In the structure of all gynecological diseases Endometrial pathology occupies far from the last place and is becoming more and more common every year. Diseases of this localization are characterized by rapid progression, severe course and a tendency to malignancy. The standard and high-quality method for diagnosing them is endometrial ultrasound, which can be performed in several ways.
What is the endometrium and its functions
The endometrium is the inner (mucous) layer of the uterus and consists of uterine glands rich in blood vessels connective tissue and prismatic single-layer epithelium. The structure of the latter consists of the presence of a thin main membrane, basal (from which cells differentiate) and functional layers.
The basal layer is located on the muscular layer and, being relatively permanent, is the source of new cells necessary to restore the functional layer after menstruation. Its normal thickness does not exceed 1.5 cm. In addition, the composition of this layer is rich in the mouths of the glands, which branch widely and penetrate into the functional layer, and connective tissue cells tightly adjacent to each other. It also houses great amount small vessels coming from the middle lining of the uterus.
The basal layer reacts extremely poorly to cyclical changes in a woman’s body. Due to its growth, there is a constant regeneration of cells of the functional layer, which were destroyed and sloughed off as a result of menstrual or dysfunctional bleeding, after childbirth or diagnostic curettage uterus.
The endometrium undergoes monthly cyclic changes under the influence of sex hormones. In the second period menstrual cycle its thickness increases significantly and local blood circulation accordingly increases. If fertilization of the egg does not occur, the cells of the functional layer desquamate, which manifests itself in the form of menstrual bleeding.
The main functions of the inner lining of the uterus are to prepare the environment for possible pregnancy and preventing the adhesion of the walls of the uterus, which prevents the development of adhesions.
Ultrasonographic stages of development of normal endometrium
The onset of pregnancy depends not only on the functioning of the ovaries, but also on the functional state of the uterine epithelium - the endometrium. Since during folliculometry it is possible to examine the endometrium, a large number of scientists are studying the indicators and echostructure of the inner uterine lining, which are the most optimal for conceiving and bearing a child:
- How the endometrium looks on ultrasound depends on the level of concentration of estrogen and progesterone in the blood plasma. In addition, ultrasonographic features of the structure of the uterine mucosa are directly dependent on the phase of the menstrual cycle. On the days of menstruation, only a thin and broken line of a hyperechoic nature is recorded in the projection of the uterine cavity.
- IN proliferative phase the anteroposterior size of the uterine mucosa thickens to 3.5 mm, and the echostructure becomes isoechoic and more homogeneous. IN in this case Ultrasound signs such as a slight decrease in echogenicity and increased homogeneity indicate the rapid development of glands, which also change their location. After ovulation has occurred, the endometrium of the uterus on ultrasound acquires a higher echogenicity due to the accumulation of a large amount of secretion in the dilated ducts of the glands.
- During the periovulatory period, the entire endometrial tissue is somewhat hypoechoic. This sign serves as a reliable criterion that reflects ovulation that has occurred. However, when performing transvaginal echography, this endometrial condition occurs before and after ovulation. During the secretory phase, the thickness of the endometrium reaches its maximum, which is 6-12 mm. At the same time, in the luteal phase, echogenicity is also increased, which is explained by changes in the glandular component and swelling of the endometrial stroma.
- Effect on the endometrium medications, aimed at stimulating ovulation, is also proven by ultrasound, although it has no practical significance.
- Diagnostically significant innovation in functional state of the uterus is the registration of “peristaltic waves” of the epithelial lining of the uterus during transvaginal ultrasound.
What does an echographic examination show?
In order to understand which day of the cycle to schedule a study, you should know when and what pathology is best visualized. Usually you can see the clearest and most reliable picture on the 7-10th day of the menstrual cycle.
What endometrial diseases can be diagnosed using ultrasound examination:
- ovarian endometriosis;
- signs of endometrial hyperplasia;
- endometriotic cyst criteria;
- polyps in the uterine cavity;
- oncological pathology of the endometrium.
Endometriosis
Before considering what endometriosis looks like on ultrasound, you should understand its cause and clinical manifestations. Due to the fact that the disease is polyetiological, it is quite difficult to identify the leading factor in its occurrence. There is a connection with hormonal imbalance, genetic predisposition, immunosuppression, etc. As a result, the uterine mucosa grows beyond its boundaries. Intermenstrual bleeding, irregularities in the menstrual cycle, pain in the suprapubic region and often infertility appear.
When to do an ultrasound for endometriosis: despite the fact that the standard for conducting the study is the 7-10th day, with this pathology the procedure will be performed closer to the end of the menstrual period, when the endometrium is most enlarged.
Ultrasound diagnosis of endometriosis is as follows:
- a more rounded shape of the uterus due to an increase in its anteroposterior size;
- the thickness becomes asymmetrical;
- the uterus increases in size;
- discontinuity of the organ contour and hyperechogenicity of the tissue appears;
- if the myometrium is damaged, an echo suspension can be detected.
