This the second lecture of a series of 3 lectures and deals with the endometrium as it appears during various phases of the menstural cycle, polyps, menopausal bleeding, tamoxifen endometrium, saline sonohysterography etc

1. The Endometrium

2. Uterus Part 2
Dr. Durr-e-Sabih
MBBS. MS. FRCP. FANMB.
Multan Ultrasound Service
Distt Jail Road- Multan
dsabih@yahoo.com

3. Stages of the Menstrual Cycle
• Menstrual phase
o Endometrium degenerates due to falling estrogen and
progesterone.
• Proliferative phase
o Endometrium thickens due to increased estrogen.
• Secretory phase
o Endometrium continues to grow and secrete substances
needed for implantation, supported by estrogen and
progesterone secretion by corpus luteum.

4. Endometrium (Histological
Structure)
• Basal layer
o Constant
• Functional layer (changes during cycle)
o Basalis (Constant)
o Inner compactum or functionalis
o Spongiosum

5. Endometrium (Ultrasound
Structure)
• Outer hypoechoic layer
o Basalis
o Inner compactum
• Inner echogenic layer
o Spongiosum
• Echogenic cavity line (sometimes with fluid)

6. Endometrial Stripe
Basal layer (hypoechoic)
Functional Layer
Endometrial canal

7. Endometrial Stripe
Measure the thickest
echogenic stripe in AP

8. Subendometrial Halo
(Retroverted Uterus)

9. Different Stages of Menstrual
Cycle
• Menstrual phase
o Endometrium degenerates due to falling estrogen
and progesterone.
• Proliferative phase
o Endometrium thickens due to increased estrogen.
• Secretory phase
o Endometrium continues to grow and secrete
substances needed for implantation, supported by
estrogen and progesterone secretion by corpus
luteum.

10. Endometrium
• Days 0-5 2-3 mm Hyperechoic
(Menstrual)
• Days 7-9 4-6 mm Hypoechoic
(Early Proliferative)
• Days 12-14 8-12 mm Isoechoic
(Late Proliferative)
• Days 15-20 8-15mm Hyperechoic
(Secretory)

11. Endometrium
• Menstrual
• Proliferative
• Secretory

12. Endometrium
• Menstrual
o Hypoechoic basalis
o Thin hyperechoic band
• Endometrial cavity and residual functionalis
• Proliferative
• Secretory

13. Endometrium
• Menstrual
o Hypoechoic basalis
o Thin hyperechoic band
• Endometrial cavity and residual functionalis
• Proliferative
• Secretory

15. Endometrium• Menstrual
• Proliferative, progressively thickens to 8-
12mm by day 14
o Outer hypoechoic line (Basalis)
o Hyperechoic line (Boundary of the functionalis
with basalis)
o Slightly hypoechoic band (Proliferating
funcionalis)
o Central hyperechoic line (Canal)
• Secretory

16. Endometrium• Menstrual
• Proliferative, progressively thickens to 8-
12mm by day 14
o Outer hypoechoic line (Basalis)
o Hyperechoic line (Boundary of the functionalis
with basalis)
o Slightly hypoechoic band (Proliferating
funcionalis)
o Central hyperechoic line (Canal)
• Secretory

17. Day 12

18. Endometrium
• Menstrual
• Proliferative
• Secretory no further thickening, but
echogenicity increases to give single band
appearance
o Thin hypoechoic line (basalis)
o Thick hyperechoic band (functionalis)
o Thin hyperechoc line (cavity)

19. Endometrium
• Menstrual
• Proliferative
• Secretory no further thickening, but
echogenicity increases to give single band
appearance
o Thin hypoechoic line (basalis)
o Thick hyperechoic band (functionalis)
o Thin hyperechoc line (cavity)

20. Numbers are not important
in pre menopausal women

21. Endometrium
• Changes under the influence of hormones at
different time of cycle.
• Possible to recognize
o Menstrual
o Prolifereative
o Secretory

22. Normal
Endometrium
5
9
14
25
25

23. Endometrium

24. Menopausal
• If not bleeding, numbers are not important
• If irregular or heterogeneous, this should be
further evaluated by sonohysterogram

25. Menopausal

26. Menopausal bleeding
• Very concerning for possible endometerial
cancer
• If <4mm, this is then probably atrophic
endometritis and benign
• If >4mm, must be worked up by biopsy,
could be a polyp or carcinoma… even a
polyp in this age should be biopsied because
many can harbour nests of cancer

