3. Cont.
Histological appearance is rely on last hormonal pattern before the menopause
Simple atrophic epithelium is seen when last cycle end in deficient proliferation
or secretion.
Cystic atrophy is when cycles end prior to decline in estrogen levels
Incomplete to complete atrophy is when there is protracted hormonal decline
(Fig 1)
6. Possible
causes of
increased ET
in USS
Hyperplasia with atypia
Hyperplasia without atypia
Carcinoma
Polyps
Submucosal fibroid & Adenomyosis may mimic
the condition
7.
8. Endometrial polyp
• Common & Prevalence increase with age
• Frequent in postmenopausal age than premenopausal age (12% vs
6%)
• Tamoxifen users are at high risk (30-60% prevalence) together with
Obese, hypertensive ladies
• Exact Aetiology is unknown.
• Excess estrogen receptors have found in polyps than adjacent
endometrium
• Chromosome 6 &12 may have a role
9. Histology of polyps
• Mixture of dense stroma ,
vascular channels & glandular
spaces covered by epithelium
• Glands arrange with the long axis
of glands parallel to surface
epithelium
10. Clinical
presentation
• Symptomatic as PV bleeding
• Asymptomatic incidental scan detection
• 2-12% PMB related to this
• Symptoms do not correlate with polyp size ,
location or number
• 25% co exist with endocervical polyps
11. Malignant potential
• Most are benign
• When PMB exists , malignant risk increases to 2.3%
• Malignant risk (0.3%) in asymptomatic patients is 10 times lesser than
symptomatic pts
• Atypical Hyperplasia prevalence is 1.2% in asymptomatic pts & in symptomatic
pts , it is about 2.2%
• If the mean diameter of asymptomatic polyp increases > 18mm , chance of
abnormal finding increases
13. • TVS polyp appearance is typically seen as regular hyper-echoic lesion
within uterine cavity with surrounding thin hypo-echoic halo
• Sometimes cystic spaces may evident with dilated fluid filled glands
• If doppler shows single feeding vessel , the 95% specific with 94% NPV for
polyp
• SIS & GIS can perform with less fail rate particularly with GIS
• Hysteroscopy + Biopsy is the gold standard with 100% sensitivity & 97%
specificity for polyps
14. Management
• If symptomatic- remove
• If asymptomatic , think about risk vs benefits. As perforation risk high
in asymptomatic patients.
• If mean polyp diameter is >18 mm , there is a risk of abnormal
endometrium. Therefore removal may need.
15. Atrophic Endometritis
• Chronic endometritis can easily develop after menopause & this may
associate with polyp or carcinoma
• They are generally asymptomatic but may present with pruritis ,
discharges or PMB
• Pyometra may occur if cervical stenosis present
• Early endometritis may have normal sonographic findings
• Thick , heterogenous endometrium with intra cavity fluid & gas may
seen
• Genital swabs sufficient to make diagnosis , but need to exclude CA
16. management
• If atrophy associated with PM estrogen deficiency , topical estrogen
without progestogens is sufficient
• Infective causes may need antibiotics
• Long term Rx may need as symptoms frequently recurs after
cessation of Rx
17. Endometrial Hyperplasia
• Irregular proliferation of endometrial glands with increase gland to
stroma ratio
• Precursor for carcinoma unless treated
• 3 times commoner than endometrial carcinoma
• Present as abnormal uterine bleeding as HMB , PMB , IMB ,
Unscheduled bleeding while on HRT
18. Risk factors
• High BMI
• Unopposed estrogen effect (drug induced)-can happen at any dose
• Anovulation (perimenopausal & PCOD related)
• Estrogen secreting tumors (40%-Granulosa)
• Infection
• Immunosuppression ( transplant recipients have 2 fold increased risk
of endometrial hyperplasia)
20. Diagnosis & Surveillance-Histology
• Outpatient hysteroscopy + Bx
• Inpatient hysteroscopy + Bx-(if out patient results inconclusive)
• TVS
• OPD hysteroscopy is convenient & highly accurate procedure & 2%
false negative results for endometrial hyperplasia
• Negative hysteroscopy reduce pretest probability significantly (CA
0.6% vs HPP 3% ) & superior in Cancer rather HPP
• TVS will give a further reason to proceed with endo biopsy & when ET
<4mm , less than 1% risk for malignancy . but larger cutoff may need
for those are on Tamoxifen &HRT
21. cont
• Role of USS in premenopausal women is restricted to identify
structural abnormalities, as there may be an overlap between normal
ET & abnormalities.
• Below the ET 7mm- it is unlikely to have hyperplasia in
premenopausal age group.
• Up to 10% of endometrial pathology may missed even with in patient
hysteroscopy but it will avoid repeated curetting & Asherman
syndrome in those who got fertility wishes.
22. CT or MRI
• Not routinely used in evaluation
• But pre-op CT in atypical endometrial hyperplasia or grade 1
endometrial hyperplasia could alter management in 4% cases
• Need further studies
