Female gynaecologic conditions arising from the endometrium are common and depend on a woman's age, her menstrual history, and the use of medications such as hormone replacement and tamoxifen.
Both benign and malignant conditions affect the endometrium.
Benign conditions must be distinguished from malignant and premalignant conditions.
The most commonly used imaging modality for evaluating the endometrium is pelvic ultrasound with transabdominal and transvaginal techniques. Additional imaging methods include hysterosonography and magnetic resonance imaging
Women with benign heavy menstrual bleeding have the choice of a number of medical treatment options to reduce their blood loss and improve quality of life.
Adherent placenta occurs when there is a defect in the decidua basalis, Resulting in an abnormal invasion of the placenta directly into the substance of the uterus
When a sound source and the reflector are moving toward each other, the sound waves are spaced closer together and reach the receiver at a higher frequency than they were originally emitted “
enal transplantation is the most effective treatment option in patients with end-stage renal disease.
Studies have shown that the 5-year survival after renal transplantation is 70%, as compared to 30% survival in patients receiving dialysis.
The use of appropriate diagnostic method in preoperative analysis and also in postoperative follow up protocol is necessary for accurate preparation and early diagnosis of complications and workflow efficiency .
The most important role of diagnostic radiological methods is to identify multiple complications in the posttransplant period
Generally, the transplanted kidney is placed heterotopically in an extraperitoneal space in the pelvis; that is, a right kidney is placed in the left iliac fossa and vice versa
The right iliac fossa is usually preferred, since the right iliac vein runs a more superficial and horizontal course on this side of the pelvis, making the creation of vascular anastomoses easier.
WHY IS THIS topic important
It is because prostate cancer is very common and but a good proportion of these cancers are considered clinically insignificant
And then there are more aggressive ones which are clinically significant which need to be treated
Our goal is to improve detection of these before they spread So that they can be treated
Xeroradiography is the production of visible image utilizing the charged surface of a photoconductor (amorphous selenium) as the detecting medium, partially dissipating the charge by exposure to X rays to form a latent image and making the latent image visible by xerographic processing.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. ⊳ age
⊳ menstrual history
⊳ hormone replacement & tamoxifen.
⊳ Both benign and malignant conditions affect the
endometrium.
⊳ Benign conditions must be distinguished from
malignant & premalignant conditions.
⊳ M/C used -pelvic USG with TAS and TVS techniques.
⊳ HSG & MRI
2
13. 13
Normal appearance
● Thin, homogenous & echogenic
double-layer thickness of less than 5 mm without focal
thickening excludes significant disease and is
consistent with atrophy
14. ET thickest prior to progestin exposure and thinnest after
progestin phase
14
Cyclic estrogen & progestin therapy ET Vary upto 3mm
Unopposed estrogen ET >8mm consider biopsy
Progesterone + estrogen therapy Scan at the beginning or end to
check change in ET
21. Endometrial Adenocarcinoma
● M/C gynecologic malignancy
● in developing countries, it is the 2nd M/C abnormal uterine bleeding
(intermenstrual or postmenopausal) in more than 80% of cases.
● EC is more common during the 6th and 7th decades
21
22. Endometrial Adenocarcinoma
● US signs of endometrial carcinoma include heterogeneity
and irregular endometrial thickening
● These signs are nonspecific
● Biopsy
● More specific sign is irregularity of endometrium-
myometrium border.
● Intrauterine fluid collections - raise concern for endometrial
carcinoma.
