the

The Endometrium ultrasound

[Music]

you

thank you very much this is an area

which it has always been of great

interest to me because it is so it's

it's so variable during the month that

it's very important to look at the

endometrium very carefully and correlate

it with the time of the month that the

patient is at or whether or not she's

pre or postmenopausal because it will

tell you a lot first of all how many of

you still feel filled with filled

bladders for these patients anybody if

you please don't it's unnecessary it's

torture nowadays you really you know

then you can't even see anything when

the bladder is that full we really do

not fulfill the bladder we do an

abdominal scan just to see if there's

anything up above the uterus and then we

do the transvaginal scan that shows us

the uterus and so it is unnecessary to

fill the bladders so and averted retro

verted you can see here the endometrium

is well seen and there is this line in

the middle right here that indicates

that there's absolutely nothing in the

cavity this is where the mucosa meets

the mucosa and there's nothing in there

here you don't see it quite as well

because we're a little bit further away

from the ultrasound beam but during the

menstrual cycle the endometrium goes

through a series of changes and in the

middle of the cycle when when you

ovulate this is pretty much what you

have is the Tri laminar appearance and

again this line is very important

because it shows you that there's

there's no polyp and and or no fibroid

inside the cavity and again here here it

is and that's an important line to look

at now as you go on after ovulation the

luteal phase the Mya the endometrium

thickens up and actually becomes very

very thick and and sometimes even

heterogeneous and so you really can't

measure it or you can measure it but you

it doesn't mean anything

to measure the amount the endometrium

after ovulation and in fact it really

doesn't mean much to measure it at all

on pre menopausal patients part of

looking at the endometrium is looking at

the end of cervix and the end of

cervical canal at the same time you also

get to see the cul-de-sac and anything

that's going on down there but you see

very well here the anterior and

posterior lip of the cervix and post

anterior phoronix posterior fornix right

in here and and the endo cervical canal

the canal the cervix and probably stops

here but it's very difficult to tell

exactly where the serve at the internal

AHS is compared to where the rest of the

uterus starts and I don't think there's

much of a reason to try and struggle to

do that so there's always a question of

what what the normal width of the

endometrium is and in premenopausal

patients there there is no number there

is absolutely no number what you need to

look at is the pattern of the

endometrial echo you know is it

heterogeneous does it have something in

it like a polyp or a fibroid does it

have cystic areas in it but the actual

number itself does not matter and it may

be thinner if the patient's on birth

control pills but still I wouldn't get

hung up on a number now if the patient

is postmenopausal it that changes a

little bit and it depends greatly on

whether the patient is bleeding or not

if the patient is coming in for a

postmenopausal bleeding the number that

the most accepted number is less than

four there are some data out there less

than 5 we have switch to less than 4

because that's a predominance of the

data right now but anything greater than

4 requires that in mutual biopsy or

further evaluation if the patient is not

bleeding there is no number again there

is no number if the patient is not

bleeding some people have put out 810

whatever again look at the endometrium

and if you're concerned about the

texture of the endometrium do a sono

histogram

we'll talk about that in a minute that's

really the easiest thing to do rather

than trying to get hung up on a number

so the postmenopausal endometrium most

of the time is very thin you can see

we've measured the anterior and

posterior aspects of the endometrium

there's a little bit of fluid inside the

cavity that's very common that's normal

doesn't mean anything in fact it's very

useful when there's a little bit of

fluid because it can outline whatever

might be in there like a little polyp so

this is completely normal

here's a postmenopausal patient with a

small uterus you can see the uterus is

very small and you can see there's a

little bit of fluid in the under me trim

again that's normal now be careful that

when you look at the endometrium you

have to look at the entire endometrium

you can't just see part of it measure it

and give that number and not have seen

the entire part because the other side

of it may contain something so if you

don't see the entirety then I report it

as not well seen and that's really

important don't don't be overconfident

now polyps are usually pretty well seen

even when there's no fluid in there you

can actually see a different texture

echo texture of the polyp itself and if