27. Menopausal
bleeding

28. RPOC
• Presents with PPH
• Echogenic intracavitary mass(es)
• If it is continuous with the myometrium
high velocity low resistance flow can be
found on Doppler
• May calcify with time

29. RPOC

30. Calcified RPOC

31. Saline sonohysterography
• Endometrial polyps, hyperplasia, carcinoma.
• Fertility evaluation / recurrent pregnancy loss
intrauterine adhesions
• Screening before in-vitro fertilisation (IVF)
• Congenital uterine anomalies (3D
ultrasound or pelvic MRI may be better
options)
• Postmenopausal bleeding, submucosal
fibroids, retained products of conception

32. Saline sonohysterography
• In most cases the appropriate time is in the
early proliferative phase, just after
menstrual flow has stopped.

33. Saline Sonohysterogram (SSH)

34. Endometrial polyps
• Common 8-35%
• Benign nodular projection of endometrial
surface
• Largely asymptomatic but can cause
abnormal bleeding

35. • Might appear as focal endometrial thickening
or masses within the endometrial canal
• Focal thickening with thin echogenic
endometrial border is fairly specific
• Cystic spaces corresponding to dilated glands
filled with proteinaceous fluid may be seen
within the polyp and is considered a relatively
characteristic feature
• Feeding vessel may be seen extending to the
polyp on colour Doppler imaging
• 3D will show focal echogenicity in the
endometrium
Endometrial polyps

36. Endometrial polyp TVS

37. Natural SSH

38. Normal SSH
Exam continues while
cath withdrawn

39. SSH Polyps

40. Polyps

41. Submucous myoma

42. Growth vs. polyp

43. Polyp on 2D and 3D, not on SSH

44. Trauma

45. Trauma

46. C-section wound

47. Asherman syndrome
• Uterine synechia
• Instrumentation
o D&C
o Pregnancy
o C-section
o Infection
• Intrauterine
adhesions, can calcify

48. Uterine AVMs
• Formation of multiple arteriovenous
fistulous communications within the uterus
without an intervening capillary network.
Usually acquired and can occur with:
• Multiple pregnancies
• Miscarriage
• Iatrogenic
o Dilatation and curettage
o Termination of pregnancy
o Caesarian section

49. Ultrasound features
• Gray scale can be nonspecific, focal heterogeneity,
tubular spaces, prominent parametrial vessels,
mass like region but with minimal mass effect.
• Color Doppler. High vascularity, low resistance,
high velocity pattern. Feeding artery draining vein
might be prominent
• β - HCG might be needed to rule out hydatidiform
mole and RPOC

50. AVM

51. Traumatic AVM
After 3 months

52. IUCD

53. MIRENA

54. Forgotten MIRENA

55. IUCD

56. Partial Perforation

57. Perforation
© Allan J Worral MD, Alaska

58. Complete perforation

59. Complete
perforation

60. Cervical lesions

62. Tamoxifen
o Antiestrogenic with weak estrogenic effect
o Stimulate endometriosis
o Stimulate myoma growth.
o Stimulate endometrial proliferation with
more benign endometrial polyps and
hyperplasia.
o Patients who have pre-existing endometrial
lesions ( before starting Tamoxifen) have
higher risk of developing atypical lesions.

63. Tamoxifen
• The risk of developing endometrial cancer in
patients on Tamoxifen prophylaxis is only
observed in post-menopausal women

64. Tamoxifen
• Women on Tamoxifen should be told to immediately
report any gynecological symptoms
• Premenopausal women need no follow-up while on
Tamoxifen
• Post-menopausal women should have a pre-treatment scan
and should be regularly checked for endometrial
hyperplasia or polyps.. Presence of pretreatment polyps
increases risk of atypia
• If endometrial atypia arises, consider stopping Tamxifen or
hysterectomy. Tamoxifen can be re-started after
hysterectomy.
ACOG committee opinion. 601. June 2014. Tamoxifen and Uterine Cancer

65. Tamoxifen
© Dr. Gunjan Puri, Gujrat

66. End Part 2

67. 3D TVS

68. 3D

69. 3D specific enough
to obviate need
for SSH in some
cases

70. Intracavitary vs. submucous

71. Intracavitary vs.
submucous

72. End