22
30. Intrauterine fluid collections
● tiny amount of fluid within the postmenopausal endometrial canal may be
considered normal
● associated with both endometrial & cervical cancers
● obstructing tumor must be excluded
● premenopausal patients, fluid collections are M/C associated with
menstruation, early IUP, or the pseudogestational sac in an ectopic
pregnancy
30
35. IETA
In an attempt to standardise the ultrasound examination of
the endometrium and the uterine cavity, the International
Endometrial Tumor Analysis (IETA) group
● how to perform an ultrasound examination of the
endometrium and of the uterine cavity
● terms and definitions to be used to report the ultrasound
findings
35
36. ● The ultrasound examination should start with the acquisition of a proper
midsagittal section of the uterus
● If 3D acquisition is not available, the endometrial thickness should NOT
be measured (it should be reported as ‘not measurable’, together with a
short explanation of the reason why)
● Fluid instillation sonography will usually highlight the endometrium
enabling a reliable endometrial measurement.
● The endometrium is measured in midsagittal section where the
endometrium is considered to be at its thickest
36
45. Conclusion
There are many different imaging appearances of the normal and abnormal
endometrium. Although US is almost always the first modality used in the
radiologic work-up of endometrial disease, the use of multiple imaging
modalities is common. Whether using US, MR imaging, sonohysterography, or
hysterosalpingography, radiologists must understand that the appearance of
the endometrium is dynamic. They must take into account the patient’s age,
stage in the menstrual cycle, and pregnancy status and whether she has
undergone hormonal replacement therapy or tamoxifen therapy.
45
Female gynaecologic conditions arising from the endometrium are common and depend on a woman's age, her menstrual history, and the use of medications such as hormone replacement and tamoxifen.
Both benign and malignant conditions affect the endometrium.
Benign conditions must be distinguished from malignant and premalignant conditions.
The most commonly used imaging modality for evaluating the endometrium is pelvic ultrasound with transabdominal and transvaginal techniques. Additional imaging methods include hysterosonography and magnetic resonance imaging
endometrium generally appears as a thin, echogenic line
Approximately one-fourth of neonates will have fluid collections within the endometrial cavity
Normal pediatric endometrium. in a 2-year-old girl demonstrates a thin endometrium
The most common pelvic masses in neonates include hydrocolpos, hydrometrocolpos, and ovarian cysts.
Hydrocolpos is characterized by distention of the vagina
Hydrometrocolpos is characterized by dilatation of both the uterus and vagina with serous fluid and possibly urine if there is a urogenital sinus
The endometrium is intrinsically normal, but the endometrial cavity is distended with fluid.
Both hydrocolpos and hydrometrocolpos result from vaginal or cervical stenosis, hypoplasia, or agenesis
US demonstrates a cystic midline mass with internal echoes representing mucoid material and cellular debris
On the other hand, hematocolpos and hematometrocolpos in adolescent girls are generally associated with an imperforate hymen without an increase in associated congenital anomalies. US demonstrates an echogenic, tubular, cystic midline mass with internal echoes representing fluid and debris
Hematometrocolpos in a 12-year-old girl with abdominal pain. Sagittal US image demonstrates a markedly distended vagina (straight arrow) and uterine cavity (curved arrow).
The best way to measure the endometrial thickness is on a midsagittal transvaginal image.
The normal endometrium is composed of 2 layers and the combined thickness of the 2 layers depends on where a woman is in her menstrual cycle.
In this stage, the endometrium may measure up to 11 mm in thickness. The layered appearance usually disappears 48 hours after ovulation.
Immediately following menses, the endometrium is a thin echogenic line measuring 1-4 mm (Figure 1).
normal endometrium in periovulatory phase. There is a trilaminar appearance. Central functional layer of endometrium is relatively hypoechoic. 3 echogenic lines formed by the 2 basal layers of hyperechoic endometrium and the collapsed endometrial cavity
normal endometrium in the secretory phase. endometrium measures 15 mm
Endometrium is echogenic due to mucus and glycogen in the endometrial cells.
) A 51-year-old woman with postmenopausal bleeding. Transvaginal sagittal ultrasound (US) shows atrophic endometrium that measures 2 mm (arrowheads; typically less than 5 mm). The myometrium is heterogeneously echogenic in the fundus due to calcified arcuate arteries (asterisk).