The presence of a cyst on the ovary (a round hypo- or anechoic formation) with a thick capsule may also indicate external endometriosis.
Polyps
A polyp is a benign neoplasm that is formed from certain tissues of the uterus, including the endometrium. This pathology equally affects both women of reproductive age and patients undergoing menopause.
An endometrial polyp on ultrasound usually protrudes into the uterine cavity, as it has a stalk, is characterized by increased or equal echogenicity to the uterine epithelium and a rich blood supply. The contours of the polyp are usually smooth with an echo-negative rim around.
Endometrial hyperplasia
An increase in the volume of cells, and therefore the thickness of the endometrium itself, is called its hyperplasia, which can be both local and widespread. Pathology most often occurs due to overweight, long-term use of estrogen-containing drugs, polycystic ovaries and menopause. Clinically, the disease can be suspected by menstrual irregularities, pain in the lower abdomen and infertility.
Endometrial hyperplasia on ultrasound manifests itself in the form of thickening of the internal uterine layer, regardless of the phase of the cycle. Another criterion is clear smooth contours organ.
Endometrial cancer
Any malignant neoplasm can be characterized by infiltrative or expansive growth, which plays a big role in the severity of the disease and the prognosis for treatment.
Endometrium of the uterus - slime layer, which is located inside the uterine body, completely lines its cavity and provides a large amount blood vessels. He is given the main role during the menstrual period.
The main function of the endometrium is to create a favorable environment and conditions for the attachment of the fertilized egg inside the uterine body.
If it is too thin or thickening is noted, then the pregnancy will not proceed normally, and a miscarriage is possible in this situation. Treatment of any pathological process should be carried out exclusively by a specialist, after a preliminary examination.
Endometrium - what is it?
The endometrium of the uterine body is a mucous layer of the organ that creates favorable conditions for the attachment of the fertilized egg. It changes during the entire menstrual period, that is, its thickness. The greatest thickness occurs at last days cycle, and the smallest in the first days.
Due to the influence of unfavorable factors, the endometrium of the organ may become thin; this condition will interfere with the attachment of the embryo, and can also cause infertility in a woman. There are cases when the egg is attached to a thin layer, but after a while an arbitrary miscarriage occurs. Correct treatment It will help you get rid of the problem and help you conceive and bear a baby.
Normal thickness of the endometrium of the uterus
As mentioned earlier, the endometrium and its thickness changes throughout the menstrual period. Each phase of the cycle corresponds to a certain layer thickness. All changes occur under the influence of female sex hormones.
For pregnancy to occur, the thickness of this layer must be normal. The norm of the endometrium of the uterine body for the attachment of a fertilized egg is 0.7 cm.
This parameter can be determined using ultrasound examination, which is prescribed to a woman at a certain period of the cycle.
Any deviations from the norm may indicate that the pathology is progressing; the reasons for this process can be varied.
Thin layer of endometrium in the uterus
Hypoplasia or a thin layer of the endometrium of the uterine body is a deviation from the norm. Pathology manifests itself in the form of underdevelopment of the upper or lower mucous membrane of the organ. This violation leads to the impossibility of attachment of a fertilized egg.
Causes of hypoplasia:
Symptoms of hypoplasia may not appear on initial stage, and pathology is determined only when gynecological examination.
Symptoms of a disease of the mucous layer of the organ:
Thin endometrium and pregnancy cannot be combined. This pathology provokes violations reproductive function and can lead to absolute infertility. In such a situation, treatment should be carried out immediately to avoid serious consequences.
Timely therapy can increase the chance of bearing and giving birth to a healthy baby.
Thickening of the endometrial layer of the uterine body
In gynecology, there is also a definition such as hyperplasia, which indicates thickening of the mucous layer and the formation of polyps. This pathology has a benign course.
Deviation of thickness from the norm can be determined during a gynecological examination, as well as using an ultrasound examination. Treatment may not be carried out if infertility is not observed and there are no symptoms of pathology.
Hyperplasia can be of simple type and atypical form. Simple hyperplasia is characterized by a predominance of glandular cells, leading to the development of cystic formations. Treatment includes not only the use of drugs, but also surgery. Polyps depending on cellular structure can be glandular, fibrous, mixed type.
Pathology of the mucous layer of the uterine body of an atypical form includes the progression of adenomatosis. Histological analysis shows changes in tissue structure. Adenomatosis is more of a malignant disease.
The following various reasons can provoke a thickening of the layer:
Many experts are also of the opinion that hyperplasia can also be caused by reasons such as hormonal imbalance, tumor progression, inflammatory processes, diseases endocrine system, sexually transmitted infections.
Pathology also occurs as a result of long-term use of contraceptives that contain exclusively estrogens.
