Abnormal uterine bleeding is evaluated using various ultrasound techniques and parameters according to the IETA model. Transvaginal ultrasound is used to measure endometrial thickness and assess echogenicity, vascularity, and the endo-myometrial junction. Additional techniques like saline infusion sonography can outline intracavitary lesions in more detail. Precise ultrasound evaluation and scoring systems can detect endometrial abnormalities and help determine the risk of endometrial cancer. Following guidelines and algorithms helps manage patients and determine if further testing or procedures are needed.

1. Evaluation of Abnormal Uterine Bleeding (AUB)
Dr. T L N Praveen
Director, Consultant Radiologist
Abhisheks Institute of Imageology
Hyderabad
IETA Model

2. Abnormal uterine bleeding - AUB
AUB - is considered when there is significant deviation from a women’s
established menstrual pattern
AUB can occur in the pre, peri, and postmenopausal states
AUB is the commonest (20%) clinical presentation in the Gynec OP

3. FIGO - Classification of AUB
PALM - COEIN
P – Polyp ( AUB -P)
A - Adenomyosis (AUB- A)
L – Leiomyoma (AUB – L)
M – Malignancy & hyperplasia (AUB- M)
C – Coagulopathy (AUB – C)
O – Ovulatory dysfunction (AUB- O)
E – Endometrial pathologies ( AUB -E)
I – Iatrogenic (AUB – I)
N – Not yet classified ( AUB – N)

4. PALM Group of causes –Discrete,
Structural, which can be measured
and evaluated by imaging techniques
COEIN Group related to entities
that are not defined by imaging
techniques (non-structural)

5. Preamble
• Endometrium is the mucus membrane lining the uterine cavity.
• Evaluation of endometrium is done during pre, peri and postmenopausal
states.
• Important component is quantitative assessment of endometrium.
• Thickness is best assessed by obtaining a true mid-sagittal section of
the uterus either Transvaginal or Trans rectal USG
• Comprehensive assessment is achieved using color/ power Doppler, 3D
Ultrasound with or without Saline instillation sonography (SIS)

6. Technical requirements
• High resolution intra cavitary USG
• Color / power Doppler USG
• 3D Ultrasound
• Saline / Gel infusion sonography

7. IETAFactors
• Endometrial thickness ( Quantitative)
• Echogenicity of the endometrium ( Qualitative)
• Demonstration of endometrial mid line echo
• Endo-myometrial junction - Junctional zone
• Vascularity - color score
• Vascular pattern

8. Additional factors
Saline / Gel infusion sonography
For intracavitary lesions
• Localized or extended
• Pedunculated or Sessile
• Outline of the lesion
• Color score with vascular pattern of the lesion
Coupled with 3D USG

9. Ultrasound evaluation of endometrium
• Sagittal section of the uterus.
• Image sould be magnified to occupy 75% of the screen
• Callipers placed at the two opposite endo-myometrial interfaces.
• Measured at the thickest, perpendicular to the endometrial line.

10. Ultrasound evaluation of endometrium
• In the presence of fluid, sum of both single endometrial lining gives the
thickness.
• In the presence of asymmetric thickness of endometrium, largest
anterior & posterior endometrial thickness should be taken into
consideration.
• When endometrium is not clearly delineated – it should be reported as “
non-measurable”

11. Endometrialthickness
< 4 mm > 5 mm Not measurable
< 1% Ca Endometrium 10% - Biopsy recommended High incidence of Ca
Universally accepted cut off 4.5 mm

12. Endometrialechogenicity
• Endometrial echogenicity in relation to the echogenicity of the
myometrium
Isoechoic
Hypoechoic
Hyperechoic

13. Uniformly echogenic Non-uniform echgenicity
Mixed echogenic
Endometrialechogenicity(Qualitative -morphology)

14. Endometrialmid-line
Linear
Ill defined
Irregular
• Endo-myometrial interface - Junctional zone

15. Interrupted Endo-myometrial junction
Preserved endo-myometrial junction
Endo-myometrial junction

16. Endometrial lesions
• Localized - base of the lesion < 25% of the endometrial surface
Pedunculated or sessile polyp
Pedunculated polyp - a/b ratio <1
Sessile if a/b ratio 1