The MR imaging appearance of normal endometrium is best demonstrated on T2-weighted images because the uterus has homogeneous intermediate signal intensity with T1-weighted sequences.
T2-weighted images delineate the uterine zonal anatomy.
The normal endometrium is of uniformly high signal intensity, and the inner myometrium, or junctional zone, is of uniformly low signal intensity
Normal premenopausal endometrium. T2- weighted MR image shows the normal endometrium (straight arrow) and junctional zone (curved arrow).
The postmenopausal examination should take into consideration patient’s clinical history (eg, vaginal bleeding) and whether she has undergone hormonal replacement therapy.
The normal postmenopausal endometrium should appear thin, homogeneous, and echogenic.
In general, a double-layer thickness of less than 5 mm without focal thickening excludes significant disease and is consistent with atrophy
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 (22).
The endometrium will appear thickest prior to progestin exposure and thinnest after the progestin phase. Imaging should be performed at the beginning or end of a cycle of treatment, when the endometrium will be at its thinnest and any pathologic thickening will be most prominent.
A patient undergoing unopposed estrogen therapy with endometrial thickening exceeding 8 mm should be considered for biopsy, whereas patients receiving progesterone in addition to estrogen can be rescanned at the beginning or end of the following cycle to determine if there has been a change in endometrial thickness
Imaging should take place immediately after bleeding has stopped, when the endometrium is presumed to be thinnest and any disease entity will be most prominent.
Endometrial thickness less than 4 –5 mm at transvaginal US generally excludes cancer
Postmenopausal endometrial atrophy. (15) Transvaginal US image demonstrates a postmenopausal endometrium with thin walls and outlined with fluid. (16) T2-weighted MR image demonstrates an atrophic postmenopausal endometrium (arrows).
Any thickness greater than 5 mm in the setting of postmenopausal bleeding or any endometrial heterogeneity or focal thickening seen at transvaginal US should be investigated further with sonohysterography, biopsy, or hysteroscopy.
Endometrial polyps are a common cause of postmenopausal bleeding and are most frequently seen in patients receiving tamoxifen.
Polyps are best seen at sonohysterography and appear as echogenic, smooth, intracavitary masses outlined by fluid
The polyp may be broad-based and sessile or pedunculated
The point of attachment should not disrupt the endometrial lining.
Polyps may also be seen at hysterosalpingography as pedunculated filling defects within the uterine cavity
T2-weighted MR imaging as low signal-intensity intracavitary masses surrounded by high-signal-intensity fluid and endometrium
Color Doppler US may be used to image vessels within the stalk.
Fibroids or foci of endometrial hyperplasia or carcinoma can mimic a sessile polyp, and foci of atypical hyperplasia are sometimes found within polyps
Endometrial polyp. Sonohysterogram reveals a small polyp attached by a stalk to the endometrium (black arrow).
An echogenic focus in the endometrial cavity (white arrow) represents injected air.
On hysterosalpingograms demonstrate a pedunculated filling defect within the uterine cavity (arrows).
They are commonly identified at US as hypoechoic solid masses, but they may be heterogeneous or hyperechoic, depending on the degree of degeneration and calcification.
Fibroids tend not to interrupt the endometrium unless they are submucosal in location.
Submucosal fibroids may distort the uterine cavity with varying degrees of intracavitary extension and are best visualized at sonohysterography
Submucosal fibroid. (a) Transvaginal US image reveals a uterine mass (arrows) with posterior acoustic shadowing. (b) Sonohysterogram reveals that the mass is submucosal in location, a finding that is consistent with an echogenic fibroid.
At hysterosalpingography, submucosal fibroids are seen as filling defects with enlargement or deformity of the uterine cavity (Fig 21).