Symptoms of hyperplasia:
- Irregular menstruation (the cycle becomes longer or, on the contrary, shorter).
- Smearing of blood, which is observed in the patient a few days before menstruation.
- Bleeding with clots.
- Discharge of blood during sexual intercourse.
- Changes in the duration and abundance of discharge during menstruation.
Treatment is carried out either conservatively (sometimes, in combination, it is also carried out folk remedies), or through an operation. If you refuse therapy or do it untimely, the following complications may occur:
Towards prevention of this disease include:
- exclusion of unplanned pregnancy and abortion;
- correct and healthy image life;
- reduction of stressful situations;
- timely treatment of diseases and pathologies of the reproductive system, as well as the endocrine system.
Pathology, symptoms, causes and treatment
IN modern medicine There are several pathologies of the mucous layer of the uterine body, each of which has specific causes, symptoms and methods of treatment.
Diagnosis of pathology
If a woman has shown signs of the disease, she must undergo a thorough examination, blood and urine tests. During a gynecological examination, a specialist may find that the endometrium has become thin or, on the contrary, thickened, the uterus has changed shape and is in good shape. The patient is also recommended to undergo:
The norm is when the ultrasound and test indicators are within acceptable values.
Is treatment possible without surgery?
Treatment of the disease can be carried out conservatively and surgically. Surgical intervention is performed only in advanced situations.
Conservative therapy includes treatment with medications and folk remedies. Choice hormonal drugs will depend on the patient’s age category, desire to have children in the future, and stage of the disease.
Treatment with folk remedies is carried out under the supervision of a specialist; the course is selected individually depending on many factors. The patient may be recommended nettle, calendula, rose hips, yarrow, plantain. These herbs will help stop bleeding. Hirudotherapy is also prescribed, which has a positive effect on blood thickening.
The endometrium is the inner lining of the uterus. It consists of basal and functional layers. The first is not subject to changes throughout the month, and the second is rejected every time with menstrual flow, and then grows again.
Often women do not think about the significance of the endometrium. Meanwhile, the course of pregnancy and health reproductive system largely depend on his condition. It is he who creates the necessary conditions for attachment to the walls of the uterus of the fertilized egg. And if its structure deviates from the norm, this can affect the course of pregnancy, including miscarriage.
The structure of the endometrium changes throughout the menstrual period. Closer to the regula it reaches its maximum thickness. If fertilization does not occur, then part of the uterine mucosa is rejected along with blood into the critical days. And the glands begin to actively grow again. Along with the uterine epithelium, the unfertilized egg also leaves the body. Therefore, the regularity and volume of menstruation in women also depend on it.
Let's figure out how the structure of the endometrium changes over the course of a month and what it depends on. In the first and partially in the second phases of the menstrual cycle, the inner lining of the uterus becomes three-layered. And on ultrasound, all layers and the boundaries between them are clearly distinguished.
Since in the study all layers are visualized in the form of straight, clearly distinguishable lines, such an endometrium is called linear. In a normally functioning female body a similar phenomenon is present immediately after menstruation and partially in the second half of the cycle. This means that the woman is able to become pregnant. But if this type of mucous membrane is located at another time, then this is a sign of pathology.
Avascular endometrium is the lining of the uterus without blood vessels or poorly supplied with blood. This condition can lead to thinning of the inner lining of the organ responsible for reproduction. And as a result, a woman will not be able to get pregnant or carry a child. If such words are present in the ultrasound report, then you need to consult with your local gynecologist. The doctor will tell you what measures need to be taken in this regard.
Stages of endometrial development
Under the influence of female sex hormones, the thickness of the endometrium in the uterus constantly changes throughout the month. For pregnancy to occur, its value must correspond to the norm. Within 30 days after menstruation, the uterine mucosa increases from 4 mm to 2 cm in thickness. All indicators that go beyond these limits indicate deviations.
- From 4 to 8 days – from 3 to 6 mm.
- From 8th to 11th – 5–8 mm.
- From 11th to 15th – 7 mm – 1.4 cm.
- From the 15th to the 19th – 1–1.6 cm.
- From the 19th to the 24th – 1–1.8 cm.
- From the 24th to the 27th – up to 1.2 cm.
In order for the fertilized egg to attach to the wall of the uterus, it needs a 7 mm layer of endometrium. determined by ultrasound, where the gynecologist gives a referral. Any deviations in the structure of the mucous membrane reproductive organ talking about a disease that needs to be treated.
Thickening of the endometrial layer of the uterine body
If endometrial cells begin to divide too actively, and the mucous layer in the uterus thickens, polyps form. This condition is called hyperplasia. It is benign in nature. This deviation can be detected during a gynecological examination or ultrasound. IN healthy body This shouldn't happen.
There are simple and . At simple type a large number of glandular cells leads to the formation of cysts. The atypical form involves the degeneration of tissue from benign to cancerous.
