3. NORMAL ENDOMETRIUM
• Endometrium undergoes cyclic changes which prepare it for
implantation of a fertilized ovum.
• The normal endometrial cavity is seen as a thin echogenic line.
• The sonographic appearance of the endometrium varies during the
• The endometrium is composed of a superficial functional layer and a
deep basal layer.
4. • Functional Layer (stratum
-Changes in response to ovarian
-Sheds during menstruation
• Deep basal layer (stratum basalis)
-Remains intact during the cycle
-Contains spiral arteries which supplies
the functional layer as it thickens
-Unresponsive to ovarian hormones.
5. • The endometrium is best measured
- on a midline sagittal scan of the uterus
- should include both anterior and posterior portions of the
- It is important not to include the thin hypoechoic inner layer of
myometrium in this measurement.
6. • The menstrual phase
endometrium consists of a
thin echogenic line.
• During the proliferative
phase, the endometrium
thickens, reaching 4 to 8 mm
• Periovulatory phase .
endometrium measures 6-
10mm and gives three layer
7. Normal, thin ,early proliferative
endometrium with triple-layer
appearance. Central echogenic
line is caused by opposed
surrounded by a thicker
hypoechoic functional layer,
bounded by an outer echogenic
Normal, early-secretory phase
endometrium. The functional
layer surrounding the
echogenic line has become
8. Normal, thick, hyperechoic late-secretory
• Secretory phase.
The endometrium in this
phase measures 7 to 14
mm in thickness.
11. POSTMENOPAUSAL ENDOMETRIUM
• Postmenopausal Endometrium should be
thin, homogeneous, and echogenic.
• Homogeneous, smooth endometria
measuring 5 mm or less are considered
within the normal range with or without
hormonal replacement therapy.
• The endometrium in a patient
undergoing hormonal replacement
therapy may vary up to 3 mm if cyclic
estrogen and progestin therapy is being
12. HYDROMETROCOLPOS AND
• Obstruction of the genital tract results in the accumulation of
secretions and blood in the uterus(metro) and/or vagina (colpos),
with the location depending on the amount of obstruction.
• Before menstruation, the accumulation of secretions in the vagina
and uterus is referred to as hydrometrocolpos.
• After menstruation, hematometrocolpos results from the presence
of retained menstrual blood.
15. ENDOMETRIAL HYPERPLASIA
-Proliferation of glands of irregular size and shape, with an increase in
the gland/stroma ratio compared with the normal proliferative
-The process is diffuse but may not involve the entire endometrium.
-Hyperplasia without cellular atypia (<2%progress to carcinoma)
-Hyperplasia with cellular atypia (25%progress to carcinoma)
16. • Each of these types may be further subdivided into:
- simple (cystic) hyperplasia the glands are cystically dilated and
surrounded by abundant cellular stroma
-complex (adenomatous) hyperplasia the glands are crowded
together with little intervening stroma.
17. • Endometrial hyperplasia is a common cause of abnormal uterine
• Develops from
-unopposed estrogen stimulation in postmenopausal women.
-It is usually caused by unopposed estrogen HRT in perimenopausal
18. • Causes of endometrial hyperplasia
- persistent anovulatory cycles
- polycystic ovarian disease
- obese women with increased production of endogenous estrogens.
-estrogen-producing tumors ovarian granulosa cell tumors, endometroid Ca and
-Tamoxifen therapy=> associated with endometrial polyps, adenomysosis, carcinoma
19. • Ultrasound Findings
-Endometrial hyperplasia is considered when the endometrium
exceeds 10 mm in thickness, especially in menopausal patients
-In postmenopausal women, 5mm thickness is significant.
-May also cause asymmetric thickening with surface irregularity, an
appearance that is suspicious for carcinoma.
20. Thickened endometrium caused by multiple
small polyps confirmed on sonohysterogram
Thick, cystic endometrium caused by
hyperplasia in patient taking tamoxifen
1. normal thickening
during the secretory
2. sessile endometrial
3. submucosal fibroids,
4. Endometrial cancer,
5. adherent blood clots
6. Pregnancy and ectopic
7. Incomplete abortion
21. • Endometrial hyperplasia has a nonspecific appearance so any focal
abnormality should lead to biopsy if there is clinical suspicion for
22. ENDOMETRIAL ATROPHY
• The majority of women with postmenopausal uterine bleeding have
-endometrial glands may be dilated
-cells are cuboidal or flat
-the stroma is fibrotic
23. • On transvaginal sonography
-an atrophic endometrium is usually thin
-measuring less than 5 mm
these patients, no further investigation or therapy is necessary.