At T1- weighted MR imaging, fibroids appear iso- to hypointense relative to the myometrium, whereas at T2-weighted imaging they appear homogeneously hypointense or heterogeneously hyperintense when degeneration is present
Endometrial hyperplasia is an abnormal proliferation of endometrial stroma and glands
All types of endometrial hyperplasia (cystic, adenomatous, atypical) can cause diffusely smooth or, less commonly, focal hyperechoic endometrial thickening
Endometrial hyperplasia is considered whenever the endometrium appears to exceed 10 mm in thickness, especially in menopausal patients
Endometrial hyperplasia. US image shows an endometrium with diffuse thickening (maximum thickness, 1.74 cm) due to hyperplasia (cursors). This finding was confirmed at biopsy
Adenocarcinoma.—Endometrial adenocarcinoma is the most common invasive gynecologic malignancy,
US signs of endometrial carcinoma include heterogeneity and irregular endometrial thickening
These signs are nonspecific and can be seen in endometrial hyperplasia as well as polyps, leading to biopsy of almost any irregularity in the setting of postmenopausal bleeding.
A more specific US sign is irregularity of the endometrium-myometrium border, a finding that indicates invasive disease.
A small amount of fluid in the endometrial canal is likely related to benign cervical stenosis and does not require further evaluation.
An intrauterine fluid collection in a postmenopausal patient, although possibly related to cervical stenosis, should raise concern for endometrial (or cervical) carcinoma.
EC spreads by direct infiltration or via lymphatic, transtubal peritoneal seeding or hematogenous routes. Locally, EC initially invades the myometrium and then the endocervix. After transserosal spread, direct invasion of the parametrium, bladder, or bowel may occu
Stage I reflects ECs that are confined to the uterine corpus. It is further divided into stages IA and IB. Stage IA reflects tumors that are confined to the inner endometrium and invade less than 50% of the myometrial thickness. Stage IB represents tumors with more than 50% of myometrial thickness invasion.
Stage III represents tumor with local or regional spread beyond the uterus, but not outside the true pelvis. It is further divided into stage IIIA which includes tumors that invade the uterine serosa and/or adnexa, stage IIIB which includes tumors that extend into the parametrium and/or with vaginal involvement, and stage IIIC which includes tumors with spread to pelvic or para-aortic lymph nodes. Stage IIIC is further divided into stage IIIC1 when the tumor presents with pelvic lymph node involvement and stage IIIC2 when there is para-aortic lymph node involvement (with or without pelvic nodes).
Stage IV represents tumors that are locally advanced or have distant metastases. It is further divided into stage IVA that includes tumors with extension to the bladder or bowel mucosa and stage IVB consisting of tumors that have distant metastases.
endometrial thickness threshold of 5 mm, in postmenopausal women, is used to define abnormal endometrial thickening
endometrial cancer. demonstrate a thickened and heterogeneous endometrium measuring 2.0 cm (arrows).
It can be difficult to delineate the tumor margins on ultrasound, especially when it is diffusely infiltrating the myometrium
Myometrial invasion is suggested when there is irregularity of the endometrium - myometrium border and disruption of the subendometrial halo (inner layer of myometrium) or the tumor extends asymmetrically into the myometrium
A 72-year-old female with endometrial cancer. thickened and heterogeneous endometrium (arrows) with ill-defined anterior border and no clear separation from the myometrium (arrowheads), suggestive of myometrial invasion
On contrast-enhanced CT, EC appears as a hypoattenuating and hypoenhancing mass in the endometrial cavity [Figure 3].
However, this appearance is nonspecific and the differential diagnosis of a hypoenhancing endometrial mass on CT includes submucosal leiomyomas, endometrial polyps, or cervical stenosis CT's poor soft tissue differentiation limits its use in the local staging of EC. CT is less sensitive and less specific in accurately visualizing myometrial invasion and cervical involvement than MRI.
A 66-year-old female with endometrial cancer. (A) Coronal and (B) sagittal reformatted contrast-enhanced computed tomography images of the pelvis show thick hypodense and hypoenhancing endometrium (arrows). (C) T2W MR image showing a thick and heterogeneous endometrium (arrow) in this patient with biopsy-proven diagnosis of endometrial cancer
MRI is considered the most accurate imaging modality.