17. Endometriallesions - Localized
Sessile Pedunculated

18. Intracavitarymyoma- Prognostication
Grade ‘0’ -100% in the cavity
Grade ‘1’ - 50% in the cavity
Grade ‘2’ - < 50% in the cavity

19. Endometriallesions
• Extended - base of the lesion > 25% of the endometrial surface

20. Vascularityscore/Factors
• Colour Doppler or Power Doppler (more sensitive)
• PRF 0.3 / 0.6
• Velocity scale 3-6 cm/sec
• Balance 220
• Doppler gain just below artefact level

21. Vascularity- Colorscore
Score 1 - No color Score 2 - Minimal vascularity
Score 3 - Moderate vascularity Score 4 – Abundant vascularity

22. Vascularpattern
Single dominant vessel without branching Single dominant vessel branching
Focal origin Multiple origin

23. Vascularpattern
Scattered vessels Circular pattern

24. Predictive of focally growing lesion
High positive predictive value but low negative predictive value
Timmerman 2003 UOG
Feeding vessel sign

25. Gel contains lidocaine hydrochloride 20 mg/g,
Chlorhexidine digluconate, methyl hydroxybenzoate,
propyl hydroxybenzoate, sodium lactate, hydroxy-
ethylcellulose and purified water
Lesion
out line
Saline/Gel Installation Sonography

26. Endometritis
• Due to deficiency in the molecular mechanism of endometrial repair
• USG - Thick, irregular endometrium
• Obliterated endo-myometrial junction

27. Endometrialhyperplasia

28. Adenomyosis
Rain in the forest or
Stripy shadows
Myometrial cysts
Sub-endometrial lines

29. • Endometrial thickness - > 5mm
• Hyper or mixed echoic endometrium.
• Irregular interrupted endo-myometrial interface
• Multiple, densely packed, large, irregular branching
vessels.
• High color scoring.
• SIS showing irregular surface
Endometrial thickness is the
most specific parameter
Featuresof Endometrialcancer

30. Atypicalpresentation- Diagnosticdilemmas

31. Atypical presentation - Diagnosticdilemmas

32. • Endometrial thickness >5mm or unmeasurable
Global
Simple Endometrial
biopsy
Failed/ Insufficient
Sample
Diagnostic
/operative
Hysteroscopy
Feeding vessel
Failed
Inconclusive
Exam
Diagnostic
Hysteroscopy
Flowchart in evaluatingendometrialabnormality
(Epstein 2002 ACTA Obstet Gynecol Scandinavica)

33. Ultrasound in Obstetrics & Gynecology
Volume 43, Issue 5, pages 557-568, 2 MAY 2014
Risk of endometrial cancer ( REC) score –
9 variables – value between 0 to 9
REC score 4 or more – Malignancy.
REC score 3 (not including GIS) Malignancy
Risk ofendometrialcancer Dueholmetal

34. • Endometrial thickness < 4mm – no further investigation.
• “ Unmeasurable “ endometrium should be evaluated.
• Vascularity of the endometrium and colour score helps in
grading the lesions.
• SIS /GIS outlines the lesions and its surface
irregularities.
• Endometrial and myometrial junction helps in identifying
focal lesions.
• Pre-operative assessment of myometrial and cervical
invasion is effectively done by ultrasound.
Summary

35. • Trans vaginal ultrasound is the imaging modality of choice.
• IETA guideline are useful in early detection of endometrial
abnormalities and “ Score the risk of Endometrial cancer”.
• Flow charts are useful in managing these patients.
• Newer techniques such as elastography & Contrast enhanced
ultrasound are complimentary to the conventional techniques
Takehomepoints

36. Thank you