• A thin endometrium with cystic changes on transvaginal sonography
is consistent with a diagnosis of cystic atrophy, but when the
endometrium is thick, the appearance is indistinguishable from that
of cystic hyperplasia
24. ENDOMETRIAL POLYPS
• Endometrial polyps are common benign lesions more frequently seen
in perimenopausal and postmenopausal women.
• Polyps may cause uterine bleeding, although most are asymptomatic.
• In the menstruating woman, endometrial polyps may be associated
with intermenstrual bleeding or menometrorrhagia and may be a
cause of infertility.
25. • Histologically
- polyps are localized overgrowths of endometrial tissue covered by
epithelium and projecting above the adjacent surface epithelium.
- broad based
- may have a thin stalk
26. • Ultrasonographic findings
-Frequently identified as focal masses
within the endometrial canal.
-Or as nonspecific echogenic
-They may also appear as a focal,
round, echogenic mass within the
endometrial cavity. Transvaginal scan shows a thick
endometrium (arrowheads) with central
round polyp (arrow)
27. • Color Doppler US
-used to image vessels within the
-A feeding artery in the pedicle can
frequently be seen with color
Doppler ultrasound (pedicle artery
Color Doppler ultrasound shows feeding
29. • Sonohysterography
-Polyps are best seen at
-appear as echogenic, smooth,
intracavitary masses outlined by fluid
Sonohysterogram confirms polyp (arrow)
and thick endometrium (arrowheads)
caused by hyperplasia.
32. • MRI T2-weighted MR imaging
-Appears as low-signal-intensity intracavitary masses surrounded by
high-signal-intensity fluid and endometrium.
33. ENDOMETRIAL CARCINOMA
• Most common carcinoma of the female reproductive system.
• Most endometrial carcinomas (75%-80%) occur in postmenopausal
women, age 55-62years
• The most common clinical presentation is uterine bleeding.
34. • strong association with
-estrogen replacement therapy in postmenopausal women.
-anovulatory cycles in premenopausal women.
• An increased risk of endometrial carcinoma has been reported in
patients receiving tamoxifen therapy, as well as an increased risk of
endometrial hyperplasia and polyps.
35. • Other risk factors include
- low parity
36. Carcinoma of the endometrium staging (FIGO)- International federation of Gynecology and
Obstetrics, revised 2009
37. • Ultrasound Findings
- A thickened endometrium must be
considered cancer until proven
-The thickened endometrium may be well
defined, uniformly echogenic, and
indistinguishable from hyperplasia and
38. • Cancer is more likely when the
endometrium has a heterogeneous
echotexture with irregular or poorly defined
• Sonography may be used in the
preoperative evaluation of a patient with
endometrial carcinoma by determining
myometrial invasion. transvaginal scan, show a large,
heterogeneous endometrial mass
(arrowheads) compressing the
39. • An intact subendometrial halo (inner layer of myometrium) usually
indicates superficial invasion, whereas obliteration of the halo
indicates deep invasion.
• Endometrial carcinoma may also obstruct the endometrial canal,
resulting in hydrometra or hematometra.
• Although certain sonographic appearances tend to favor a benign or
malignant etiology, there are overlapping features, and endometrial
biopsy is usually required for a definitive diagnosis.
40. Transvaginal scans show localized irregular endometrial thickening with echogenic polypoid projections
(arrows) into the fluid-filled endometrial canal.
41. • color and spectral Doppler ultrasound
- Blood flow is difficult to detect in the normal endometrium.
42. • Endometrial thickness
-A better method for discriminating between normal and pathologic or
benign and malignant endometrium than Doppler ultrasound of the
uterine, subendometrial, or intraendometrial arteries
43. • MRI
• Ideal imaging modality for staging of endometrial Ca.
• An important predictor of lymph node metastases.
• Also allow accurate assessment of more advanced disease such as
cervical stromal invasion or adnexal involvement.
• Contrast-enhanced MRI has been shown to be superior to both in
demonstrating myometrial invasion.
• MRI can also assess cervical extension (stage II) and extrauterine
extension (stages III and IV).
45. • On unenhanced T1-weighted images
-Endometrial cancer is isointense relative to hypointense normal
• On T2-weighted images
-shows heterogeneous intermediate signal intensity relative to
hyperintense normal endometrium.
• Relative to normal myometrium, the tumor is mildly hyperintense on
• At conventional MR imaging, the depth of myometrial invasion is
optimally depicted with T2- weighted sequences.