Causes of endometrial thickening:
- frequent stress;
- disruption of hormone secretion;
- disruptions in the functioning of the endocrine system;
- chronic form of endometritis;
- abortions;
- liver dysfunction;
- sexually transmitted infections;
- tumors or inflammations;
- long-term use of hormonal contraceptive pills.
Diagnosis of pathology
To make an accurate and detailed diagnosis, as well as assess the condition and thickness of the uterine mucosa, the following types of information collection are used:
- gynecological examination;
- survey;
- Analysis of urine;
- blood test for hormone levels;
- vaginal smear;
- transvaginal ultrasound;
- biopsy;
- histological examination of the endometrium;
- checking for intrauterine infections.
If the examination reveals this pathology, then antispasmodic and painkillers are prescribed. Further treatment will depend on the severity of the disease and the woman’s age.
Therapy methods
If the endometrium of the uterus is not changed globally, then the pathology can be treated with medication. In case of formation of cysts and polyps, it is prescribed combination therapy. It combines medication and surgery. Getting rid of the disease by surgery is provided in case of advanced state of the reproductive system.
The choice of treatment method is made solely by the doctor. At the same time, he is based on his experience, the degree of growth of the inner layer of the uterus, the well-being and age of the woman.
Drug therapy
To treat this disease there are various groups drugs:
- Hormonal birth control pills. They normalize the balance of hormones in the body. Such drugs are suitable for young nulliparous girls. They are drunk for at least 6 months according to a certain scheme. In this way, it is possible to regulate the menstrual cycle, and the discharge becomes less abundant. Logest, Marvelon, Regulon, Janine are often used.
- Chemical substitutes for progesterone. The use of such drugs will help get rid of excessive growth of the uterine mucosa and bring it back to normal. After taking them, the arrival of menstruation becomes regular. At the same time, they help women of any age category with various types endometrial hyperplasia. The course of treatment lasts from 3 months to six months. The most popular and effective of the gestagens are Duphaston and Norkolut.
- Gonadotropin-releasing hormone agonists. They are able to reduce cell division and even out the thickness of the uterine mucosa. Such drugs are sold in ampoules. Treatment for many of them involves giving an injection once a month.
Coagulation
Very effective method fight the disease. There are several types of this minimally invasive intervention, which eliminates the pathological formation inside the uterus:
- Electrocoagulation - electrical impulses are applied to the affected tissue. The manipulation is carried out under anesthesia and in the absence of menstrual flow. It is indicated only for women who have given birth, since it leaves a scar on the cervix.
- Laser ablation – a laser specifically burns out pathological areas on the affected organ. After this procedure, the tissue regenerates and recovers faster. After manipulation, a clear grayish liquid is released abundantly over the next few weeks.
- Chemical coagulation - a mixture of drugs is applied to the affected area, which destroys the pathological surface. Killed cells are rejected and leave the organ after 2 days.
- Radio wave vaporization - the overgrown endometrium evaporates under the influence of an electromagnetic beam directed at it. This method is harmless and suitable for all women.
- Cryodestruction - the affected area is frozen under the influence of liquid nitrogen, and then dies and leaves the uterine cavity.
The next day after the manipulations are possible painful sensations in the abdominal area. But it will pass quickly. A month after the procedure, menstrual irregularities will disappear, and the woman will be able to become pregnant. A re-examination should be carried out six months after the procedure.
Scraping
This procedure is similar to. It is used to remove hyperplastic endometrium and polyps. Parts of the tissue are sent to a laboratory for testing. They are checked for the detection of cysts, polyps, cells prone to degeneration into cancer, as well as other disorders.
After the procedure, if the uterine mucosa is excessively vascularized, bleeding is possible. A woman needs to rest for a couple of days and stock up on sanitary pads. During the rehabilitation period, antibiotics and hormones are prescribed to prevent inflammation after surgery and recurrent endometrial hyperplasia.
Treatment without surgery
This disease occurs due to an excess of estrogen hormones. To equalize hormonal levels, it is prescribed oral contraceptives, artificial analogues of progesterone or GnRH (these drugs were discussed above). But such drugs often have side effects. The gynecologist selects their dosage and dosage regimen individually, based on the woman’s medical history and tests.
Installation of the Mirena intrauterine device does not allow the endometrium to grow in the uterus. Treatment occurs due to the release of levonorgestrel into the uterine cavity by a modern contraceptive. This is a synthetic analogue of progesterone. The validity period of the IUD is 5 years. Therapy with Mirena is carried out in parallel with other hormonal agents.
Complications and consequences
If the disease is detected on early stage development, then it can be easily dealt with. The difficulty is that in the initial stages it hardly manifests itself at all. Therefore, in order to recognize it, you need to do an ultrasound of the uterus or get an appointment with an experienced gynecologist.
The most terrible and dangerous complications and the consequences of endometrial hyperplasia are:
- Infertility. Since the inner lining of the uterus is deformed, a fertilized egg simply cannot attach to it.
