0:01

So, endometrium, when you're thinking about

0:02

that, you have to take all of these factors

0:04

into account when you're evaluating whether the

0:07

thickness of the endometrium is normal or not.

0:10

So, the important things are going to be the age

0:11

of the patient, whether they are pre-menopausal,

0:14

post-menopausal, or within a menstrual cycle.

0:17

It's also important to note at what stage

0:19

they are within a menstrual cycle because it's

0:21

going to vary depending on where they are.

0:23

And then, of course, the pregnancy

0:25

status that's going to affect what

0:26

the endometrium should look like.

0:30

So, let's talk about the cycle and

0:32

let's talk about premenopausal

0:34

and postmenopausal endometrium.

0:36

So, at birth, the uterus is, in general,

0:38

the similar size to the cervix itself.

0:40

It may have a little bit of fluid

0:42

in the endometrium at that point.

0:43

And then, with age, the endometrium

0:45

and the uterus are going to grow.

0:47

The endometrium, at that point, starts

0:48

to appear as a thin echogenic line.

0:51

And then you reach the age of menstruation.

0:54

So, at menstruation, in general, at the very

0:57

beginning, right after the period ends, so maybe

0:59

day three, day four, day five, you're going to

1:01

have a thin echogenic line, as we can see here

1:04

in this retroverted retroflex uterus, generally

1:06

going to be around one to four millimeters.

1:08

It's going to be thin.

1:09

And it's going to be echogenic.

1:12

Next, you have your proliferative

1:14

phase, that's around day 6 through 14.

1:17

You're going to range there

1:17

from around 5 to 7 millimeters.

1:20

At this point, it's going to become even

1:21

more echogenic compared to the myometrium.

1:23

So, you can see right here, we have

1:25

a little bit of fluid in this one,

1:26

but echogenic compared to the

1:28

myometrium and a little bit thicker.

1:29

That's the proliferative phase.

1:32

Your late proliferative phase is

1:33

going to look a little bit different.

1:35

That measures up to around 11 millimeters

1:37

and will have this trilaminar

1:38

appearance that you can see here.

1:44

And then you get the secretory phase.

1:47

The trilaminar phase itself will resolve

1:49

after ovulation, and that's when you're

1:51

going to convert into the secretory phase.

1:53

It's going to be the thickest, ranges

1:54

from around 7 to 16 millimeters, and

1:57

that's when it's very echogenic, as

1:58

you can see in this example right here.

2:00

It's important to note that when you're in

2:02

secretory phase, the endometrium could obscure

2:05

small or subtle findings such as an echogenic

2:08

polyp because polyps are echogenic, sitting

2:10

in a background of thickened endometrium,

2:12

may be a little bit difficult to find those.

2:14

So, if you're not sure that you may or may

2:16

not see one, if you have vascularity, for

2:18

example, you might want to re-image when

2:20

they're in the menstruation or just post

2:22

menstruation or early proliferative phase.

2:26

And then postmenopausal.

2:28

So, in postmenopausal patients, you're going

2:30

to see a thin homogeneous echogenic line in

2:34

general, less than five millimeters and no focal

2:37

thickening of greater than five millimeters.

2:39

That's going to be considered

2:40

normal in all comers.

2:42

It's important to note that atrophy

2:44

is the most common cause of bleeding.

2:46

But you can also have polyps, hyperplasia,

2:49

and carcinoma, and you can't tell by physical

2:52

exam which one it is, so you're going to

2:53

come to ultrasound to evaluate them more.

2:57

Polyp, in general, you're going to look for

2:59

a focal echogenic structure, often has a

3:02

single feeding vessel, they can have cystic

3:05

change, and that overlaps, therefore, with

3:07

hyperplasia, which can be thick with cystic

3:09

change and may or may not be vascular.

3:11

That also overlaps with carcinomas, which

3:14

can be thick and have cystic change.

3:18

One other thing to think

3:19

about is a submucosal fibroid.

3:21

In those cases, they're going to

3:22

distort the cavity but not expand it.

3:25

They're often going to have a broader base

3:27

than a polyp or hyperplasia would.

3:31

So let's talk a little bit more

3:32

about the postmenopausal endometrium.

3:34

That's going to change depending on if they

3:37

are bleeding or if they're not bleeding.

3:39

So I made this little diagram

3:41

here that you can follow.

3:42

If they are less than five

3:43

millimeters all comers, this is

3:45

going to be due to vaginal atrophy.

3:46

They're done.

3:47

They don't need a biopsy.

3:49

However, if it's thicker than five millimeters,

3:51

you need to know whether they are bleeding or

3:53

not bleeding in their postmenopausal status.

3:56

If they are bleeding and it's greater than five

3:58

millimeters, they need to go for DNC or biopsy

4:00

if something's more focally thickened there.

4:03

However, if they're not bleeding,

4:04

you go down this column here.

4:07

If they're not bleeding and it is less than

4:09

about eight millimeters and not focally thick,

4:12

this is again, most likely due to atrophy

4:14

and you can just kind of watch them and wait.

4:17

However, if they're greater than eight

4:19

millimeters, either overall thickness or

4:21

focal, then you go back down to this DNC

4:24

or biopsy category for further evaluation.92 00:03:21,130 --> 00:03:22,260 In those cases, they're going to

3:22

distort the cavity but not expand it.

3:25

They're often going to have a broader base

3:27

than a polyp or hyperplasia would.

3:31

So let's talk a little bit more

3:32

about the postmenopausal endometrium.

3:34

That's going to change depending on if they

3:37

are bleeding or if they're not bleeding.

3:39

So I made this little diagram

3:41

here that you can follow.

3:42

If they are less than five

3:43

millimeters all comers, this is

3:45

going to be due to vaginal atrophy.

3:46

They're done.

3:47

They don't need a biopsy.

3:49

However, if it's thicker than five millimeters,

3:51

you need to know whether they are bleeding or

3:53

not bleeding in their postmenopausal status.

3:56

If they are bleeding and it's greater than five

3:58

millimeters, they need to go for DNC or biopsy

4:00

if something's more focally thickened there.

4:03

However, if they're not bleeding,

4:04

you go down this column here.

4:07

If they're not bleeding and it is less than

4:09

about eight millimeters and not focally thick,

4:12

this is again, most likely due to atrophy

4:14

and you can just kind of watch them and wait.

4:17

However, if they're greater than eight

4:19

millimeters, either overall thickness or

4:21

focal, then you go back down to this DNC

4:24

or biopsy category for further evaluation.