Diagnostic Ultrasound - Abdomen and Pelvis

Abnormal Endometrium
○ Multiple effects include
– Polyps
– Endometrial hyperplasia
– Reactivation of foci of adenomyosis
– Cystic endometrial atrophy with subendometrial cysts
– Endometrial carcinoma
□ Endometrial cancer in patients taking tamoxifen is
frequently in endometrial polyps
Helpful Clues for Rare Diagnoses
• Endometritis
○ In postpartum patient, painful enlarged uterus
○ In nonpregnant patient, associated with pelvic
inflammatory disease
○ Elevated white blood cell count
○ Thick, heterogeneous endometrial contents ± gas in
septic endometritis
• Unopposed Estrogen Use
○ Estrogen use without progesterone → endometrial
polyps, hyperplasia, and carcinoma
• Polycystic Ovary Syndrome
○ Enlarged ovaries with multiple, small, peripheral follicles
○ Central stroma may be echogenic but not a necessary
component for diagnosis
○ No dominant follicle
○ Diffuse endometrial thickening due to prolonged
proliferative phase or endometrial hyperplasia
Other Essential Information
• Transvaginal scanning is best for evaluation of
endometrium
○ Saline infused hysterosonography helpful to
differentiate focal lesions from diffuse thickening
○ Diffuse thickening can be sampled with blind biopsy
○ Focal mass best assessed with hysteroscopic biopsy
• In some patients, orientation of endometrial cavity is such
that transabdominal scan allows for better insonation and
evaluation of endometrium
• Additionally fibroids or very large uteri may preclude
assessment using transvaginal probes
• In uterine duplication anomalies, each endometrium must
be separately evaluated
Alternative Differential Approaches
• Solid or complex ovarian lesion in association with
endometrial lesion
○ Estrogenic effect from granulosa cell tumor may
produce endometrial hyperplasia or carcinoma
○ Estrogen secretion from thecoma → endometrial lesions
○ Synchronous ovarian and endometrial carcinoma
○ Endometrioid ovarian carcinoma resembles endometrial
carcinoma, associated with endometrial hyperplasia or
carcinoma
○ Metastatic disease to ovaries from endometrial
carcinoma
SELECTED REFERENCES
1. Van den Bosch T et al: Intra-cavitary uterine pathology in women with
abnormal uterine bleeding: a prospective study of 1220 women. Facts Views
Vis Obgyn. 7(1):17-24, 2015
2. Langer JE et al: Imaging of the female pelvis through the life cycle.
Radiographics. 32(6):1575-97, 2012
3. Sakhel K et al: Sonography of adenomyosis. J Ultrasound Med. 31(5):805-8,
2012
4. Sofoudis C et al: Endometrial stromal sarcoma in a 29-year-old patient. Case
report and review of the literature. Eur J Gynaecol Oncol. 33(3):328-30, 2012
5. Allison SJ et al: saline-infused sonohysterography: tips for achieving greater
success. Radiographics. 31(7):1991-2004, 2011
6. Bennett GL et al: ACR appropriateness criteria(®) on abnormal vaginal
bleeding. J Am Coll Radiol. 8(7):460-8, 2011
7. Salim S et al: Diagnosis and management of endometrial polyps: a critical
review of the literature. J Minim Invasive Gynecol. 18(5):569-81, 2011
Differential Diagnoses: Female Pelvis
Secretory Phase Endometrium
Secretory Phase Endometrium
(Left) Longitudinal US in a
patient on day 24 of her
menstrual cycle shows
secretory phase endometrium
ſt. The coapted walls of the
cavity remain partially visible
as a thin echogenic line .
(Right) Longitudinal US in a
patient late in her menstrual
phase shows a thickened,
slightly hyperechoic
endometrium ſt consistent
with the secretory phase.
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