-A nonsteroidal antiestrogen compound which is widely used for
adjuvant therapy in premenopausal and postmenopausal women with
-Tamoxifen acts by competing with estrogen for estrogen receptors.
48. • In premenopausal women
-Tamoxifen has an antiestrogenic effect
• In postmenopausal women
- It may have estrogenic effects.
• An increased risk of endometrial carcinoma, endometrial
hyperplasia and polyps has been reported in patients receiving
49. • On sonography
-Tamoxifen-related endometrial changes are nonspecific and similar to
those described in hyperplasia, polyps, and carcinoma.
-Cystic changes within the thickened endometrium are frequently seen
-Polyps are frequently seen.
-A correlation exists between increased endometrial thickness and
duration of tamoxifen therapy longer than 5 years.
50. • In some patients taking tamoxifen, the cystic changes actually have
been shown to be subendometrial in location and represent
abnormal adenomyosis-like changes in the inner layer of
• Because it may be difficult to distinguish the endometrial-myometrial
border in many of these patients, sonohysterography is valuable in
determining whether an abnormality is endometrial or
• May occur
- after D&C
- association with PID.
• the endometrium may appear thick and/or irregular, and the cavity
may or may not contain fluid.
• Gas with distal acoustic shadowing may be seen within the
54. ENDOMETRIAL ADHESIONS
• Endometrial adhesions (synechiae, Asherman’s syndrome) are
posttraumatic or postsurgical in nature and may be a cause of
infertility or recurrent pregnancy loss.
• The sonographic diagnosis is difficult unless fluid is distending the
55. • Transvaginally
- Irregularities or a hypoechoic
bridgelike band within the
- This is best seen during the secretory
phase, when the endometrium is
56. • SHG is an excellent technique for demonstrating adhesions and
should be performed in all cases of suspected adhesions.
• Adhesions appear as bridging bands of tissue that distort the cavity
or as thin, undulating membranes best seen on real-time sonography.
• Thick, broad-based adhesions may prevent distention of the uterine
cavity. The adhesions can be divided under hysteroscopy.
57. INTRAUTERINE CONTRACEPTIVE DEVICES
• Sonography has an important role in evaluating the location of
intrauterine contraceptive devices (IUCDs).
• IUCDs are readily demonstrated on both transabdominal and
• They appear as highly echogenic linear structures in the endometrial
cavity in the body of the uterus.
• Acoustic shadowing from the IUCD is usually demonstrated, and two
parallel echoes (entrance-exit reflections), representing the anterior
and posterior surfaces of the IUCD, may also be observed.
58. • Sonography can demonstrate
-Eccentric position of an IUCD suggests myometrial penetration.
• If the IUCD is not seen on sonography, a radiograph should be taken
to assess whether it is lying free in the peritoneal cavity or is not
present, having been previously expelled.
60. Adenomyosis Radiopedia and Haaga 6/e
• Focal – adenomyoma
Enlarged globular uterus (AP asymmetry)
Myometrial heterogeneity due to endometrial implants and smooth muscle
Diffuse echogenic nodules 2-6 mm
Subendometrial cysts (HHG in cysts)
Endometrial pseudowidening- due to poor endomyometrial junction
Rain shower appearance: multiple fine areas of attenuation throughout the
61. • MRI:
• T2 ill defined thickening of low T2 signal band
• JZ: <8 mm excludes the diagnosis
• 8-12 mm Possible cases
• Supporting features:
• High T2 si linear striations (finger like projections) extending out from
endometrium to myometrium
• T1WI high si foci: endometrial rests +- punctate HHG
• >12 mm highly specific for adenomyosis
The proliferative phase of the cycle
- before ovulation is under the influence of estrogen.
The secretory phase
-following ovulation progesterone is mainly responsible for maintenance of the endometrium
A. A relatively hypoechoic region that represents the functional layer can be seen around the central echogenic line.
In the early proliferative phase, this hypoechoic area is thin
, B. but it increases and becomes more clearly defined in the later proliferative phase (periovulatory), probably as a result of edema.
The hypoechoic appearance of the proliferative endometrium has been related to the relatively homogeneous histologic structure because of the orderly arrangement of the glandular elements.
D. After ovulation, the functional layer of the endometrium changes from hypoechoic to hyperechoic as the endometrium progresses to the secretory phase.
The hyperechoic texture in the secretory endometrium is related to increased mucus and glycogen within the glands, as well as to the increased number of interfaces caused by the tortuosity of the spiral arteries.
After menopause, the endometrium becomes atrophic because it is no longer under hormonal control.
Sonographically, the endometrium is seen as a thin echogenic line measuring no more than 8 mm in the normal asymptomatic woman.