On MRI, EC is usually seen as a hypo-to-isointense mass on T1-weighted images (T1WI)
with an intermediate signal intensity lower than the normal endometrium on T2-weighted images (T2WI). EC enhances less than the myometrium
A 64-year-old female with endometrial cancer. (A) T2W image show a hyperintense signal intensity tumor distending the endometrial cavity (arrow).
(B) On T1W post-contrast image, the tumor (arrow) is low in signal compared to the enhancing adjacent myometrium. It presents restricted diffusion with high signal on DW images
(C) and low signal on ADC map (D) (arrows). (E) It presents with high FDG uptake on FDG-PET/CT (arrow)
Depth of myometrial invasion is one of the most important prognostic factors[27]
The depth of myometrial invasion is optimally depicted with T2-weighted sequences.
T2W image showing high signal intensity fluid in endometrial cavity (black arrow) with intact low signal intensity junctional zone (white arrows).
(B) T1W post-contrast image shows no evidence of myometrial invasion or cervical involvement indicating stage IA disease
Dynamic contrast-enhanced MR imaging improves the accuracy of the assessment of the depth of myometrial invasion. EC enhances less than normal myometrium after administration of intravenous gadolinium
Sagittal T2W MR image, (B) T1W post-contrast image, (C) DW image, and (D) ADC map image show a large and irregular endometrial mass (white arrows) which disrupts the cervical stroma (black arrowheads), but does not extend beyond the uterus indicating stage II disease. Note normal posterior cervical lip (white arrowheads)
Although a tiny amount of fluid within the postmenopausal endometrial canal may be considered normal (44), any significant fluid collection is abnormal and requires careful evaluation of the uterus and adnexal structures for associated findings. Intrauterine fluid collections are associated with both endometrial and cervical cancers (45– 47).
An obstructing tumor must be excluded even when cervical stenosis has been identified clinically.
In premenopausal patients, fluid collections are most commonly associated with menstruation, early IUP, or the pseudogestational sac in an ectopic pregnancy.
In prepubertal patients, fluid in the endometrial canal may be related to hematometrocolpos.
Other benign causes of obstruction leading to intrauterine fluid production include polyps, infection, and submucosal fibroids.
The fluid may range in appearance from hypoechoic to hyperechoic depending on whether it is composed of serum, mucin, or blood.
Tamoxifen causes the endometrium to appear thickened, irregular, and cystic at US
The punctate cystic spaces may be secondary to reactivation of adenomyosis within the inner myometrium or to obstructed glands in the endometrium due to the drug’s weak estrogenic effects
Two MR imaging patterns associated with tamoxifen have been described.
The first pattern manifests as homogeneous high signal intensity on T2-weighted images,
The second pattern manifests as heterogeneous signal intensity on T2-weighted images
Endometrial thickening associated with tamoxifen therapy. (a) US image reveals marked endometrial thickening (arrowheads) associated with subendometrial cysts (arrows) resulting from tamoxifen therapy.
Endometrial thickening associated with tamoxifen therapy. T2-weighted MR image shows a thickened endometrium (straight arrows) with focal areas of decreased signal intensity (curved arrow) associated with polyps resulting from tamoxifen therapy.
Endometrial adhesions are posttraumatic or postsurgical in nature and can cause Asherman syndrome, which includes infertility, recurrent pregnancy loss, and amenorrhea.
Sonohysterography may demonstrate synechiae as echogenic bands bridging the uterine cavity. If the bands are thick and fibrotic, they may prevent complete uterine distention.
Hysterosalpingography will demonstrate similar findings, with incomplete filling of the endometrial cavity and numerous irregular filling defects (Fig 27).
Intrauterine contraceptive devices (IUD) should lie within the endometrial cavity
IUDs should be readily detected at US as highly echogenic structures with distal acoustic shadowing (Fig 28).
