menopause has different probems and risks, menopausal women need special screening and dignosis USG offers a good non invasive modality

1. Ultrasound in Menopause
Jaideep Malhotra
Narendra Malhotra
Ashok Khurana
Kuldeep Singh
www.rainbowhospitals.org

2. When in Doubt, Cut it Out
“ A palpable postmenopausal ovary should
not be reevaluated or followed up but be
investigated promptly by liberal indications
of surgery”
Hugh Barber, 1971

3. In the Presidential Symposium of the North American
Menopause Society Annual Meeting in 2011, it noted,
that, the sensitivity of newer imaging technology has
resulted in the delineation of findings that are much
more common and far more clinically innocuous than
appreciated .
• Has created a tricky situation where because
of lack of information and guidelines, women
are being put through unnecessary procedures.
• These procedures are being carried out consequent to
the fear of missing a malignancy, both on the part of
the treating physician and the patient.

4. At the outset it is important to mention that
ultrasound remains the principal modality in
assessing the pelvis in menopause and
beyond, and that CT, MRI and PET-CT remain
problem solving and cancer staging modalities
as in other gynecologic scenarios.

5. • High frequency transvaginal
scans
• Color flow mapping
• Duplex Doppler
• Power Doppler
• Three dimensional ultrasound
Ultrasound techniques

6. Ultrasound techniques
Complimentary techniques
• Power and color Doppler
• Saline infusion sonohysterography
• Positive contrast sonohysterography
• 3D & 4D (Real time 3D)

7. AIM
• TO IMPROVE RECOGNITION OF PELVIC LESION ANATOMY
• CHARACTERISATION OF SURFACE FEATURES
• DETECTION OF TUMOR INFILTRATION
• PRECISE DEPICTION OF SIZE AND VOLUME

8. INDICATIONS
• Endometrial evaluation in vaginal bleeding
• Evaluation of palpable pelvic mass
• Screening for endometrial and ovarian cancer in
high risk group

9. TECHNIQUES
• Transabdominal
• Transvaginal
• Transperineal

10. EVALUATION
• Uterus
• Ovaries
• Extra-ovarian adnexal areas
• Cervix
• Pouch of douglas

11. SYSTEMIC EVALUATION
• Pleura
• Peritoneum
• Retroperitoneum
• Liver
• Kidneys
• Bladder

12. Post menopausal woman

13. Uterus
Atrophy

14. Uterus
Measurements
X
X 

15. Uterus
Measurements

16. The Endometrium in Menopause
Norms

17. Endometrium
Measurements



18. Endometrial Thickness
Considerations
• Include the entire endometrial thickness and not just
one leaf
• The thickest anteroposterior measurement is to be
considered
• The extent of a fluid collection should not be included

19. Endometrium
Measurements

20. Endometrium
Abnormal morphology
Focal increased echogenecity, diffuse increased echogenecity
and diffuse inhomogeneity increase the predictability of pathologic findings.

21. Endometrium
Abnormal morphology

22. Endometrium
Abnormal morphology

23. Endometrium
Abnormal morphology

24. Endometrium
Abnormal morphology

25. Endometrium
Abnormal morphology

26. Endometrial polyps
3D Power Doppler

27. Endometrium
Saline infusion sonohysterography

28. Single/orthogonal/TUI
3D Display Formats
Single plane Tomographic display

29. Cervical Polyps
Vascular Pedicle

30. Endometrial Thickness
Study
No.
Endometrial
Thickness
Cutoff (mm)
Number of
Cases Below
Cutoff
Histological Findings
Minimal
Thickness of
Endometrial
Carcinoma
09 < 8 46
Negative : 32 (70%)
Hyperplasia or polyps: 14 (30%)
-
10 < 5 11 Negative : 11 (100%) -
11 < 5 117 Negative : 117 (100%) 9
12 < 4 60 Negative : 60 (100%) -
13 < 5 150 Negative : 150 (100%) 9
14 < 5 58
Negative : 57 (98%)
Endometrial Carcinoma : 01 (2%)
5
15 < 4 54
Not Malignant : 51 (94%)
Malignant : 03 (6%)
2
16 < 5 11 Negative : 10 (91%), Polyp : 1 (9%) 10
17 < 4 46
Negative : 44 (96%), Endometrial
Polyp : 1 (2%), Endometrial
Carcinoma : 1 (2%)
3
Negative : 491 (95%), Endometrial
Polyp : 6 (1%), Endometrial