you add some color it'll even enhance it

even more because you'll actually see

the feeder vessel going into the polyp

and sometimes even if you don't see the

feeder vessel we still call a polyp

although it could be a little clot at

that point but the echo texture of the

endometrium is really important and now

we have instruments in our ultrasound

machines that are so good that we can

actually tell a lot about looking at the

endometrium just looking at the texture

rather than getting hung up on a number

we do a lot of 3d for the endometrium

and in this case we knew there was a

polyp this shows you exactly where it is

what we do now a lot is we include this

picture in the report to the referring

physician so that the referring

physician knows exactly when they do the

hysteroscopy I mean where to go and

where the

so here is a 67 year old patient with

postmenopausal bleeding she has a thick

endometrium it's heterogeneous clearly

there's some fluid in the endometrium

it's dirty fluid sort of a second you

know gotta go genic material in it you

can see that this is sort of a mass

inside here there's a lot of color

there's a lot of blood flow can't color

is very important this is great -

endometrial carcinoma and what's

important about the endometrial

carcinoma is when you see them is how

invasive are they we decided that this

was not terribly invasive because we

could still see portions of the

endometrium here and we didn't we saw

some pretty good thick myometrium and so

less than 50% invasion indicates that

the patient won't need chemotherapy and

will be cured by hysterectomy and

greater than 50% invasion through the

myometrium they will need for their

treatment here's a polyp and this was a

polyp that you couldn't really tell it

was a polyp just looking at this but

then we turn on the color and you can

see that there's a single feeder vessel

which suggested that this was all one

entity it was a pod that was a lot of

blood flow here turns out that this was

an adenocarcinoma of the of inside the

polyp in a patient that was bleeding so

polyps can contain cancer obviously they

don't spread quite as well as much which

is good but if there's bleeding the

polyps have to come out here's a 63 year

old with postmenopausal bleeding and

here it this is a little more

problematic now the back here looks

pretty good okay there's certainly a

mass in the uterus it's echogenic

there's a lot of color this is bad this

is cancer of the endometrium but you're

missing the borders of the front here of

the anterior wall of the endometrium and

that's worrisome here and this was in

fact an

90% invasion with nodes and so that's

bad news for this patient she will need

some further treatment after her

hysterectomy so 3d as I said is very

very important in gynecology we do a 3d

on every gynecologic patient that we

scan and I think that it replaces MRI

and in many situations when we want to

look at the shape of the endometrial

cavity is certainly for mullerian duct

abnormalities and the light and how many

of you do 3d and your GYN scans so great

that quite a few of you I think it's

very important to just do it and get

used to doing it because as you take

your volume and your three orthogonal

planes come up your third plane here

your Z plane is the money plane where

you will see a reconstructed view of the

endometrium that you otherwise don't see

now going on to spending more time on

patients with postmenopausal bleeding

here was a postmenopausal patient you

can see very thin endometrium by the way

don't just measure it here you got to

measure it over here because again you'd

be misleading if you measured it

somewhere here this is not very well

seen so that you really can't put your

caliper here but the measurement is not

what counts here what counts is that

there's something inside the endometrial

cavity and so you have to really look

and see what it is and it was a little

polyp right here inside the enemy troll

cavity now here's a submucosal fibroid

and if you bring them in at a time when

after ovulation in the luteal phase of

the cycle the endometrium will be thick

enough so that it will act as a contrast

and it'll outline the fibroid for you so

you don't even have to put any fluid in

and so we do that a lot when patients

come in for locate localization of

fibroids how much of it is submucosal we

have them come in in a latter part of

the cycle as opposed to the early part

here's another fibroid looks it's

completely in Turkey vetere

here but in fact it's not totally

intricate Airy it's probably I would say

75% gentle cavitary but this is the

picture that the surgeon wants this will

tell the surgeon how much they'll be

able to shave off hysteroscopic Lee now

one thing that is extremely useful when

looking at the endometrium is the zone

of historiography we do I would say an

average of three to four a day and

they're very very easy to do you thread

a little insemination catheter up in the

endometrium and you just put a little

bit of saline and you outline the cavity