If US cannot help identify an IUD within the endometrial canal, conventional radiography or CT may be performed to determine whether it lies within the peritoneal cavity.
If so, the diagnosis of perforation of the uterine wall can be made
In an attempt to standardise the ultrasound examination of the endometrium and the uterine cavity, the International Endometrial Tumor Analysis (IETA) group on how to perform an ultrasound examination of the endometrium and of the uterine cavity and on the terms and definitions to be used to report the ultrasound findings
The ultrasound examination should start with the acquisition of a proper midsagittal section of the uterus, followed by the measurement of the endometrium.
The whole uterus should be scanned from right to left and from fundus to cervix.
In case the endometrium is not readily visible at first glance, it can usually be traced starting from the endocervical canal and then moving up.
Sometimes the uterus is twisted laterally, precluding the visualisation of a proper mid‐sagittal view. In these cases, minimal manipulation of a 3D volume usually enables the sonographer to achieve the correct section.
If 3D acquisition is not available, the endometrial thickness should NOT be measured (it should be reported as ‘not measurable’, together with a short explanation of the reason why).
If the endometrium is not visible on unenhanced ultrasound, switching on the colour/power Doppler may help the orientation by visualising the vascularisation of the myometrium stopping at the basal layers of the endometrium.
Fluid instillation sonography will usually highlight the endometrium enabling a reliable endometrial measurement.
The endometrium is measured in midsagittal section where the endometrium is considered to be at its thickest (and this is not necessarily in the fundus)
The endometrium should be measured where it appears to be at its thickest.
(b) When intracavitary fluid is present, the thickness of both single layers is measured in the sagittal plane and the sum is recorded
After measurement, the examiner should report on the echogenicity of the endometrium (uniform or not uniform)
Uniform endometrial echogenicity: (a) three‐layer pattern; (b) hypoechogenic; (c) hyper‐ echogenic; (d) isoechogenic
the endometrial midline, the endometrial‐myometrial junction, the colour score
Figure 3
(a) colour score of 1: no colour; (b) colour score of 2: minimal colour (i.e. minimal flow); (c) colour score of 3: moderate colour (i.e. moderate flow); (d) colour score of 4: abundant colour (i.e. abundant flow).
and, if applicable, the vascular pattern
Figure 4
Vascular pattern: single ‘dominant’ vessel (a) without branching and (b) with branching; multiple vessels with (c) focal origin, (d) multifocal origin or (e) scattered vessels; (f) circular flow.
The principle of FIS is that fluid (saline or gel) acts as a negative contrast agent (fluid being echolucent). Especially focal lesions protruding into the uterine cavity (such as polyps, fibroids) are highlighted against the echolucent background of the instilled fluid
An endometrial lesion may be localised or extended Estimation of the extend of an endometrial lesion: (a) localised, if the base of the lesion < 25% of the endometrial surface; (b) extended, if the base lesion > of the endometrial surface
A localised lesion may be pedunculated of sessile Type of localized lesion: (a) pedunculated if the a/b ratio < 1; sessile if the a/b ratio >1
An intracavitary fibroid should be graded as grade 0, grade 1 or grade 2 Proportion of the myoma protruding into the uterine cavity: (a) grade 0 (100% in the cavity); (b) grade 1 ( 3 50% in the cavity); (c) grade 2 (< 50% in the cavity). The colour score and, if applicable, the vascular pattern within the lesion should also be described
There are many different imaging appearances of the normal and abnormal endometrium. Although US is almost always the first modality used in the radiologic work-up of endometrial disease, the use of multiple imaging modalities is common. Whether using US, MR imaging, sonohysterography, or hysterosalpingography, radiologists must understand that the appearance of the endometrium is dynamic. They must take into account the patient’s age, stage in the menstrual cycle, and pregnancy status and whether she has undergone hormonal replacement therapy or tamoxifen therapy.