31. Endometrium
• A 3 mm cutoff limit after 5 years or more since
menopause greatly improves the specificity and
false positive rate for endometrial pathology.
• For a specific diagnosis of endometrial cancer
(and not the entire gamut of endometrial
disease) a thickness of 5mm and 6mm
respectively are appropriate cut offs for women
post-15 years menopause and women who are 5-
15 years post menopause.

32. Endometrial Thickness
Patients without bleeding
• Old standard: 4-6 mm
• Positive predictive value of > 5mm is 10%
for any disease and 4% for cancer or
hyperplasia
• A sampling should be considered at > 8mm
• Age is, however important. At age 50 the
risk at 8mm is 4.1% and at age 79, 9.3%

33. Endometrium
Increased thickness (IMS criteria)
Hormone replacement therapy
Combined continuous
regimen
+ 1 – 1.5 mm
Sequential regimen + 3 mm
Time since menopause 3 mm after 5
years
Hypertension
Asymptomatic on
medication
6.2 mm
Untreated hypertension 4.3 mm

34. Endometrium
Increased thickness
Tibolone 5.5 mm
Raloxifene 4.0 mm
Tamoxifen 8.0 mm

35. Endometrium
• Proliferative endometrium
• Hyperplasia
• Cancer
• Residual adenomyosis
Tamoxifen

36. Endometrium
• 6 mm or less + homogeneous :
EXPECTANT MANAGEMENT
• Focal increased echogenecity / Diffuse
inhomogeneity / Focal lesion (any
thickness) : AGGRESSIVE EVALUATION
Thickness and morphology
Khurana A, Sheikh M et al. Acta Obstet Gynecol Scand 2000

37. • In a postmenopausal woman without vaginal bleeding,
if the endometrium measures > 8 mm a biopsy should
be considered as the risk of cancer is 6.7%, whereas if
the endometrium measures < or = 8 mm the risk of
cancer is extremely low.
• In the situation of a thickness of 11 mm or less in
patients without bleeding the patient’s age is worth
considering in deciding to sample an endometrium.
• As a woman's age increases, her risk of cancer
increases at each endometrial thickness
measurement.

38. • Non-gynecological: trauma, systemic & bleeding disorders,
medication including hormone therapy (HT)
• Vaginal atrophy
• Endometrial hyperplasia; simple, complex, and atypical.
• Endometrial carcinoma
• Endometrial polyps or cervical polyps
• Carcinoma of cervix
• Uterine sarcoma, ovarian, vaginal, vulval, tubal cancers
Postmenopausal Bleeding
Causes

39. Post Menopausal Bleeding
A complete survey

40. Post Menopausal Bleeding
The atrophic endometrium

41. Post Menopausal Bleeding
Abnormal endometrial patterns

42. ENDOMETRIAL THICKNESS
5-8 mm > 8 mm< 4 mm
Sequential
Hormones
All other
hormones
Bleeding No Bleeding Bleeding No Bleeding
Probably
Atrophy
Normal Biopsy Likely normal
No Biopsy
Rescan early or
Late in cycle
Biopsy

43. Myometrium
• Myometrium atrophies gradually during & after menopause.
• This results in a reduction of uterine size but no appreciable
change in echo pattern.
• Arcuate arteries may calcify, particularly in the diabetic patient.
• Fibroids undergo a reduction in size after menopause & variably
shrink and calcify.
• Multiple fibroids may occasionally distort & obscure the
postmenopausal endometrium

