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Endometrial sonography
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Normal endometrium
Premenopausal Endometrium
• During menstruation---- a thin echogenic line, 1–4 mm in thickness
• In early proliferative phase of the menstrual cycle(after day 6) becomes thicker (5–7 mm) and more echogenic relative to the myometrium, (glands, blood vessels, and stroma)
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• Late proliferative (periovulatory) phase
• a multilayered appearance.
• an echogenic basal layer and hypoechoic inner functional layer, separated by a thin echogenic median layer.
• may measure up to 11 mm in thickness.
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• During the secretory phase, becomes even thicker (7–16 mm) and more echogenic .
• stromal edema and glands distended with mucus and glycogen.
• increased posterior acoustic enhancement.
• The endometrium typically reaches a maximum thickness during the mid secretory phase
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On Ultrasound
• Endometrial thickness is measured from echogenic border to echogenic border across the endometrial cavity on a sagittal midline image.
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Postmenopausal Endometrium
• should be thin, homogeneous, and echogenic.
• Homogeneous, smooth endometriameasuring 5 mm or less are considered within the normal range with or without hormonal replacement therapy.
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Endometrial Polyps
• a common cause of postmenopausal bleeding
• most frequently seen in patients receiving tamoxifen or HRT.
• may be broad-based and sessile or pedunculated.
• Typically measure 5-15mm.
• The point of attachment should not disrupt the endometrial lining.
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Ultrasonographic appearance
• frequently identified as focal masses within the endometrial canal.
• as nonspecific endometrial thickening.
• Color Doppler US may be used to image vessels within the stalk
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Sonohysterogram reveals a small polyp attached by a stalk to the endometrium.
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Endometrial polyp.
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Multiple endometrial polyp.
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• Endometrial fibroids are hypoechoic, well demonstrated in echogenic endometrium of secretory phase and have peripheral vascularity, typical of fibroids
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Endometrial hyperplasia
• an abnormal proliferation of endometrial stroma and glands
• represents a spectrum of endometrial changes ranging from glandular atypia to frank neoplasia
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Causes
• Polycystic ovaries
• Obesity
• Exogenous hormones
• Endogenous excess estrogen production
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Ultrasonographic appearance
Endometrial hyperplasia is considered
• when the endometrium exceeds 10 mm in thickness, especially in menopausal patients
• In postmenopausal women 5mm thickness is significant.
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Endometrial hyperplasia. US image shows an endometrium with diffuse thickening (maximum thickness, 1.74 cm) due to hyperplasia. This finding was confirmed at biopsy.
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Endometritis
• Acute endometritis presents as thick, isoechoic endometrium with disruption of junctional zone
• minimal fluid in endometrial cavity and increased vascularity, even in early follicular phase.
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Synechiae
• When the endometrium is triple line or the cavity is distended with the fluid, synechiae are seen as lines bridging between layers of endometrium
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• Other endometrial lesions are postcurettageendometrial collection, vesicular mole, missed abortion, incomplete abortion, etc.
• These are all avascular and show heterogeneous echogenicity. Clinical history guides to the diagnosis
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• Vesicular mole shows a thick echogenic endometrium with small anechoic areas snowstorm appearance.
• This echogenicity is higher than that of a normal secretory endometrium as it is because of decidual reaction.
• If it becomes malignant, it would break the endometriomyometrial interface
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