off the fundal aspect of the uterus.

It's worth making clear in a report while the convention is to include the uterine myomas in an overall, dimensions of the, uterine size.

There are times when it's a clearer under, more clearly understood when described in this way, an exophytic myoma measured and reported separately.

These details are important to the gynecologist making decisions regarding clinical management of symptomatic fibroids.

The surgical treatment for fibroids is myomectomy. The approach hysteroscopic laparoscopic or transabdominal is determined in large part by the size and location of the fibroids we see are there.

Management options include uterine artery embolization or hysterectomy, another patient with abnormal bleeding and known myomas presented for an ultrasound.

Submucosal Myoma and Sonohysterography

And on these two endo vaginal images, you'll see there's a subtle solid mass, nearly a cowork with adjacent myometrium, centrally positioned outlined on these, on these views, the centrally positioned solid mass suggests the submucosal myoma.

An appearance such as this would often prompt an additional evaluation by means of sonohysterography, sometimes referred to as saline infusion sonohysterography, a maneuver by which fluid is instilled into the uterine cavity and additional ultrasound images obtained.

The indications for this procedure include abnormal bleeding in the pre or postmenopausal patient, a suspected abnormality as in this patient with what appears to be a submucosal myoma, or in those instances where imaging of the endometrium on conventional views is inadequate.

The questions pursued by this maneuver include is there an endometrial lesion, is it a focal or diffuse one?

And based on these findings, the next step is determined random biopsy, DNC or hysteroscopy listed.

Technique for Sonohysterography

Here are the, items needed for performing these procedures.

It's very much like doing a, hys ping agram.

The difference being that the catheters instilled with fluid, not contrast, not air, and additional endo vaginal images are obtained.

The technique involves a preliminary bimanual exam to identify the location of the cervix and always a preliminary endo vaginal ultrasound. Assessment On occasion, patients are premedicated.

We visualize and cleanse the cervix, insert the catheter flushed with saline to avoid injection of air bubbles, remove the speculum, insert the transducer, and during continuous ultrasound visualization, instill sterile saline into the lumen of the uterus.

We document this, maneuver, typically with cine clip images.

Here is a normal uterus shown by sonohysterography in the sagittal and transverse planes, uniform thin endometrium and fluid instilled into the normal uterine cavity.

Examples of Sonohysterography Findings

Back to the case that prompted this conversation about sonohysterography. We see now that fluid partially surrounds this solid mass, which pro protrudes into the uterine cavity, representing a submucosal, predominantly intra cavitary myoma, the reason for the patient's abnormal bleeding.

Another example, similar in appearance, unconventional views. We see a solid centrally positioned mass when fluid is instilled into the uterine cavity by means of sonohysterography, that mass is nearly surrounded by the instilled sterile saline indicating a predominantly intracavitary myoma, and that's how it would be worded, predominantly intracavitary solid lesion myoma greater than 50% intraluminal.

The reason that these details are important is that it informs the decision regarding possible hysteroscopic resection of the myoma.

This maneuver works well with intracavitary myomas that are less than five centimeters in diameter, and at least 50% intracavitary.

Various gynecologic methods are used to excise the lesion and sometimes, following a hysteroscopic myomectomy endometrial ablation may be performed.

Again, crediting Dr. Mindy Goldman, my colleague in the gynecology department at UCSF.

Here's an example of a procedure being performed excising a predominantly submucosal intracavitary myoma.

This device is morcellating the myoma, removing it and leaving an otherwise normal thin, endometrium.

This in this way, treating the cause of her persistent abnormal bleeding.

Additional Considerations for Sonohysterography

One other comment about sonohysterography and the findings made these endo vaginal views are somewhat difficult to interpret obtained during the performance of a sono histogram.

In such instances, it may be helpful to take an additional transabdominal view and realize that what is demonstrated here is a very large transmural anterior myoma. With fluid now, instilled into the uterine cavity.

We pay particular interest to endometrial thickness in patients with abnormal bleeding, but sometimes it's hard to see the endometrium well, and my suggestion is if the endometrium is not well visualized on conventional views, don't guess or force a thickness onto the images.

If bleeding persists and the endometrium is not reliably assessed by ultrasound, sonohysterography plays a role in this instance.

And a guess at an endometrial thickness was obtained and it became clear following installation of sterile saline that there is a large heterogeneous, intracavitary mass.

In this case, a polyp better appreciated when it was surrounded by fluid.

Another instance, where Sonohysterography can prove useful is when the endometrial biopsy findings and the ultrasound findings are discordant.

This endometrial thickness appeared thick. However, the biopsy result, obtained revealed atrophy.

That discordance prompted a sono histogram, and it was clear when fluid was instilled that the thickness was due to an endometrial polyp, which was missed on random biopsy.