- Degeneration of pathology into malignancy. The probability of atypically changed cells developing into cancer is from 30 to 50%.
- Relapses of the disease. After drug treatment hyperplasia returns 2 times more often than after surgery.
- Anemia. This is an obligatory companion to the growth of the endometrium. If you do not detect it in time and do not begin to get rid of the disease, iron deficiency in the blood will certainly develop.
Preventive actions
In order to recognize transitional endometrium in time and prevent it from developing into a disease, you need to regularly go for examination to a gynecologist, especially when painful menstruation, and be sure to inform him of all changes. And for prevention purposes:
- use hormonal contraceptives;
- eat right, make sure that food is free of preservatives and dyes;
- plan pregnancy and avoid abortion;
- do not abuse strong alcoholic drinks and stop smoking;
- conduct regular sex life with a permanent partner;
- watch your figure, avoiding any extremes.
Comprehensive gynecological examination in mandatory includes ultrasound of the endometrium. During a preventive gynecological examination and if certain types of disease are suspected, this type of study is prescribed. If it was produced surgical intervention into the pelvic organs, then the condition of the endometrium is monitored through ultrasound. This can be either artificial termination of pregnancy or surgical delivery.
In addition, such an ultrasound is prescribed if a woman has a hormonal disbalance. This is necessary for early diagnosis pathology and prescription of drug treatment if necessary. The gynecologist should explain when and at what time it is advisable to conduct an ultrasound examination of the endometrium.
The endometrium is inner layer uterus. After receiving the test results, the doctor compares the indicators with the norm and can make a diagnosis.Normal endometrial indicators according to ultrasound
The endometrium is the first inner layer lining the uterine cavity. The thickness of this layer must be a certain size, which depends on the phase of the woman’s cycle. Normal physiological state The endometrial layer on ultrasound should correspond to the following parameters:
- 5-9 mm. height of the dark stripe in the first two days of the cycle;
- 3-5 mm. height of a thin light layer on 3-4 days;
- 6-9 mm. light stripe with dark edges on days 5-7;
- 10 mm: there is an alternation of light and dark stripes on days 8-10;
- on days 11-14 it is also 10 mm, only the alternation of the color of the layers differs.
On other days, the endometrial layer may change in size, but its color pattern no longer changes. Thus, ultrasound diagnostics must be done taking into account the menstrual cycle.
Allows you to identify the following pathological conditions endometrium:
- endometriosis of the uterine cavity;
- ovarian endometriosis;
- endometrioid ovarian cysts;
- endometrial polyp;
- endometrial hyperplasia;
- endometrial cancer.
Doppler examination of the endometrium
In combination with ultrasound examination, Doppler ultrasound is performed during a gynecological examination (). Doppler ultrasound is used to study endometrial vessels; it is used to assess their condition and the extent to which they are able to normally supply the mucous membrane of the uterine cavity with blood. In addition, Doppler ultrasound is used to diagnose neoplasms in the uterus and ovaries.
Doppler ultrasound allows you to determine the malignancy or benignity of neoplasms in the ovaries and uterus. Such an examination is based on the fact that the nature of the blood flow in them during cancer is different, and Doppler measurements make it possible to determine this condition.
Doppler testing of the endometrium is performed simultaneously with ultrasound diagnostics. It allows you to determine the hemodynamics of endometrial vessels and identify blood supply disorders Endometriosis on ultrasound
Using ultrasound, you can identify many different pathologies of the endometrial layer of the uterus. The most common of these is endometriosis. This is a disease that is characterized by the growth of uterine tissue beyond its cavity. Such growth can extend into the area of the fallopian tubes and peritoneum. Endometriosis quite often causes female infertility.
Endometriosis is divided into two types - internal and external. Internal cases primarily affect the body of the uterus. If endometriosis is external, then the growth of the epithelium reaches the vagina and the adjacent part of the cervix. In addition, the peritoneum, ovaries and the fallopian tubes. Depending on the depth of the lesion, internal endometriosis is characterized by 3 degrees of development. The first degree is characterized by damage to the myometrium by 2-3 mm. in depth. In the second degree, almost half of the uterine cavity is affected. In the third degree, the lesion reaches the serous layer. When conducting ultrasound diagnostics endometriosis, its signs are revealed only from the second stage.
This is due to the fact that the existing pathological foci increase at this time, the nodes swell, and endometrioid cysts are better visualized. In some cases, ultrasound examination is performed in the first half - on days 5-7.
The following signs of endometriosis appear on ultrasound:
- the uterus acquires a rounded shape (this occurs as a result of an increase in its anteroposterior size);
- the size of the uterus increases;
- the thickness of the uterus is asymmetrical;
- increased echogenicity of some areas and intermittent contours;
- the average M-echo has an uneven and thickened contour;
- suspension content is observed in the affected areas of the myometrium.