44. Myometrium
Fibroids

45. Myometrium
Fibroids

46. Ovaries
Atrophy
8.6 + 2.3 ml in the 1st
year
2.2 + 1.4 ml after that

47. Ovarian Cancer
• 80% of ovarian cancers occur in women
over 50 years of age
• Cost of screening versus quality of life
• Annual pelvic exam + tumor markers +
ultrasound scan (TVS + color Doppler +
4D)
Considerations

48. Benign Versus Malignant Disease
• General wall thickness
• Focal wall thickening
• Septations
• Nodularity / solid areas
• Heteroechoic pattern
Grey scale criteria
• Peritoneal fluid
• Lymphnode
enlargement
• Metastases

49. Benign Versus Malignant Disease
Grey scale criteria

50. BENIGN VERSUS MALIGNANT DISEASE
TRADITIONAL MARKERS

51. Ovary in Menopause
• Women with unilocular cysts on transvaginal
ultrasound (TVS) and a normal CA-125 are
monitored with repeat TVS at 3 to 6 months.
Those with a complex mass <5 cm and normal
CA-125 should have repeat TVS and CA-125
testing in 4 weeks.
• Surgery is recommended for any women
with increasing morphologic complexity or a
rising CA-125.

52. Benign vs malignant
• Malignant lesions usually produce a significant
increase in color Doppler flow signals
secondary to angiogenesis.
• The color content of the tumor probably
reflects tumor vascularity better than any
other Doppler parameter.

53. • A color score is used to describe the amount
of blood flow for the tumor as a whole:
• color score 1, no detectable blood flow;
• score 2, minimal flow;
• score 3, moderate flow;
• and score 4, highly vascular.

54. • Malignancies often exhibit their increased flow
signals not only at the periphery of the mass, as
seen with benign lesions, but also in the central
regions of the mass, including within septations
and solid tumor areas.
• The neovascularity within malignancies is made
up of abnormal vessels, lacking smooth muscle
within their walls and containing multiple
arteriovenous shunts, resulting in low-impedance
flow
• (pulsatility index < 1.0)
• and (resistance index < 0.4),
• high time-averaged maximum velocity (> 15
cm/s),
• and absence of a diastolic notch in such masses .

55. Ovarian masses
• Neoplastic ovarian masses have a wide
pathological spectrum and vary in
appearance from simple, thin walled,
unilocular, avascular cysts to completely
solid masses.
• Advances in transducer technology,
color Doppler, power Doppler and 3D
studies have greatly enhanced the
accuracy of histological prediction of
benign and malignant adnexal lesions

56. • The criteria for a diagnosis of a malignant
mass include grey scale observations of
• a solid mass,
• a cystic mass with solid areas,
• focal or diffusely thick walls or septations,
• mural nodules
• and heterogeneous internal echoes.
• Pelvic and paraaortic lymph nodes
enlargement, ascites, suprarenal and liver
metastases and pleural effusions can be
elucidated by transabdominal ultrasound.

57. • Color flow and 3D vascular
reconstruction criteria include
• abnormal calibration of vessels,
• dichotomous branches,
• elongation, coiling, aneurysms,
• vascular lakes,
• arteriovenous anastamoses
• and veno-venous anastomoses

58. Benign Versus Malignant Disease
• 40% - 90% accuracy
• Non universal selection of parameters
• Highest, lowest or mean impedance values
• Selection of vessels
• Operator variance
• System sensitivity
Color flow criteria
Doppler parameters

59. BENIGN VERSUS MALIGNANT DISEASE
COLOR FLOW MAPPING

60. BENIGN VERSUS MALIGNANT DISEASE
NEWER MARKERS (!)
IMPEDANCE VALUES

61. Benign Versus Malignant Disease
• Dilated, saccular and tortuous
• Elongation and coiling
• Dichotomous branching
• No decrease in diameter of higher
order branches
3D color flow criteria

