Cervix and Endometrium

Question 1

What should an ultrasound examination of the endometrium cover?

Answer 1

○ Measurement of the endometrium
○ Classified in the context of the menstrual cycle
○ Correlated with the menstrual cycle
○ Classification of the borders, well-defined or poorly defined
○ Evidence of pathology
○ Dynamic assessment

Question 2

Describe the routine measurement of the endometrium.

Answer 2

TV allows delineation of the endometrium in three planes, AP, length and width
○ AP is most relevant
Endometrium should be measured in the sagittal plane, in which two layers appear symmetrical
○ Thickness of anterior endometrium and posterior endometrium
○ AP thickness varies with age, hormones and cyclical phase

Question 3

What are the normal measurements of the endometrium?

Answer 3

Pre-menopausal:
	○ Menstrual phase: 1-4mm
	○ Proliferative phase: 4-8mm
	○ Secretory phase: 7-14mm
Post-menopausal:
	○ Without HRT: <5mm
        ○ With HRT: <8mm

Question 4

What can cause pathology of the endometrium?

Answer 4

atrophy
hyperplasia
polyps
carcinoma
endometritis
malposition of IUD

Question 5

What does endometrial pathology present as?

Answer 5

Amenorrhea
Hypermenorrhea
infertility
pain

Question 6

List some strategies to improve delineation of the endometrium

Answer 6

Defer assessment for later if there are uterine contractions causing focal bulging or contour irregularity.
Change level of insertion, especially for axial uteruses
Adjust system settings
use colour flow
Defer assessment to another stage of the cycle
- secretory endometrium can hide pathology

Question 7

What is the dynamic assessment of the endometrium?

Answer 7

• Identify the layers of the endometrium sliding on each other
• this can confirm the presence of an intra-endometrial lesion such as a polyp or confirm a normal/hyperplastic endometrium
• use gentle, varied pressure on the transducer and varied lower abdominal pressure on the anterior abdominal wall.

Question 8

What is sonohysterography?

Answer 8

• Sonohysterography is where saline or contrast media is instilled into the endometrial cavity
  
  • SHG helps when the endometrium is asymmetrical, unexpectedly thickened or poorly imaged
  • SHG easily demonstrates secondary amenorrhea or hypomenorrhea caused by endometrial synechiae
  • Included in the workup for infertility
  • Further defines suspected abnormalities
    Surgical repairs and biopsies

Question 9

What is an IUD?

Answer 9

• Highly reflective and cause acoustic shadowing
  
  • Indications could be for malposition, perforation and incomplete removal
  • If IUD is not present in the endometrial cavity, then it may have been expelled or perforate the myometrium
    Radiograph should be taken if not seen

Question 10

Describe nabothian cysts

Answer 10

• variable sizes
• single or multiple
• can have internal echoes due to haemorrhaging or infection
• can be cause of benign enlargement of the cervix

Question 11

Describe cervical polyps

Answer 11

• frequent cause of vaginal bleeding
• usually a clinical diagnosis
• may be a fibroid
• can be pedunculated and prolapse into the vagina

Question 12

Describe an adenoma malignum

Answer 12

Adenocarcinoma
Rare
associated with Peutz-Jeghers syndrome
Watery vaginal discharge has been described as a common symptom
There are often multiloculated cystic masses with a solid component or completely solid masses

Question 13

Describe a cervical carcinoma

Answer 13

Usually diagnosed clinically
may demonstrate a solid, retrovesical mass
Will appear as a heterogeneously hypoechoic solid mass with increased vascularity.

Question 14

Describe the staging of endometrial carcinoma

Answer 14

Stage 1A: cancer is in the endometrium only or less than halfway through the myometrium
Stage 1B: the tumour is still localised to the uterus but has spread halfway or more into the myometrium
Stage 2: cancer has spread into the connective tissue of the cervix but has not spread outside the uterus
Stage 3: the cancer has spread outside the uterus or into nearby tissues in the pelvic area
Stage 4: the cancer has spread to the urinary bladder or the rectum, to lymph nodes in the groin, and or to distant organs such as the bones, omentum or lungs

Question 15

What are the sonographic findings in endometrial carcinoma?

Answer 15

Sonographic findings: thickened endometrium, poor definition of the endometrial/ myometrial interface and an indistinct endometrium in an enlarged uterus
Thickened endometrium may be well defined, uniformly echogenic and indistinguishable from hyperplasia and polyps
Cancer is more likely when the endometrium has a heterogeneous echotexture with irregular or poorly defined margins
Endometrial carcinoma may also obstruct the endometrial canal resulting in hematometra

Question 16

Describe endometrial adhesions

Answer 16

Post traumatic, postinfection or post surgical in nature and may be a cause of infertility or recurrent pregnancy loss
Asherman syndrome is the combination of synechiae that lead to menstrual dysfunction or infertility
Adhesions may be seen TVS as irregularities or a hypoechoic bridgelike band within the endometrium
Best seen during the secretory phase when the endometrium is hyperechoic
SHG is an excellent technique for demonstrating adhesions

Question 17

What is endometrial ablation?

Answer 17

Endometrium is typically indistinct after global endometrial ablation procedures
Complications may arise when there is residual non ablated endometrium and adjacent endometrial scarring
This can result in a cornual hematometra or a central hematometra and they may cause pain
Postablation tubal sterilisation syndrome is a delayed complication of endometrial ablation that may occur in patients who previously had tubual ligation; these patients usually have pain due to a hematosalpinx of the proximal tubal stump and a cornual hematometra

Question 18

Describe the post-partum uterus

Answer 18

Uterus will be enlarged initially and will return to its normal size 6-8 weeks after delivery
Often soft and easily compressible
Inner myometrium may be hyperechoic relative to the outer myometrium in the early postpartum period and can potentially be mistaken for the endometrium
Echogenic foci due to air are normal and can persist up to 3 weeks
Small amounts of fluid and heterogeneous tissue due to clots
Bleeding postpartum is normal
When patients have an abnormal amount of bleeding, pain or fever then RPOC or endometritis should be considered

Question 19

describe endometritis

Answer 19

Should be considered when a postpartum patient was fever and or pain
Clinical diagnosis
Fluid and or air may be seen in the endometrial cavity in patients with endometritis but there are also common findings in the first few weeks postpartum

Question 20

describe placental-site trophoblastic tumour

Answer 20

Uncommon cause of postpartum bleeding
Presents with vaginal bleeding
90% of cases occur after normal delivery
Should be considered by low levels of human chorionic gonadotropin (hCG) or elevated levels of human placental lactogen
A heterogeneous predominantly solid mass involving the endometrium and or myometrium occasionally it can be cystic with marked vascularity simulating an arteriovenous malformation

Question 21

What are the normal findings after a c-section

Answer 21

Transverse incision in the lower uterine segment
Small echogenic foci due to sutures or gas in the anterior myometrium of the lower uterine segment
Heterogeneity in this region of the myometrium