Cystic formations in the endometrium
In addition to endometriosis, a disease such as ovarian endometriosis can occur in the uterine cavity. In this case, ultrasound examination reveals their small cellularity internal structure, they have a double contour and are located on the lateral side behind the uterus.
In addition, the presence of a dense cyst capsule may be a sign of ovarian endometriosis. At the same time, there are no changes in its structure relative to different periods menstrual cycle.
Ovarian cysts formed as a result of endometriosis are called endometrioid. They have a round or oval shape, the wall thickness is uneven and can vary from 2 to 8 mm. The thickness of the walls of such a cyst varies depending on the duration of the cyst’s existence. Such neoplasms have pronounced accumulations of blood clots located in the parietal space. The fluid located in the cavity of the ovarian cyst has heterogeneous structure. If we carry out the dynamics of the development of the cyst, we can record an increase in its volume during or immediately after menstrual bleeding, which is caused by the influx of menstrual blood.
Endometrial polyps
Often, an ultrasound examination of the endometrium reveals polyps. A polyp is a benign formation that is formed from endometrial tissue. Endometrial polyp is equally common in women of reproductive age and during menopause. An endometrial polyp is diagnosed by ultrasound; the usual location of the polyp is the inner lining of the uterus.
The combination of ultrasound and Dopplerography allows us to identify benign neoplasms internal tissues of the uterus - polyps. They grow from endometrial cells and can cause menstrual irregularities. An endometrial polyp usually has a stalk on which it is attached and a developed choroid plexus. The main sign by which a polyp can be identified is bleeding outside the menstrual cycle.
Hyperplasia and malignant neoplasms
Ultrasound also detects endometrial hyperplasia. This disease is caused inflammatory processes in the pelvic organs or hormonal imbalance. Endometrial hyperplasia is an overgrowth of the lining of the uterus. Sometimes hyperplasia can develop into cancer.
For hyperplasia, diagnosis is carried out 2 times in one cycle - at the beginning and at the end. This is necessary in order to determine whether the excess layer of the endometrium is being rejected and whether qualified medical care is required.
Hyperplasia can affect the entire layer of the endometrium of the uterus or specific areas of it, which is a focal manifestation of the disease. Hyperplasia is a consequence of increased estrogen levels in a woman’s body.
Excessive growth of the mucous layer can cause malignant tumors- endometrial cancer or uterine cancer. Cancer of this organ is caused hormonal disorders in the female body. Since endometrial cancer (uterine cancer) is a very common disease, its detection at an early stage of development is a very urgent task.
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01/19/2017 "Articles"
AUTHORS: Dueholm, C. Møller, S. Rydbjerg, E. S. Hansen, G. Ørtoft, P.G.Leone, D.Timmerman, T.Bourne, L.Valentin, E.Epstein, S.R.Goldstein, H.Marret, A.K.Parsons, B.Gull, O.Istre, W.Sepulveda, E.Ferrazzi, T.Van den Bosch
Transvaginal ultrasound examination It has great importance in the diagnosis of endometrial cancer in women with postmenopausal bleeding. Women with an endometrial thickness ≤ 4 mm measured by transvaginal scanning have a low risk of developing endometrial cancer (1 in 100 cases) if they do not take hormone replacement therapy. hormone therapy; 1 in 1000 if they are taking therapy). Women with postmenopausal bleeding and endometrial thickness ≥ 5 mm have high risk endometrial cancer (1 in 4 cases), so it is necessary to obtain a high-quality intrauterine scraping for histological analysis. Ultrasound can provide information about individual risk malignant neoplasms in postmenopausal women with bleeding and endometrial thickness ≥ 5 mm.
Our study included women with postmenopausal bleeding and endometrial thickness ≥ 5 mm, as measured by a transvaginal probe. The study was conducted at the University Hospital in Aarhus, Denmark, between November 2010 and February 2012. All women underwent transvaginal scanning (TVS) and gel infusion sonography (GIS). All were scheduled for hysteroscopy with resectoscopic biopsy and additional curettage to assess intrauterine pathology (Table 1).
Table 1. Patient selection scheme for the study.
Transvaginal scan (TVS)
TVS was performed on a Voluson E8 Expert equipped with an endovaginal sensor (6-12 MHz), according to the scanning protocol. Doppler parameters were preset in a standardized manner (frequency 6 MHz, Doppler power gain 50, dynamic range 10 dB; persistence 2, map color 1, filter 3).
The TVS scan included a visual assessment of the following parameters, determined International Group Endometrial Tumor Analysis (IETA): endometrial thickness, its echogenicity (hyper-, hypo-, and isoechoic, homo/heterogeneous); cystic component (yes/no), if present, then smooth or uneven limits; endometrial boundaries (smooth or uneven, homo-/heterogeneous); closure line (yes/no), interrupted (yes/no).
