1. ENDOMETRIAL
ABNORMALITIES
Dr. Fathmath Shudhfa Ibrahim
1st year Resident
MD Radiodiagnosis

2. CONTENTS
• Normal Endometrium
• Endometrial Hyperplasia
• Endometrial Atrophy
• Endometrial Polyps
• Endometrial Carcinoma
• Endometritis
• Endometrial Adhesions
• Intrauterine Contraceptive devices

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
menstrual cycle.
• The endometrium is composed of a superficial functional layer and a
deep basal layer.

4. • Functional Layer (stratum
functionalis)
-Changes in response to ovarian
hormone cycles
-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
endometrium.
- 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
appearance

7. Normal, thin ,early proliferative
endometrium
Normal, late-proliferative
endometrium with triple-layer
appearance. Central echogenic
line is caused by opposed
endometrial surfaces
surrounded by a thicker
hypoechoic functional layer,
bounded by an outer echogenic
basal layer.
Normal, early-secretory phase
endometrium. The functional
layer surrounding the
echogenic line has become
hyperechoic

8. Normal, thick, hyperechoic late-secretory
endometrium
• Secretory phase.
The endometrium in this
phase measures 7 to 14
mm in thickness.

9. Normal, thin, postmenopausal endometrium

10. IMAGING MODALITY
• Transvaginal sonography
• Sonohysterography
• Reconstructed coronal view, 3-D sonography

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
used

12. HYDROMETROCOLPOS AND
HEMATOMETROCOLPOS
• 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.

13. • Causes
Congenital
- imperforate hymen.
- vaginal septum
-vaginal atresia
-rudimentary uterine horn.
acquired
-cervical stenosis from endometrial or
cervical tumors
-postirradiation fibrosis

15. ENDOMETRIAL HYPERPLASIA
• Definition
-Proliferation of glands of irregular size and shape, with an increase in
the gland/stroma ratio compared with the normal proliferative
endometrium.
-The process is diffuse but may not involve the entire endometrium.
• Histologically
-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
bleeding.
• Develops from
-unopposed estrogen stimulation in postmenopausal women.
-It is usually caused by unopposed estrogen HRT in perimenopausal
women.

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
thecomas
-Pregnancy
-Tamoxifen therapy
-Endometrial Carcinoma
-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
Differential thickness:
1. normal thickening
during the secretory
phase,
2. sessile endometrial
polyps,
3. submucosal fibroids,
4. Endometrial cancer,
5. adherent blood clots
6. Pregnancy and ectopic
pregnancy
7. Incomplete abortion

21. • Endometrial hyperplasia has a nonspecific appearance so any focal
abnormality should lead to biopsy if there is clinical suspicion for
malignancy.

22. ENDOMETRIAL ATROPHY
• The majority of women with postmenopausal uterine bleeding have
endometrial atrophy.
• Histologically
-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.
• Types
- pedunculated
- broad based
- may have a thin stalk

26. • Ultrasonographic findings
-Frequently identified as focal masses
within the endometrial canal.
-Or as nonspecific echogenic
endometrial thickening.
-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
stalk.
-A feeding artery in the pedicle can
frequently be seen with color
Doppler ultrasound (pedicle artery
sign)
Color Doppler ultrasound shows feeding
vessel.

28. Well-defined, round echogenic
polyp
Carpet of small polyps Polyp on a stalk.

29. • Sonohysterography
-Polyps are best seen at
sonohysterography
-appear as echogenic, smooth,
intracavitary masses outlined by fluid
Sonohysterogram confirms polyp (arrow)
and thick endometrium (arrowheads)
caused by hyperplasia.

30. Polyp with cystic areas Small Polyp Small Polyp

31. • Hysterosalpingography
-Seen as pedunculated filling defects
within the uterine cavity

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.
• Histologically
-Adenocarcinoma (95%)
-Sarcoma (5%)
• 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
- Obesity
- Diabetes
- Hypertension
- 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
otherwise.
-The thickened endometrium may be well
defined, uniformly echogenic, and
indistinguishable from hyperplasia and
polyps.
Abdominal Ultrasound

38. • Cancer is more likely when the
endometrium has a heterogeneous
echotexture with irregular or poorly defined
margins.
• 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
surrounding myometrium

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
- controversial.
- 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
endometrium.
• On T2-weighted images
-shows heterogeneous intermediate signal intensity relative to
hyperintense normal endometrium.
• Relative to normal myometrium, the tumor is mildly hyperintense on
T2-weighted images.
• At conventional MR imaging, the depth of myometrial invasion is
optimally depicted with T2- weighted sequences.

47. Tamoxifen
-A nonsteroidal antiestrogen compound which is widely used for
adjuvant therapy in premenopausal and postmenopausal women with
breast cancer.
-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
tamoxifen therapy.

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
myometrium.
• 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
subendometrial.

51. Thick, cystic endometrium caused by large polyp in
patient receiving tamoxifen.

52. ENDOMETRITIS
• May occur
- Postpartum
- after D&C
- association with PID.
• Sonographically
• 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
endometrial canal.

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
endometrial cavity.

55. • Transvaginally
- Irregularities or a hypoechoic
bridgelike band within the
endometrium.
- This is best seen during the secretory
phase, when the endometrium is
more hyperechoic.
Endometrial Adhesions

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
transvaginal sonography.
• 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
-Malposition
-Perforation
-Incomplete removal
-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
• Diffuse
• USG:
 Enlarged globular uterus (AP asymmetry)
 Myometrial heterogeneity due to endometrial implants and smooth muscle
hypertrophy
 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
lesion

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

62. REFERENCES
• Diagnostic Ultrasound Carol M.Rumack
• Fundamentals of Diagnostic Radiology-Bryant&Helms
• Other sources from internet