Transvaginal sonography is better able to image and depict subtle abnormalities within the endometrium and clearly define the endometrial-myometrial border because of it’s improved resolution.
Sonohysterography has been shown to be of great value in further evaluating the abnormally thickened endometrium. SHG can distinguish between focal and diffuse endometrial abnormalities
Reconstructed coronal view, 3-D sonography also has been a valuable addition to standard transvaginal ultrasound in patients with suspected endometrial abnormalities and in those with an endometrium greater than 6 mm.
Sonographically, if the obstruction is at the vaginal level, there is marked distention of the vagina and endometrial cavity with fluid.
If seen before puberty, the accumulation of secretions is anechoic.
After menstruation, the presence of old blood results in echogenic material in the fluid. There may also be layering of the echogenic material, resulting in a fluid-fluid level.
Acquired hydrometra or hematometra usually shows a distended, fluid-filled endometrial cavity that may contain echogenic material.
Superimposed infection (pyometra) is difficult to distinguish from hydrometra on sonography, and this diagnosis is usually made clinically in the presence of hydrometra.
Imaging cannot reliably allow differentiation between hyperplasia and carcinoma. Up to one-third of endometrial carcinoma is believed to be preceded by hyperplasia. Because hyperplasia has a nonspecific sonographic appearance, biopsy is necessary for diagnosis.
Approximately 20% of endometrial polyps are multiple.
Malignant degeneration is uncommon. Occasionally, a polyp will have a long stalk, allowing it to protrude into the cervix or even into the vagina
Endometrial polyps may not be diagnosed on D&C because a polyp on a pliable stalk may be missed by the curette.
If abnormal bleeding persists after a nondiagnostic D&C in a postmenopausal woman with an endometrial thickness greater than 8 mm, hysteroscopy with direct visualization of the endometrial cavity is recommended.
although only about 10% of women with postmenopausal bleeding will have endometrial carcinoma.
Approximately 25% of patients with atypical endometrial hyperplasia will progress to well-differentiated endometrial carcinoma
The tumor spreads initially by invasion into the myometrium and cervix, followed by lymphatic spread to the pelvic and retro peritoneal nodes, then continued direct spread into the broad ligaments, parametrium and ovaries.
Peritoneal seeding will occur with the penetration of the uterine serosa.
Hematogenous spread to the lung, bone, liver and brain occurs late in the course of the disease, with the most critical factors being the depth of myometrial invasion and the involvement of lymph nodes.
Cystic changes within the endometrium are more frequently seen in endometrial atrophy, hyperplasia, and polyps but can also be seen with carcinoma.
Initial studies using transvaginal color and spectral Doppler ultrasound suggested that endometrial carcinoma could be differentiated from a normal or benign postmenopausal endometrium by the presence of low-resistance flow in the uterine arteries in women with endometrial cancer, compared with high-resistance flow in women with normal or benign endometria.
Subsequent reports, however, have shown no significant difference in uterine blood flow between benign and malignant endometrial processes.
Polyps are frequently seen and have a higher incidence in women receiving tamoxifen than in untreated women, and these polyps can be quite large
However, gas can also be seen in up to 21% of clinically normal women, after uncomplicated vaginal delivery in the first 3 weeks postpartum.140 Clinical correlation is necessary when endometrial gas is seen in the postpartum patient.
The endometrium usually appears normal on transabdominal and transvaginal sonograms.
Several types of IUCDs demonstrate a characteristic appearance on sonography, reflecting their gross appearance.
Newer hormone containing IUCDs (e.g., Mirena) may be difficult to visualize sonographically.
3DUS has been extremely useful in providing a more complete assessment of IUCD location by imaging the entire IUCD simultaneously in the coronal plane.
The IUCD may be hidden by coexisting intrauterine abnormalities, such as blood clots or an incomplete abortion.
When an IUCD is present in the uterus in association with an intrauterine pregnancy , it can be seen reliably early in the first trimester, but it is rarely identified thereafter. In the first trimester the device can usually be removed safely under ultrasound guidance.
A,b,E,G Transabdominal scans H&ITransvaginal Scans.
A-Highlyechogenic linear structure in normal location within endometrial canal in body of uterus.
B-Unusual Chinese ring IUCD
C-Radiograph of B. D-3-D coronal reconstruction shows entire IUCD in normal location.
E-IUCD in upside down position with limbs positioned inferiorly. F-Radiograph of E
G-IUCD abnormally positioned in lower uterine segment. H-IUCD located in outer myometrium. I-IUCD in 30weeks gravid uterus.