Power Doppler analysis included a visual assessment of the following parameters: vessels present (yes / no), presence of a dominant vessel (yes / no), if there is a dominant vessel, then single (yes / no) or double (yes / no), origin (focal / multifocal) multiple vessels (yes/no); branches (yes/no), if there are branches, then ordered/disordered, circular direction of the vessels (yes/no). We assessed subjectively: large vessels (yes/no), color Doppler (yes/no), density of vessels (yes/no).
GIS was carried out after TVS. We used a small flexible sterile catheter equipped with a 10 ml syringe containing Instillagel® (E.Tjellesen A/S, Lynge, Denmark) which was inserted into the uterine cavity. In patients with an obstructed cervix, we used a small Hegar dilator. The gel was introduced into the uterine cavity under ultrasound control.
The uterine cavity was then scanned in the sagittal and transverse planes, assessing the same parameters as for conventional TVS. The following were also assessed: the presence of formation, its location and the percentage of endometrial damage (that is, ≤ 25% of the surface is damaged) (yes/no); surface structure of local damage (uniform / uneven); structure of the general surface of the endometrium (smooth, polypoid, uneven).
Hysteroscopy
Outpatient hysteroscopy was performed in all patients using local or general anesthesia. In 112 patients, hysteroscopy was performed immediately after the ultrasound examination, in other patients at the next visit within 3 weeks after the ultrasound examination. During hysteroscopy, attempts were made to remove all tissue from the uterine cavity. Three to five endometrial samples were collected from one patient.
Calculation of the risk of developing endometrial cancer using a scoring system
(Risk of endometrial cancer score (REC score))
Based on our analyses, we developed a risk scoring system for endometrial cancer (Fig. 1). The scoring system included body mass index (≥30 = 1 point), endometrial thickness (≥10mm = 1 point), (≥15mm = 1 point), presence of vascularization, dominant vessel (present = 1 point), multiple vessels (present = 1 point), large vessels (present = 1 point) and dense vessels (present = 1 point), discontinuous endomyotrial zone (present = 1 point) and uneven endometrial surface on GIS (present = 1 point). Adding these values creates an endometrial cancer risk score. Score 3 for TVS or 4 for GIS showed good scan results and correctly diagnosed high level development of endometrial cancer in about 90% of all patients.
Fig.1. Schematic representation of determining the risk of developing endometrial cancer using a scoring system.
Ultrasound examination parameters of the endometrium were determined by the International Endometrial Tumor Analysis Group (IETA)
Endometrial thicknessmeasured in the sagittal plane. Calipers should be placed at the endometrial-myometrial interface, perpendicular to the endometrial midline (Fig. 2). When fluid is present, then the thickness of individual parts of the endometrium is measured and their sum is recorded (Fig. 2b).
Fig.2. Schematic and ultrasound image of endometrial measurement in normal conditions (a), and in the presence of intrauterine fluid (b).
Echogenicity of the endometriumis assessed in comparison with the echogenicity of the myometrium as hyperechoic, isoechoic or hypoechoic.
Homogeneity of the endometrium assessed by its structure. “Homogeneous” endometrium is homogeneous and has a three-layer structure (Fig. 3). “Heterogeneous” endometrium is described when there is heterogeneity in structure, asymmetry, or cystic formations(Fig.4).
Fig.3.“Homogeneous” endometrium: (a) schematic representation of a three-layer endometrium, (b) hypoechoic, (c) hyperechoic, (d) isoechoic.
Fig.4.“Heterogeneous” endometrium: cystic formations with smooth edges are visualized against a homogeneous background (a), cystic formations with uneven edges are observed against a homogeneous background (b), a heterogeneous background without cystic areas (c), cystic formations with smooth edges are present against a heterogeneous background ( d) and on a heterogeneous background, cystic formations with uneven edges (e).
The endometrium is considered “linear” if the line of closure of the endometrial layers is defined as straight; and “nonlinear” if the closure line is visualized as “jagged” or “interrupted” or completely absent (Fig. 5).
Fig.5. The line of closure of the endometrial layers: “linear” (a), “jagged” (b), “interrupted” (c) and one that is not visualized (d).
The endometrial-myometrial region is described as “smooth,” “ragged,” “interrupted,” or “indeterminate” (Fig. 6).
Fig.6. Endometrial-myometrial area: “smooth” (a), “uneven” (b), “interrupted” (c) and “indeterminate” (d).
Intrauterine fluid is described as anechoic, isoechoic, or mixed echogenicity (Fig. 7).
Fig.7. Intrauterine fluid: (a) hypoechoic, (b) isoechoic, (c) mixed echogenicity.
Doppler assessment
Doppler settings should be adjusted to ensure maximum sensitivity (ultrasound frequency at least 5.0 MHz, pulse repetition frequency (PRF) 0.3-0.9 kHz, vessel wall filter 30-50 Hz, Doppler color gain should be reduced to until all color artifacts disappear).