and it shows you if there's any question

about whether there was some lesion in

the endometrium it just it shows it to

you so much better then you take your

volume you take a couple of quick

volumes and then you can save the volume

and you can go back and rescan after the

patient's gone because you've got the

entire picture you don't have just a few

snapshots of the fluid going in the

other reason to do 3d is because if

unless you use a balloon catheter if you

use a little insemination catheter that

the fluid will come come out come

pouring out as you put it in so that

you'll have to keep putting saline and

in order to get all your pictures

whereas if you're doing it with 3d you

put your burst of saline you take a

couple of quick volumes and then you're

done and you don't have to blow up a

balloon which is tends to be more

painful to the patient so here's a

patient that clearly has an abnormal

endometrium and again you can measure it

if you want it's not going to mean

anything unless use postmenopausal and

bleeding but you still want to find out

what's going on in here and so the way

to do it is to put some fluid in so we

put the fluid in and sure enough you

don't really need the 3d in this case we

do it to archive everything but you can

see the polyp right there and there's a

couple of several polyps the advantage

to doing 3d is that you can get all your

polyps photographed all at once then you

can go back and measure them at your

leisure without having to keep putting

fluid in but nonetheless this shows you

what

is going on in here rather than trying

to guess and by the way if they do an

endometrial biopsy here they probably

won't get anything because most of the

time when there were polyps the

endometrial biopsy is negative and

because they miss the polyp so it's very

important to be able to tell that the

referring physician

these are polyps you better go in there

with a scope because otherwise you're

gonna you're not gonna get a piece of

whatever this is all right now can you

measure the endometrium and then

postmenopausal patient well you might

say sure I can measure it right here but

that's not good enough because up here

you can't tell what's going on so in

this case even though you can measure it

in certain places I would say no I can't

measure it so you put a little fluid in

and lo and behold look at what we see

here a little a little whoops a little

polyp right here so we have very low

threshold for putting a little bit of

fluid is really easy to do and it'll

outline whatever's going on here here's

another patient 43 year old with mono

Metro Raja here's the endometrium can we

see it well sort of a little bit you

know but yeah we really can't now let me

just show you go back and you see here

don't invent the endometrium and put up

to put a caliper on it just you know a

little bit of fluid will really tell you

what it is you can get fancy with it if

you want to send a nice picture at you

get to the referring physician this

really goes a long way if you send these

nice pictures and they'll send you more

patients which is always very nice and

if you take a 3d you can even make it

look like an MRI if if you want by

giving by turning your 3d into a slices

like a other cross-sectional imaging

techniques these are all techniques to

display once you have the 3d you can

display it in lots of different ways you

can display it like this you can display

it surface rendering of the polyp you

can display it in one volume you can

display it in these two different ways

depending on how you want to manipulate

your volume so this is very very useful

all right now here's somebody fifty

five-year-old on tamoxifen and she was

sent in because

and other radiologists felt that the

endometrium was thick well you know what

are you going to do here

you're gonna measure it from here to

there from here to here or from over

there to over here

well you can't measure it you can't

measure it and not only that but

patients with that are on tamoxifen you

know they they have an increased

incidence of and of polyps and

endometrial cancer but they also have

sub endometrial cysts that can confuse

the issue so the only thing to do here

is to put in some fluid and actually the

endometrium is normal these are all sub

endometrial cysts and we were able to

tell the patient that the you referring

physician that the enemies room was

entirely normal and she doesn't even

need an initial biopsy if you put some

fluid you'll outline fibroids and I

don't want to get in too much to

fibroids because I know that Mary just

just spoke about them but the fibroid

can sometimes try to deliver itself it

can be very painful to the patient

here's a fibroid trying to get out of

this through the cervix and you can see

that there's a stalk here and if you

turn on the color you will see the blood

flow going down from where the origin of

this fibroid is trying to get out and

here is this stalk they can be quite

vascular but this is a prolapsing

fibroid okay now going on to what you

can do as for infertility patients i