62. Benign Versus Malignant Disease
• No normal precapillary architecture
- Arteriovenous anastamoses
- Venovenous shunts
• Vascular lakes
- Incomplete vascular walls
- Increased interstitial pressure
- Increased vascular permeability
- Poor lymphatic drainage
3D color flow criteria

63. Benign Versus Malignant Disease
• Arteriovenous anastamoses
- Low global flow resistance
- High global blood flow
- Hypoperfused areas
3D color flow criteria

64. Benign Versus Malignant Disease
3D color flow criteria

65. Benign Versus Malignant Disease
3D color flow criteria

66. Benign Versus Malignant Disease
3D color flow criteria

67. Benign Versus Malignant Disease
3D color flow criteria

68. Adnexal Masses (ACR Criteria)
Radiologic exam
procedure
Low risk
female +
no mass
on US
High risk
female +
no mass
on US
Clinical
mass +
simple
ovarian
cyst < 30
mm
Clinical
mass +
simple
ovarian
cyst 30-50
mm
Clinical
mass +
simple
ovarian
cyst > 50
mm
Clinical mass
+ complex/
solid mass
on US
Ultrasound
Color Flow 2 4 3 4 6 8
Doppler PI/RI 2 4 2 4 6 8
Follow up Ultrasound
06 weeks - - 2 2 6 2
12 weeks 2 2 4 ? 2 2
06 months 2 2 4 7 2 2
12 months 2 8 7 7 2 2
Image-guided - - 2 4 4 2
Aspiration
CT 2 2 2 2 4 4
MRI 2 2 2 2 2 4
CA125 2 2 - - - -

69. Adnexal masses
• These criteria and conclusions of other workers suggest
that a cystic structure less than 30 mm in size, unilateral,
unilocular and with no internal echoes, solid areas or
nodules, which is avascular on color flow mapping may be
re-evaluated 06 and 12 weeks later and then annually if it
does not increase or change in morphology or vascularity.
• Any mass with abnormal vascularity and all masses greater
than 50 mm in size warrant surgical evaluation.
• Aspirates obtained even under ultrasound guidance do not
contain an adequate representation of cells from the tissue
of origin to justify the technique.
• All masses associated with a rising Ca 125 level warrant
surgical evaluation.

70. Adnexal Masses
Extra ovarian lesions

71. Adnexal Masses
Extra ovarian lesions

72. Adnexal Masses
Tuberculosis

73. Adnexal Masses
Dermoids

74. Urinary Evaluation
D
• Dynamic assessment in a sitting position
• Observation during Valsalva
• Pre and post surgical evaluation
- Anterior suspensory mechanism
- Suburethral endopelvic fascia
- Uterosacral complex
• Bladder wall thickness
• Bladder wall vascularisation

75. Urinary Evaluation
D

76. Urinary Evaluation
D

77. Urinary Evaluation
D

78. Breast Sonography
D
• Dense breasts
• Palpable lesions
• Synchronous lesions
• Interval cancers

79. Proposed Time Table
D
• Pretreatment baseline
• After 6 months of treatment
• Annual exam
• Three / six monthly exam after change of
regimen
• After a bleed
• ? Six weeks / ? Three month after finding of
abnormal morphology

80. UAE is an
effective and
safe method in
the treatment of
fibroids and
adenomyosis.
BUT the
recurrence rate
is not yet
evaluated.
Uterine arterial embolization in the
treatment of fibroids and adenomyosis

81. MRI-guided Focused Ultrasound
Surgery

82. MRIgFUS represents a new, safe
and effective method for the
ablation of adenomyotic tissue

83. • Ultrasound is the mainstay of diagnosis and
follow up of various problems associated with
menopause and is indeed a boon.
• It saves from many unnecessary surgical
procedures.
• Close monitoring and addition of 3D/4D and
color doppler have added immense value .
Conclusion

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