Doppler is scored by the presence of blood flow: 1 point is given when there is no flow of color signals in the endometrium; 2 points – if only minimal blood flow can be detected; 3 points – when moderate blood flow is present; and score 4 – when significant blood flow is evident (Fig. 8).
Fig.8. Assessment of endometrial blood supply: 1 point is given - when there is no blood flow (a); 2 points – minimal blood flow is present (b); 3 points – moderate blood flow is present (c); and 4 points – significant blood flow is determined (d).
The vascular pattern in the endometrium indicates the presence or absence of a “dominant vessel.” A “dominant vessel” is defined as one or more vessels (arteries and/or veins) that leak into the endometrium (Figure 9). The dominant vessel may have ramifications in the endometrium, described as ordered or disordered/chaotic. Several dominant vessels may originate from a single vessel (“focal” origin), or from several vessels of the endometrial-myometrial layer (multifocal origin). Other vascular structures within the endometrium include “scattered” vessels (single color signals within the endometrium with no apparent origin) and circular vascular patterns (Figure 9).
Fig.9. Vascular models: “dominant” vessel without branching (a) and with branching (b); several vessels that have a “focal” origin (two or more vessels that have a common stem) (c) and a “multifocal” origin (large vessels that have a different basis) (d); “scattered” vessels (single color signals in the endometrium, but without visible origin) (e) and the circular direction of the vessels (f).
Gel infusion sonography (GIS)
The endometrium is described as “smooth” when the inner surface of the endometrium is smooth, “wavy” when there are several concave shallow areas, or “polyp-shaped” when there is significant indentation towards the uterine cavity. The endometrium is “uneven” - if the surface of the formation faces the uterine cavity in the form of a cauliflower, or like sharply jagged tissue (Fig. 10).
Fig. 10. Endometrial contour: “smooth” (a), “wavy” (b), “polyp-shaped” (c) and “uneven” (d).
Intrauterine formations
Everything that protrudes into the uterine cavity is called intracavitary formations. Intracavitary lesions should be described as endometrial lesions or lesions arising from the myometrium.
The extent of endometrial involvement is determined based on the percentage of the total endometrial surface area involved. An endometrial mass is described as “widespread” if it covers 25% or more of the endometrial surface, and “localized” if it covers less than 25% of the surface (Fig. 11). The type of “localized” endometrial formation is calculated by the ratio between the diameter of the base at the endometrial level (a) and the maximum diameter of the diameter of the formation (b). If a/b coefficient<1 описывается, как образование на «ножке», и как образование на “широкой основе”, если коэффициент равен 1 или больше (Рис.12).
Fig. 11. Assessing the extent of endometrial damage: a “localized” lesion involves less than 25% of the endometrial surface (a), and a “widespread” lesion involves 25% or more of the surface (b).
Fig. 12.“Localized” type of formation during GIS or with already existing fluid in the uterine cavity. A/b ratio<1 указывает на образование на «ножке» (а) и а / b соотношение ≥ 1 указывает на “широкую основу “(b), где максимальный диаметр основания образования находится на уровне эндометрия и представляет максимальный поперечный диаметр образования.
The echogenicity of the lesion is defined as “homogeneous” or “heterogeneous” (the latter including cystic lesions).
The contour of the formation is defined as “smooth” or “uneven” (Fig. 13).
Fig. 13. The contour of the formation during GIS or with already existing fluid in the uterine cavity is “smooth” (a) and “uneven” (b).
When formations are detected in the uterine cavity arising from the myometrium (usually fibroids), their echogenicity and the proportion of the formation that penetrates into the uterine cavity are determined.
Subserosal fibroids should be classified based on the specific planes passing through the greatest diameter of the fibroid, as described by Leone et al: Class 0 (G0) - the fibroid is completely protruding into the cavity; Class 1 (G1) – wide base of fibroids ≥ 50% protrudes into the uterine cavity; and 2nd class (G2) with intrauterine part of fibroids<50% (рис.14).
Fig. 14. Part of the fibroid protrudes into the uterine cavity during GIS or with pre-existing fluid in the uterine cavity: 100%, class 0 (a) ≥ 50%, class 1 (b)<50%, класс 2 (c).
DISCUSSION
We constructed a scoring system (REC) that can effectively distinguish between benign and malignant endometrial lesions. The REC scoring system correctly identified lesions in nine out of 10 postmenopausal women with endometrial thickness ≥ 5 mm. The scoring approach can be used to reduce the number of invasive procedures performed.
We used terms and classifications defined by the International Endometrial Tumor Analysis Group (IETA) that can be used to measure and describe pathology located in the uterine cavity. The main goal of this work is to create a list of terms and definitions that can be used both in the daily practice of doctors and in scientific research. To conduct research, we recommend using a device from GE.