know that many of you do

hysterosalpingogram

we have we do not do them anymore we do

heiko C which I'm not going to try and

say what heiko C stands for because it's

written down here if you are interested

in reading about reading it but what it

is basically is putting some fluid in

the endometrium doing a sono histogram

but then you blow up a little balloon

and then you can put a little bit of air

we've used air because contrast wasn't

available and air works really well you

put a little bit of air in the cavity

and then it goes out the tubes and it

demonstrates the tubes the the nice

thing about the Hyksos see

is that first of all there's no

radiation there's no die

you can certainly differentiate uterine

shape abnormalities easily but in

addition to the cavity the inter cavity

lesions you can see the serosa it's very

important to see the outside of the

uterus when you're trying to figure out

what to correlate what the inside looks

like plus oh you can assess the ovaries

the tubes the whole thing so it's really

it's a lower cost it's a full pelvic

examination that doesn't have any

radiation so there's absolutely no

reason not to do these we do about two a

day of these and here is a little bit of

air being injected in the cavity right

here you can see a little puff of air

and you can see the AR going down the

tube right here now it's a quick thing

and you have to have a scenographer that

knows what he or she is doing to snap

the video right at the right time

because it's it just is a width of air

but it does show you the patency of that

tube that's see if I can go on to the

next slide that's somehow it's not being

how do you go to the next slide oh here

great thank you so if you're lucky you

can actually see both tubes at the same

time here we were getting fancy but

usually you have to do one tube at a

time but in this case things were lined

up well enough so you could see the

patency of both tubes when that when the

tube is blocked it will well up in here

and the patient will be very

uncomfortable we'll have a lot of

cramping and and so sometimes you'll see

patency and one too but not the other it

doesn't mean that the tube that's you're

not seeing is not patent and you just

can't demonstrate it but what you can do

is either call patency or if there is no

fluid no air going in and anywhere then

you can call the blockage of the tubes

and this is very consistent in accuracy

with the hysterosalpingogram another

thing you can do

here's a patient who's had a prior

c-section and patients with prior

c-sections have a lot of bleeding

because they have this niche in the

c-section scar here that collects blood

and and there's a clot that sits there

sometimes and so you put in some fluid

and here's the clot you can see it and

you can flush it out and then you can

really examine the the niche without the

clot this shows you why a lot of

patients that have had history cesarean

sections have these clots that sit in

those places and they have inner

menstrual bleeding during the month it's

very common for people with cesarean

section scars to have had this this

problem now this is probably one of the

most remarkable cases I've ever seen

last year

68 year old patient with abnormal

uterine discharge unresponsive to

antibiotics the only prior history was

that she had about of diverticulitis

six months before here's her endometrium

and here we are measuring trying to

measure that's not very good I wouldn't

put those measurements in the report but

what is this is this calcium we were

looking at it and started moving so then

I thought ah you know this must be air

so then started looking at the ad next

uh and what do we have here Heiko see in

a 68 year old and so there's hair in the

fallopian tube so based on this I

actually made the diagnosis of colon to

fallopian to fistula from diverticulitis

was that which was actually repaired and

she was she was fine

so fluid in the fallopian the fallopian

tube very very helpful to make some of

these diagnoses now going on to the

location of IUDs we have a lot of IUDs

now because we have the marina's that

deliver some hormones and so now they're

back in fashion and 3d is really really

helpful to determine where the IUD is

patients who have an abnormally placed

or slid down I UD have pain and bleeding

and we've documented that so that when

you see it you know there there's a

benefit to replacing taking it out

replacing and these IUDs can be hard to

find the shaft of the IUD is pretty

obvious here we couldn't find the arms

and that's because the arms were down

instead of up this was an anchor this

was upside down I don't know how they

got upside down but however it is that's

a lot easier to find if you can get a

volume and just see the whole thing

together now here is a type of scan

where you say well it's in the right

place here's the shaft and here at the

arms well the trouble with this is that

you don't really know where the

endometrium is and if you do the 3d

you'll see that the right arm is totally

