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Teaching Point - Postmenopausal Endometrium

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So, endometrium, when you're thinking about

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that, you have to take all of these factors

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into account when you're evaluating whether the

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thickness of the endometrium is normal or not.

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So, the important things are going to be the age

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of the patient, whether they are pre-menopausal,

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post-menopausal, or within a menstrual cycle.

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It's also important to note at what stage

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they are within a menstrual cycle because it's

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going to vary depending on where they are.

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And then, of course, the pregnancy

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status that's going to affect what

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the endometrium should look like.

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So, let's talk about the cycle and

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let's talk about premenopausal

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and postmenopausal endometrium.

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

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the similar size to the cervix itself.

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It may have a little bit of fluid

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in the endometrium at that point.

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And then, with age, the endometrium

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and the uterus are going to grow.

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The endometrium, at that point, starts

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to appear as a thin echogenic line.

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And then you reach the age of menstruation.

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So, at menstruation, in general, at the very

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beginning, right after the period ends, so maybe

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

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have a thin echogenic line, as we can see here

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in this retroverted retroflex uterus, generally

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going to be around one to four millimeters.

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It's going to be thin.

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And it's going to be echogenic.

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Next, you have your proliferative

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phase, that's around day 6 through 14.

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You're going to range there

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from around 5 to 7 millimeters.

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At this point, it's going to become even

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more echogenic compared to the myometrium.

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So, you can see right here, we have

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a little bit of fluid in this one,

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but echogenic compared to the

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myometrium and a little bit thicker.

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That's the proliferative phase.

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Your late proliferative phase is

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going to look a little bit different.

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That measures up to around 11 millimeters

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and will have this trilaminar

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appearance that you can see here.

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And then you get the secretory phase.

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The trilaminar phase itself will resolve

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after ovulation, and that's when you're

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going to convert into the secretory phase.

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It's going to be the thickest, ranges

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from around 7 to 16 millimeters, and

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that's when it's very echogenic, as

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you can see in this example right here.

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

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secretory phase, the endometrium could obscure

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small or subtle findings such as an echogenic

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polyp because polyps are echogenic, sitting

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in a background of thickened endometrium,

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may be a little bit difficult to find those.

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

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not see one, if you have vascularity, for

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example, you might want to re-image when

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they're in the menstruation or just post

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menstruation or early proliferative phase.

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And then postmenopausal.

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So, in postmenopausal patients, you're going

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to see a thin homogeneous echogenic line in

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general, less than five millimeters and no focal

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thickening of greater than five millimeters.

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That's going to be considered

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normal in all comers.

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It's important to note that atrophy

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is the most common cause of bleeding.

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But you can also have polyps, hyperplasia,

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and carcinoma, and you can't tell by physical

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

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come to ultrasound to evaluate them more.

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

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a focal echogenic structure, often has a

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single feeding vessel, they can have cystic

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change, and that overlaps, therefore, with

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hyperplasia, which can be thick with cystic

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change and may or may not be vascular.

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That also overlaps with carcinomas, which

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can be thick and have cystic change.

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One other thing to think

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about is a submucosal fibroid.

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In those cases, they're going to

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distort the cavity but not expand it.

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They're often going to have a broader base

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than a polyp or hyperplasia would.

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So let's talk a little bit more

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about the postmenopausal endometrium.

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That's going to change depending on if they

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are bleeding or if they're not bleeding.

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So I made this little diagram

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here that you can follow.

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If they are less than five

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millimeters all comers, this is

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going to be due to vaginal atrophy.

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They're done.

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They don't need a biopsy.

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However, if it's thicker than five millimeters,

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you need to know whether they are bleeding or

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not bleeding in their postmenopausal status.

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If they are bleeding and it's greater than five

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millimeters, they need to go for DNC or biopsy

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if something's more focally thickened there.

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However, if they're not bleeding,

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you go down this column here.

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If they're not bleeding and it is less than

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about eight millimeters and not focally thick,

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this is again, most likely due to atrophy

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and you can just kind of watch them and wait.

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However, if they're greater than eight

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millimeters, either overall thickness or

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focal, then you go back down to this DNC

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

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distort the cavity but not expand it.

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They're often going to have a broader base

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than a polyp or hyperplasia would.

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So let's talk a little bit more

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about the postmenopausal endometrium.

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That's going to change depending on if they

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are bleeding or if they're not bleeding.

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So I made this little diagram

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here that you can follow.

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If they are less than five

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millimeters all comers, this is

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going to be due to vaginal atrophy.

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They're done.

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They don't need a biopsy.

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However, if it's thicker than five millimeters,

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you need to know whether they are bleeding or

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not bleeding in their postmenopausal status.

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If they are bleeding and it's greater than five

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millimeters, they need to go for DNC or biopsy

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if something's more focally thickened there.

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However, if they're not bleeding,

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you go down this column here.

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If they're not bleeding and it is less than

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about eight millimeters and not focally thick,

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this is again, most likely due to atrophy

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and you can just kind of watch them and wait.

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However, if they're greater than eight

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millimeters, either overall thickness or

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focal, then you go back down to this DNC

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or biopsy category for further evaluation.

Report

Faculty

Kathryn McGillen, MD

Assistant Professor of Radiology, Medical Director of Ultrasound

Penn State University Milton S Hershey Medical Center

Tags

Vascular

Uterus

Ultrasound

Non-infectious Inflammatory

Neoplastic

Idiopathic

Gynecologic (GYN)

Body

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