embedded in the myometrium and that's

because the uterus is not big enough and

we have found and shown data that

nulliparous patients don't have a uterus

that's big enough to support the IUD and

so that's

at the study that we did looking at this

led the companies to come up with the

Schuyler which is the smaller IUD for

people who have a small uterus now the

last area that I want to get into is a

mullerian duct abnormalities if again

you have to bring these patients up in

the luteal part of the cycle because

again you're going to use the

endometrium as your contrast you can put

fluid in it but it's not necessary I

don't do the sono histograms formulary

induct abnormalities you just use the

thick endometrial and Dmitry um towards

like premenstrual II and then you don't

have to put in any any fluid so here's

your uterus you take your sweep and here

is your coronal view that shows you this

septum of the sub septum and the septum

they want to know a lot of times how

deep it goes how thick it is this is a

very thin septum it wouldn't be good if

if a pregnancy implanted here because

there's not enough blood flow and this

one actually goes all the way down and

involves the cervix too so this is all

very important and we put a lot of

pictures in that and in the report for

these referring physicians because they

are going to take these patients to the

O R and this is better than MRI because

you can really manipulate that volume so

it's exactly the way you want it rather

than you know just I take the picture

the way that it comes this is an example

of why the hsg is not as helpful as just

a plain old 3d ultrasound formulary ins

this is a septate uterus and you see the

septum goes down to here this is a

bicornuate uterus which is much more

rare that by cornea sirwhere the septum

is very common and yet with a history of

Scythia gram these would look exactly

the same and yet this does not require

treatment this does require treatment

because there's a higher incidence of

miscarriage or early pregnancy loss up

to 80 to 50 percent in patients who have

a septum this is a unicornia uterus

interestingly enough the uterus looks

very normal in 2d and it's only in 3d

that you realize that half of it's

missing a lot of times there's a

rudimentary horn sometimes it connects

sometimes it doesn't connect here it's a

rudimentary horn that doesn't connect

these are dangerous because if you get

pregnant in here it's going to explode

and it you can't carry the pregnancy in

there so if you have a rudimentary horn

and you're in the infertility group this

has to be removed before you go through

any kind of treatment and so what they

do when you have a septum is that they

resect the septum down here they shave

it down and then they send you back the

patient to see what's left and this is a

good repair they always have a little

divot here but that's a good repair of

the septum and then the patient can can

try and get pregnant this is a didelphis

didelphis is basically two completely

separate uteri

it's not two separate cavities in one

uterus that would be a septum it's two

separate uteri which actually are very

hard to image because you have to open

your angle 180 degrees in order to catch

both sides of the uterus in the same

picture now we do see infertility

patients who have funny shape unusually

shaped uterus this is a t-shaped uterus

these are very stiff uteri

patients with t-shaped uterus are

unlikely to get pregnant

here are two uteri that looked very

peculiar I I don't know what to call

them that's why I include a picture in

the referring physician for the

referring physician because I don't know

what this is this is very very tubular

looking uterus this one I don't know

whether it's t-shape or whether it's a

bicornuate that fell down it whatever it

is it's not good and these patients were

not getting pregnant and then of course

you have patients who have sandy kiai

who've had multiple DNC's and

unfortunately when there's a scar like

that you can see it in 3d you don't even

have to put any fluid in so the workup

for infertility these days is really

one-stop testing you look at the shape

of the you

inside and out with 3d you evaluate the

cavity with a sono histogram you will

blow up your balloon just to get a

little pressure just to put your air in

the tubes or heiko see and then you look

at the ovaries and cypher signs of

endometriosis and deep infiltrating

enemy tree OSIS and then you you've

really done the whole thing very very

easily in one stop

so the endometrium is a very dynamic

portion of the uterus it changes

throughout the cycle it responds to

hormonal changes like a mirror the

endometrial echo is very useful when you

do a 3d because you can manipulate it to

be to make fibroids and polyps stand out

and endometrial cancer is the most

common malignancy in the female

reproductive tract it's less lethal than

ovarian cancer which is why it gets less

pressed but it is the most common female

cancer in in the pelvis thank you very

much for your attention

[Applause]